A 54-year-old computer programmer presents with 4 months of progressive neck pain radiating into the left arm (C6 dermatome) with paresthesias and weakness in wrist extension. He reports difficulty buttoning shirts and an unsteady gait over the past 6 weeks. Examination reveals lower-limb hyperreflexia, bilateral upgoing plantars, positive Hoffmann's sign, and positive Lhermitte's sign. MRI cervical spine shows a large left paracentral posterior disc herniation at C5-C6 with focal T2 hyperintensity within the cord (myelomalacia). The structure marked **A** in the diagram is compressing the ventrolateral cord by approximately 40% of canal diameter. Which of the following is the most appropriate management for this patient?
A. Cervical disc arthroplasty to preserve motion and avoid adjacent segment disease
B. Posterior laminoplasty with fusion for decompression of multilevel posterior compression
C. Anterior cervical discectomy and fusion (ACDF) via Smith-Robinson approach with microdiscectomy and interbody cage fixation
D. Cervical collar, NSAIDs, gabapentinoids, and structured physical therapy with selective nerve root block for symptom relief
Explanation
Why Anterior Cervical Discectomy and Fusion (ACDF) is correct
The presence of cord compression with myelopathic signs (lower-limb hyperreflexia, upgoing plantars, Hoffmann's sign, Lhermitte's sign, gait disturbance) combined with T2 hyperintensity (cord edema/myelomalacia) indicates progressive myelopathy, which is a surgical emergency. According to Maheshwari Essential Orthopaedics 7e, ACDF via the Smith-Robinson approach is the gold standard for single or two-level anterior cord compression. The procedure directly removes the herniated disc material (marked A) and osteophytes, decompresses both the canal and foramina, restores cervical lordosis, and provides immediate stabilization with interbody cage and anterior plate fixation. Non-operative outcomes in myelopathy are universally poor, and neurologic deficits become irreversible without surgical intervention. ACDF achieves 90% arm pain relief and 95% fusion rates.
Why each distractor is wrong
Conservative therapy with NSAIDs and nerve root block: While appropriate for isolated radiculopathy without myelopathy, this patient has clear myelopathic signs (hyperreflexia, clonus, upgoing plantars, gait disturbance, cord edema on MRI). Conservative management in myelopathy leads to irreversible neurologic deterioration and is contraindicated.
Cervical disc arthroplasty: This motion-preserving procedure is reserved for younger patients with non-myelopathic radiculopathy to prevent adjacent segment disease. This patient has established myelopathy with cord signal changes, making ACDF with fusion the appropriate choice to provide immediate rigid stabilization and prevent further cord damage.
Posterior laminoplasty with fusion: This approach is indicated for multilevel posterior compression in a lordotic spine. The pathology here is anterior (paracentral posterior disc herniation at a single level, C5-C6), making the anterior approach more direct and effective. Posterior laminoplasty would not directly address the compressing disc material.
High-YieldNEET PG
Myelopathy (not isolated radiculopathy) is the surgical indication for cervical disc herniation; ACDF is gold standard for anterior single/two-level compression; cord signal change (T2 hyperintensity) is a poor prognostic marker requiring urgent decompression.
Maheshwari Essential Orthopaedics 7e — Cervical Myeloradiculopathy, Surgical Management
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