Cervical Myelopathy

Topic updated on 05/20/16 4:30pm
  • A clinical syndrome caused by compression on the spinal cord that is characterized by
    • clumsiness in hands
    • gait imbalance 
  • Pathophysiology
    • etiology
      • degenerative cervical spondylosis (CSM) topic
        • most common cause of cervical myelopathy
        • compression usually caused by anterior degenerative changes (osteophytes, discosteophyte complex) 
        • degenerative spondylolisthesis and hypertrophy of ligamentum flavum may contribute
      • congenital stenosis
        • symptoms usually begin when congenital narrowing combined with spondylotic degenerative changes in older patients
      • OPLL 
      • tumor
      • epidural abscess 
      • trauma
      • cervical kyphosis
    • neurologic injury
      • mechanism of injury can be
        • direct cord compression
        • ischemic injury secondary to compression of anterior spinal artery
  • Associated conditions
    • lumbar spinal stenosis  
      • tandem stenosis occurs in lumbar and cervical spine in ~20% of patients
  • Prognosis
    • natural history
      • tends to be slowly progressive and rarely improves with nonoperative modalities
      • progression characterized by steplike deterioration with periods of stable symptoms
    • prognosis
      • early recognition and treatment prior to spinal cord damage is critical for good clinical outcomes
Classification of Myelopathy
Nurick Classification
Grade 0 Root symptoms only or normal
Grade 1 Signs of cord compression; normal gait
Grade 2 Gait difficulties but fully employed
Grade 3 Gait difficulties prevent employment, walks unassisted
Grade 4 Unable to walk without assistance
Grade 5 Wheelchair or bedbound
Based on gait and ambulatory function 
Ranawat Classification
Class I Pain, no neurologic deficit
Class II Subjective weakness, hyperreflexia, dyssthesias
Class IIIA Objective weakness, long tract signs, ambulatory
Class IIIB Objective weakness, long tract signs, non-ambulatory
Japanese Orthopaedic Association Classification
  • A point scoring system (17 total) based on function in the following categories 
    • upper extremity motor function
    • lower extremity motor function
    • sensory function
    • bladder function
Presentation of Myelopathy
  • Symptoms 
    • neck pain and stiffness
      • axial neck pain (often times absent)
      • occipital headache common
    • extremity paresthesias
      • diffuse nondermatomal numbness and tingling
    • weakness and clumsiness
      • weakness and decreased manual dexterity (dropping object, difficulty manipulating fine objects)   
    • gait instability  
      • patient feels "unstable" on feet
      • weakness walking up and down stairs
      • gait changes are most important clinical predictor
    • urinary retention
      • rare and only appear late in disease progression
      • not very useful in diagnosis due to high prevalence of urinary conditions in this patient population
  • Physical exam
    • motor 
      • weakness
        • usually difficult to detect on physical exam
        • lower extremity weakness is a more concerning finding
      • finger escape sign
        • when patient holds fingers extended and adducted, the small finger spontaneously abducts due to weakness of intrinsic muscle
      • grip and release test
        • normally a patient can make a fist and release 20 times in 10 seconds. myelopathic patients may struggle to do this
    • sensory 
      • proprioception dysfunction
        • due to dorsal column involvement 
        • occurs in advanced disease
        • associated with a poor prognosis
      • decreased pain sensation
        • pinprick testing should be done to look for global decrease in sensation or dermatomal changes
        • due to involvement of lateral spinothalamic tract 
      • vibratory changes are usually only found in severe case of long-standing myelopathy
    • upper motor neuron signs (spasticity) 
      • hyperreflexia
        • may be absent when there is concomitant peripheral nerve disease (cervical or lumbar nerve root compression, spinal stenosis, diabetes)
      • inverted radial reflex
        • tapping distal brachioradialis tendon produces ipsilateral finger flexion
      • Hoffmann's sign  
        • snapping patients distal phalanx of middle finger leads to spontaneous flexion of other fingers
      • sustained clonus post
        • > three beats defined as sustained clonus
        • sustained clonus has poor sensitivity (~13%) but high specificity (~100%) for cervical myelopathy
      • Babinski test post
        • considered positive with extension of great toe
    • gait and balance
      • toe-to-heel walk
        • patient has difficulty performing
      • Romberg test 
        • patient stands with arms held forward and eyes closed
        • loss of balance consistent with posterior column dysfunction
    • provocative tests
      • Lhermitte Sign 
        • test is positive when extreme cervical flexion leads to electric shock-like sensations that radiate down the spine and into the extremities
  • Radiographs
    • recommended views
      • cervical AP, lateral, oblique, flexion, and extension views
    • general findings
      • degenerative changes of uncovertebral and facet joints
      • osteophyte formation
      • disc space narrowing
      • decreased sagittal diameter
        • cord compression occurs with canal diameter is < 13mm
    • lateral radiograph
      • important to look for diameter of spinal canal
