Cervical Myelopathy: Understanding Spinal Stenosis Symptoms and When Surgery Is Needed

What Is Cervical Myelopathy?

Cervical myelopathy is a neurological condition caused by compression of the spinal cord in the neck region, most often due to cervical spinal stenosis. It's not just a stiff neck or occasional numbness-it's a sign that the spinal cord itself is being squeezed, and that can lead to serious, lasting damage if ignored. The most common form is called cervical spondylotic myelopathy (CSM), which happens because of age-related wear and tear on the spine. By age 70, nearly 1 in 10 people show signs of it, and it's the leading cause of spinal cord problems in adults over 55.

Spinal stenosis means the spinal canal-the bony tunnel that holds the spinal cord-has narrowed. In a healthy neck, that canal is about 17 to 18 millimeters wide. When it drops below 13 mm, it’s considered stenotic. At 10 mm or less, it’s severe. This narrowing doesn’t happen overnight. Over decades, discs lose water and flatten, facet joints grow bone spurs, and the ligament behind the spine thickens. Together, these changes slowly crush the spinal cord.

Early Symptoms You Can’t Ignore

Many people mistake early symptoms of cervical myelopathy for carpal tunnel, arthritis, or just getting older. But these signs are neurological-and they don’t go away on their own.

• Hand clumsiness: You drop things more often. Buttoning a shirt, writing, or using keys becomes hard. This happens because the nerves controlling fine motor skills in your hands are being compressed.
• Gait problems: Your walk feels unsteady. You might shuffle, feel like your feet are stuck to the floor, or trip over small bumps. This is caused by damage to the pathways that tell your brain where your body is in space.
• Weakness or numbness: Your arms or legs feel heavy, tingly, or numb. It’s not just a pinched nerve-it’s the spinal cord sending confused signals.
• Hyperreflexia: Your knee and ankle reflexes are overly strong. Doctors check this with a reflex hammer during exams. It’s one of the earliest clinical signs, present in 85% of cases.
• Balance issues: You feel unsteady standing still or turning your head. This isn’t dizziness-it’s your spinal cord losing its ability to coordinate movement.

These symptoms don’t always show up at once. About 45% of people see them slowly worsen over 2 to 5 years. Another 25% get worse fast-within months. If you’re over 55 and notice any of these changes, don’t wait. Delaying diagnosis can mean losing function you can’t get back.

How Is It Diagnosed?

There’s no single test. Diagnosis needs two things: symptoms that match spinal cord damage, and imaging that shows the cord is being squeezed.

The Japanese Orthopaedic Association (JOA) score is the most used tool. It rates hand function, walking ability, sensation, and bladder control on a scale of 0 to 17. A score below 14 confirms myelopathy. It’s simple, but it works.

MRI is the gold standard. It shows exactly where the spinal cord is compressed and whether there’s damage inside the cord itself-like swelling or scarring (called T2 hyperintensity). Without this signal change, you might just have stenosis without myelopathy. Up to 21% of people over 40 have stenosis on MRI but no symptoms. That’s why symptoms matter as much as images.

X-rays can show bone spurs, disc collapse, or instability, but they can’t see the spinal cord. CT myelography is used if you can’t have an MRI. EMG and SSEP tests check nerve function and can catch early damage before you even notice it.

On average, people see three doctors before getting the right diagnosis. The delay is often over a year. That’s too long. If you suspect myelopathy, get an MRI within 2 to 4 weeks of noticing symptoms.

When Is Surgery the Only Real Option?

Conservative treatment-like physical therapy, NSAIDs, or neck braces-might help mild cases. But the data is clear: if your myelopathy is moderate to severe, surgery is the only way to stop progression and regain function.

For mild cases (JOA score 12-14), only 28% improve with non-surgical care over two years. The other 63% get worse. That’s not a gamble you want to take.

For moderate to severe cases (JOA score below 12), surgery improves neurological function in 70-85% of patients. The American Academy of Orthopaedic Surgeons gives this a strong, top-tier recommendation based on high-quality studies.

Dr. Wellington Hsu from Northwestern says recovery potential drops by about 3% per month you wait. If you delay surgery past 12 months, you’re losing a third of your chance to recover fully. Patients who have surgery within six months of symptoms start improving 37% faster than those who wait.

Types of Surgery and What to Expect

Surgery isn’t one-size-fits-all. The approach depends on how many levels are affected, your spine’s alignment, and your overall health.

ACDF is the most common for one or two levels. It removes the damaged disc and fuses the bones. It’s highly effective, but over 10 years, 5-7% of patients need another surgery because the levels above or below start breaking down.

Laminoplasty opens the back of the spinal canal like a door. It’s great for multi-level cases because it doesn’t require fusion. But it’s more complex and not ideal if your spine is unstable.

Minimally invasive options are improving. A new tubular laminoplasty technique at Johns Hopkins cuts blood loss by 65% and shortens hospital stays by nearly two days.

What Recovery Looks Like

Recovery isn’t quick. Most people need 3 to 6 months to feel like themselves again. You’ll need formal physical therapy for 8 to 12 weeks. That’s not optional-it’s critical. Therapy focuses on gait retraining, balance, and strengthening the muscles that support your neck.

Most patients see big improvements in hand function-82% report better grip and dexterity after surgery. But only 65% regain normal walking. Nearly 30% still need a cane or walker. That’s why early surgery matters: the less damage done before the operation, the better the recovery.

Some side effects are common but temporary. Swallowing trouble happens in 22% of ACDF patients in the first few months. Neck pain persists in 35% of fusion patients at six months. A small group gets what’s called post-laminectomy syndrome-chronic back-of-the-neck pain after posterior surgery.

Who Should Avoid Surgery?

Surgery isn’t for everyone. If you’re in your 80s with multiple serious health problems, or if your symptoms are very mild and stable, your doctor might suggest monitoring. But if you’re active, otherwise healthy, and your symptoms are getting worse, surgery is the best path.

Smokers have a 50% higher chance of failed fusion. Diabetics with HbA1c above 7.0 have twice the infection risk. If you’re considering surgery, stop smoking and get your blood sugar under control first.

Surgeon experience matters too. Those who do more than 50 cervical spine surgeries a year have 32% fewer complications. Ask your surgeon how many of these procedures they do each year.

The Future of Treatment

Things are changing fast. In 2023, the FDA approved the first artificial disc for use in two or three levels-the M6-C. Early results show it preserves motion better than fusion and reduces long-term reoperation risk.

Researchers are testing drugs like riluzole during surgery to protect the spinal cord from further damage. Early trials show a 12% boost in recovery scores.

Robotic-assisted surgery is coming. By 2030, it may become standard for complex cases, cutting revision rates from 10% down to 6.5% by improving precision.

But there’s a warning. The number of cervical spine surgeries has jumped 33% since 2010. Experts say 15-20% of those may be unnecessary-because patients weren’t properly screened. That’s why accurate diagnosis and timely intervention are more important than ever.

What to Do Next

If you’re experiencing hand clumsiness, gait problems, or unexplained numbness and weakness, don’t assume it’s just aging. See a spine specialist. Get an MRI. Know your JOA score.

Don’t wait for symptoms to get worse. Every month you delay, you lose a little more recovery potential. The goal isn’t just to stop the damage-it’s to get your life back.