        • a Pavlov ratio of less than 0.8 suggest a congenitally narrow spinal canal predisposing to stenosis and cord compression
      • sagittal alignment
        • C2 to C7 alignment  
          • determined by tangential lines on the posterior edge of the C2 and C7 body on lateral radiographs in neutral position
        • local kyphosis angle  
          • the angle between the lines drawn at the posterior margin of most cranial and caudal vertebral bodies forming the maximum local kyphosis
    • oblique radiograph
      • important to look for foraminal stenosis which often caused by uncovertebral joint arthrosis
    • flexion and extension views
      • important to look for angular or translational instability
      • look for compensatory subluxation above or below the spondylotic/stiff segment
    • sensitivity/specificity
      • changes often do not correlate with symptoms
        • 70% of patients by 70 yrs of age will have degenerative changes seen on plain xrays
  • MRI
    • indications
      • MRI is study of choice to evaluate degree of spinal cord and nerve root compression 
    • findings
      • effacement of CSF indicates functional stenosis
      • spinal cord signal changes 
        • seen as bright signal on T2 images (myelomalacia)  
        • signal changes on T1-weighted images correlate with a poorer prognosis following surgical decompression
      • compression ratio of < 0.4 carries poor prognosis 
        • CR = smallest AP diameter of cord / largest transverse diameter of cord
    • sensitivity/specificity
      • has high rate of false positive (28% greater than 40 will have findings of HNP or foraminal stenosis)
  • CT without contrast
    • can provide complementary information with an MRI, and is more useful to evaluate OPLL and osteophytes
  • CT myelography
    • more invasive than an MRI but gives excellent information regarding degrees of spinal cord compression
    • useful in patients that cannot have an MRI (pacemaker), or have artifact (local hardware)
    • contrast given via C1-C2 puncture and allowed to diffuse caudally, or given via a lumbar puncture and allowed to diffuse proximally by putting patient in trendelenburg position.
  • Nerve conduction studies
    • high false negative rate
    • may be useful to distinguish peripheral from central process (ALS)
  • Normal aging
    • mild symptoms of myelopathy often confused with a "normal aging" process
  • Stroke
  • Movement disorders
  • Vitamin B12 deficiency
  • Amyotrophic lateral sclerosis (ALS) 
  • Multiple sclerosis
  • Nonoperative
    • observation, NSAIDs, therapy, and lifestyle modifications
      • indications
        • mild disease with no functional impairment
          • function is a more important determinant for surgery than physical exam finding 
        • patients who are poor candidates for surgery
      • modalities
        • medications (NSAIDS, gabapentin)
        • immobilization (hard collar in slight flexion)
        • physical therapy for neck strengthening, balance, and gait training
        • traction and chiropractic modalities are not likely to benefit and do have some risks
        • be sure to watch patients carefully for progression
      • outcomes
        • improved nonoperative outcomes associated with patients with larger transverse area of the spinal cord (>70mm2) 
        • some studies have shown improvement with immobilization in patients with very mild symptoms
  • Operative 
    • surgical decompression, restoration of lordosis, stabilization 
      • indications
        • significant functional impairment AND
        • 1-2 level disease
        • lordotic, neutral or kyphotic alignment
      • techniques
        • appropriate procedure depends on
          • cervical alignment
          • number of stenotic levels
          • location of compression
          • medical conditions (e.g., goiter)
        • treatment procedures include (see below)
          • anterior cervical diskectomy/corpectomy and fusion
          • posterior laminectomy and fusion 
          • posterior laminoplasty
          • combined anterior and posterior procedure 
          • cervical disk arthroplasty 
      • outcomes
        • prospective studies show improvement in overall pain, function, and neurologic symptoms with operative treatment
        • early recognition and treatment prior to spinal cord damage is critical for good clinical outcomes
  • Goals
    • optimal surgical treatment depends on the individual. Things to consider include 
      • number of stenotic levels
      • sagittal alignment of the spine
      • degree of existing motion and desire to maintain
      • medical comorbidities (eg, dysphasia)
        • simplified treatment algorithm  
  • Anterior Decompression and Fusion (ACDF) alone
    • indications
      • mainstay of treatment in most patients with single or two level disease 
      • fixed cervical kyphosis of > 10 degrees  
        • anterior procedure can correct kyphosis
      • compression arising from 2 or fewer disc segments 
      • pathology is anterior (OPLL, soft discs, disc osteophyte complexes)
    • approach 
      • uses Smith-Robinson anterior approach  
    • decompression
      • corpectomy and strut graft may be required for multilevel spondylosis
        • two level corpectomies tend to be biomechanically vulnerable (preferable to combine single level corpectomy with adjacent level diskectomy)
        • 7% to 20% rates of graft dislodgement with cervical corpectomy with associated severe complications, including death, reported.
    • fixation
      • anterior plating functions to increase fusion rates and preserve position of interbody cage or strut graft
    • pros & cons
      • advantages compared to posterior approach
        • lower infection rate
        • less blood loss
        • less postoperative pain
      • disadvantages 
        • avoid in patients with poor swallowing function
  • Laminectomy with posterior fusion 
    • indications
      • multilevel compression with kyphosis of < 10 degrees
        • > 13 degrees of fixed kyphosis is a contraindication for a posterior procedure  
      • in flexible kyphotic spine, posterior decompression and fusion may be indicated if kyphotic deformity can be corrected prior to instrumentation
    • contraindications
      • fixed kyphosis of > 10 degrees is a contraindication to posterior decompression
      •  will not adequately decompress spinal cord as it is "bowstringing" anterior  
    • pros & cons
      • fusion may improve neck pain associated with degenerative facets
      • not effective in patients with > 10 degrees fixed kyphosis
  • Laminoplasty
    • indications
      • gaining in popularity
      • useful when maintaining motion is desired
      • avoids complications of fusion so may be indicated in patients at high risk of pseudoarthrosis
    • contraindications  
      • cervical kyphosis 
        • > 13 degrees is a contraindication to posterior decompression  
        •   will not adequately decompress spinal cord as it is "bowstringing" anterior
      • severe axial neck pain
        • is a relative contraindication and these patients should be fused
    • technique
      • volume of canal is expanded by hinged-door laminoplasty followed by fusion  
        • usually performed from C3 to C7
      • open door technique
        • hinge created unilateral at junction of lateral mass and lamina and opening on opposite side
        • opening held open by bone, suture anchors, or special plates
      • French door technique
        • hinge created bilaterally and opening created midline
    • pros & cons
      • advantages
        • allows for decompression of multilevel stenotic myelopathy without compromising stability and motion (avoids postlaminectomy kyphosis)
        • lower complication rate than multilevel anterior decompression
          • especially in patients with OPLL
        • a motion-preserving technique
          • pseudoarthrosis not a concern in patients with poor healing potential (diabetes, chronic steroid users)
        • can be combined with a subsequent anterior procedure
      • disadvantages
        • higher average blood loss than anterior procedures 
        • postoperative neck pain
        • still associated with loss of motion
    • outcomes
      • equivalent to multilevel anterior decompression and fusion 
  • Combined anterior and posterior surgery
    • indications
      • multilevel stenosis in the rigid kyphotic spine
      • multi-level anterior cervical corpectomies 
      • postlaminectomy kyphosis
  • Laminectomy alone 
    • indications
      • rarely indicated due to risk of post laminectomy kyphosis   
    • pros & cons
      • progressive kyphosis
        • 11 to 47% incidence if laminectomy performed alone without fusion
  • Surgical Infection
    • higher rate of surgical infection with posterior approach than anterior approach
  • Pseudoarthrosis
    • incidence
      • 12% for single level fusions, 30% for multilevel fusions
    • treatment
      • treat with either posterior wiring or plating or repeat anterior decompression and plating if patient has symptoms of radiculopathy
  • Postoperative C5 palsy 
    • incidence   
      • reported to occur in ~ 4.6% of patients after surgery for cervical compression myelopathy 
      • no significant differences between patients undergoing anterior decompression and fusion and posterior laminoplasty
      • occurs immediately postop to weeks following surgery
    • mechanism
      • mechanism is controversial
      • in laminectomy patients, it is thought to be caused by tethering of nerve root with dorsal migration of spinal cord following removal of posterior elements
    • prognosis
      • patients with postoperative C5 palsy generally have a good prognosis for functional recovery, but recovery takes time
  • Recurrent laryngeal nerve injury
    • approach
      • in the past it has been postulated that the RLN is more vulnerable to injury on the right due to a more aberrant pathway
        • recent studies have shown there is not an increased injury rate with a right sided approach
    • treatment
      • if you have a postoperative RLN palsy, watch over time
      • if not improved over 6 weeks, then ENT consult to scope patient and inject teflon
      • if you are performing revision anterior cervical surgery, and there is an any suspicion of a RLN from the first operation, obtain ENT consult to establish prior injury
        • if patient has prior RLN nerve injury, perform revision surgery on the same as the prior injury/approach to prevent a bilateral RLN injury
  • Hardware failure and migration
    • 7-20% with two level anterior corpectomies
    • two-level corpectomies should be stabilized from behind
  • Postlaminectomy kyphosis
    • treat with anterior/posterior procedure 
  • Postoperative axial neck pain
  • Vertebral artery injury
  • Esophageal Injury
  • Dysphagia & alteration in speech


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Qbank (32 Questions)

(SBQ12.5) A 70-year-old presents with gait instability and difficulty buttoning his shirts which has been progressively worsening over the last several months. His physical exam is notable for exaggerated patellar reflexes and sustained clonus. The provocative maneuver shown in Figure V would most likely produce which of the following symptoms or physical exam finding?
Topic Review Topic
FIGURES: V          

1. Electric shock-like sensations that radiate down the spine and into the extremities
2. Involuntary contraction of the thumb IP joint
3. Spontaneously abduction of the 5th digit
4. Spontaneously extension of the great toe
5. Unilateral arm pain and paresthesias in a dermatomal distribution

(SBQ12.16) A 50-year-old female presents with 3 years of increasing clumsiness in her hands that has progressed to the point that it is now difficult to open jars and use her keys. On physical exam she is unable to perform a tandem gait, has positive Hoffman’s signs bilaterally, and has 3+ patellar reflexes. She has 5/5 strength in all her major muscle groups. Figure A is her mid sagittal MRI. Figure B, C and D are axial images at C4/5, C5/6 and C6/7 respectively. What is the most appropriate treatment? Topic Review Topic
FIGURES: A   B   C   D    

1. Physical therapy and close observation
2. Physical therapy, an epidural steroid injection and evaluation after the injection
3. C5/6 and C6/7 Anterior Cervical Discectomy and Fusion
4. C5, C6 and C7 posterior laminectomy
5. Posterior C6 and C7 foraminotomies

(SBQ09.3) Figures A-E show the neutral lateral cervical radiographs and corresponding T2-weighted MRI of 5 patients with symptoms and physical exam findings consistent with cervical myelopathy. In which of these patients would a cervical laminoplasty alone be contraindicated as surgical treatment? Topic Review Topic
FIGURES: A   B   C   D   E  

1. Figure A
2. Figure B
3. Figure C
4. Figure D
5. Figure E

(OBQ13.181) An 80-year-old man complains of neck pain and worsening upper extremity weakness after striking his forehead during a fall. For the last 2 years, he has been using a walker because of frequent falls, and no longer wears dress shirts because of difficulty with buttons. Examination reveals a positive finger-escape sign, and he is unable to make a fist and release 10 times in 10 seconds. Distal lower extremity muscle groups are stronger than proximal muscle groups. There is no instability on flexion-extension radiographs. An MRI image is shown in Figure A. Which of the following is the most appropriate treatment of the options listed? Topic Review Topic
FIGURES: A          

1. Gait training
2. MRI of the lumbar spine
3. C4 corpectomy and instrumented fusion
4. C4 and C5 corpectomy and anterior instrumented fusion
5. Laminoplasty

(OBQ12.174) A 47-year old female with Type-2 diabetes and a pacemaker presents with bilateral buttock and leg pain that is worse with prolonged walking and improves with sitting. Her lower extremity symptoms are severe enough that she reports she feels "unstable" on her feet. Physical exam shows 5/5 strength in all muscles groups in the lower extremity. Figure V shows a result of forced ankle dorsiflexion on physical exam. A lumbar myelogram is performed and shown in Figure A, B, and C. What is the most appropriate next step in treatment. Topic Review Topic
FIGURES: V A   B   C      

1. Lumbar decompression
2. Lumbar decompression with arthrodesis
3. A trial of physical therapy and NSAIDS
4. Lumbar epidural steroid injections
5. CT myelogram of cervical spine

(OBQ12.247) A 51-year-old presents for evaluation of clumsiness of her hands. She complaints of difficulty with buttoning her shirt. On physical exam she is unable to preform a tandem gait. The strength in her upper extremities proximally is graded a 4/5, but she has significant bilateral intrinsic hand weakness and a positive Hoffmann's sign. When told to hold her fingers in an extended and adducted position, her ring and small fingers flex and abduct within 20 seconds. What is the most appropriate next step in management? Topic Review Topic

1. Reassurance and period of observation
2. Night splinting in cock-up wrist splints
3. Carpal tunnel corticosteroid injection
4. Electromyographic studies of the upper extremities
5. Cervical Spine MRI

(OBQ11.209) A 56-year-old woman presents for initial evaluation of her neck pain which has been worsened by activity for the last several years. On exam, she has 5/5 motor strength throughout bilateral upper and lower extremities. She has a normal gait and no difficulties with manual dexterity. Reflex testing shows hyperreflexia in bilateral Achilles tendons. Lateral radiographs are shown in Figure A, and MRI scan is shown in Figures B and C. What is the most appropriate management? Topic Review Topic
FIGURES: A   B   C      

1. C4-7 anterior decompression with instrumented fusion
2. C4-7 posterior decompression with instrumented fusion
3. C4-7 posterior decompression without fusion
4. C5/6 anterior discectomy and fusion
5. Physical therapy

(OBQ11.251) A 68-year-old female presents with progressive loss of ability to ambulate and dexterity problems with her hands. Six months ago she was able to walk with a cane, but now has difficulty with ambulating with a walker. She also reports difficulty with her hands and needs assistance with eating. Physical exam shows limited neck extension. Radiographs, tomography, and magnetic-resonance-imaging are shown in Figure A, B, and C respectively. What is the most appropriate treatment? Topic Review Topic
FIGURES: A   B   C      

1. NSAIDS, physical therapy, and clinical observation
2. C3 to C6 cervical laminectomy
3. C3 to C6 laminoplasty using an open-door technique
4. C3 to C6 decompressive laminectomy with instrumented fusion
5. Multilevel anterior cervical decompression with strut grafting and anterior plate fixation, followed by posterior decompression and fusion

(OBQ10.163) Which of the following variables has the strongest association with poor clinical outcomes in patients who undergo expansive laminoplasty for cervical spondylotic myelopathy? Topic Review Topic

1. Multi-level stenosis
2. Duration of symptoms
3. Local kyphosis angle > 13 degrees
4. Osteoporosis
5. MRI finding of CSF effacement

(OBQ09.253) All of the following clinical signs are characteristic of an upper motor neuron disorder EXCEPT Topic Review Topic

1. Fasciculations
2. Spasticity
3. Muscle weakness
4. Exaggerated deep tendon reflexes
5. Sustained clonus

(OBQ08.106) Following a C3-C7 laminoplasty in a myelopathic patient with cervical stenosis, the most common neurologic complication would manifest with which of the following new postoperative exam findings Topic Review Topic

1. Change in voice and difficulty swallowing
2. Triceps weakness
3. Deviation of the tongue
4. Ptosis, miosis, anhydrosis
5. Biceps weakness

(OBQ08.131) A 56-year-old male presents with gait imbalance and decreased manual dexterity. Sagittal T2 MRI images are shown in Figures A and B. What is the most appropriate surgical management? Topic Review Topic
FIGURES: A   B        

1. Posterior foraminotomy
2. Anterior decompression and fusion
3. Laminectomy alone
4. Laminectomy and fusion
5. Hinge-door laminoplasty

(OBQ07.45) A 67-year-old woman presents with low back pain and bilateral buttock and leg pain. She prefers to stoop over the shopping cart whenever shopping. She recently noticed difficulty picking up small objects and buttoning her shirt. Physical exam shows normal strength in her lower extremities, and 3+ bilateral patellar reflexes. Gait examination shows a broad, unsteady gait. Flexion and extension radiographs of the lumbar spine are shown in Figure A and B. A lumbar MRI is shown in Figure C. What is the most appropriate next step in management? Topic Review Topic
FIGURES: A   B   C      

1. Lumbar decompression only
2. Lumbar decompression and instrumented fusion
3. Discogram
4. MRI of the cervical spine
5. Lumbar epidural injection

(OBQ07.180) A 63-year-old female presents with a broad-based shuffling gait, loss of manual dexterity, and exaggerated deep tendon reflexes in the lower extremities. A T2-weighted MRI scan is shown in Figure A. What is the most appropriate treatment? Topic Review Topic
FIGURES: A          

1. C4 to C7 cervical laminectomy
2. C4 to C7 cervical laminectomy with fusion
3. C4 to C7 laminoplasty with plate fixation
4. Multilevel anterior cervical decompression with fusion and stabilization
5. Immobilization in a halo orthosis for 6 weeks followed by gradual ROM exercises

(OBQ07.189) In patients with symptoms of cervical myelopathy, what variable is associated with improved outcomes with nonoperative management? Topic Review Topic

1. Increased Central Motor Conduction Time (CMCT)
2. Transverse area of the spinal cord >70mm2
3. Isolated low intramedullary signal on T1WI
4. A midsagittal diameter of the spinal canal of <13mm
5. Younger age

(OBQ05.92) Postoperative radiculopathy is a known complication of posterior cervical decompression for myelopathy. One potential mechanism of nerve root injury is thought to be tethering of the nerve root with dorsal migration of the spinal cord. What is the most common radicular pattern seen with this condition? Topic Review Topic

1. Motor-dominant radiculopathy with weakness of the deltoid
2. Sensory-dominant radiculopathy with pain in the lateral shoulder
3. Motor-dominant radiculopathy with weakness of the wrist extensors
4. Sensory-dominant radiculopathy with pain in the lateral forearm
5. Motor-dominant radiculopathy with weakness of the triceps

(OBQ05.212) Which classification system for cervical myelopathy focuses exclusively on lower extremity function? Topic Review Topic

1. Nurick
2. Japanese Orthopaedic Association
3. Modified Japanese Orthopaedic Association
4. Ranawat
5. Oswestry

(OBQ04.61) A 66-year-old male presents with neck pain, difficulty with fine motor activities like buttoning shirts, and mild gait instability. On physical examination he has 5 of 5 motor strength in all muscles groups in his upper and lower extremities, a bilateral Hoffman sign, bilateral 3+ patellar reflexes, 3 beats of clonus on the right, and no clonus on the left. Radiographs show segmental kyphosis of 12 degrees from C4 to C7. MRI shows circumferential compression at C5/6 with complete effacement of CSF and T2 intramedullary signal. What is the most accurate description of how his symptoms will progress over time? Topic Review Topic

1. Stable over time.
2. Improvement following a course of high-dose IV spinal steroids.
3. Improvement following a period of rest, physical therapy, and oral medication.
4. Slow progression in a pattern of stepwise deterioration following periods of stable symptoms.
5. Rapid and serious deterioration requiring urgent surgical treatment.

(OBQ04.205) A 35-year-old man complains of clumsiness when buttoning his shirt and frequent episodes of falling when ambulating. Further work-up reveals congenital cervical spinal stenosis with spinal cord compression. Because of his young age, posterior laminoplasty is performed. Which nerve root is most likely to be adversely affected following surgery? Topic Review Topic

1. C2
2. C3
3. C4
4. C5
5. C6

(OBQ04.207) A 45-year-old man presents to your office with difficulty ambulating and buttoning his shirt. It started two years ago but has worsened significantly over the last year. On physical exam he is unable to perform a tandem gait and has a positive Hoffman's sign bilaterally, however he has no clonus and a down-going babinski bilaterally. He has 4/5 strength in his hands, but 5/5 strength in all other muscle groups. Figure A is a sagittal MRI. Figures B and C are an axial MRI cuts through C4/5 and C5/6, respectively. What is the appropriate next step? Topic Review Topic
FIGURES: A   B   C      

1. Observation
2. Epidural injection
3. Physical therapy and anti-inflammatory medication
4. Anterior cervical diskectomy and fusion
5. Posterior cervical laminotomy-foraminotomy

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