Alternatively, the caudal vertebral body superior articulating process (SAP) contributes to lateral recess and foraminal stenosis (see the image below). Indeed, facet hypertrophy between L4 and L5 vertebrae may impinge the L4 nerve root in the foramen and the L5 proximal nerve root sheath in the lateral recess. The 2 lower motion segments (L3-L4, L4-L5) are most commonly affected by degenerative stenosis. These segments are in a transition zone from the rigid sacrum to the mobile lumbar spine. In addition, the posterior joints in this area have less of a sagittal orientation, which affords more rotation and are therefore more vulnerable to rotatory strains.
The patient's clinical picture is consistent with cervical spondylosis. Minimal symptoms without hard evidence of gait disturbance or pathologic reflexes warrant nonoperative treatment, making physical therapy the correct answer.
Cervical spondylosis is a process that results in disc degeneration and facet arthropathy. Clinical manifestations may range from axial neck pain to profound muscle weakness and difficulties ambulating. It is generally agreed upon that patients with neuroradiologic evidence of spinal cord compression but no signs of myelopathy should be managed non-operatively. Initial management should consist of physical therapy, NSAIDs, and a cervical collar for comfort.
Boden and McCowin et al. describe the prevalence of abnormal cervical spine MRI findings in asymptomatic patients. 19 percent of asymptomatic patients were found to have abnormal scans. The most common finding in subjects less than 40 years old was a herniated disc, while the most common finding in subjects greater than 40 years of age was foraminal stenosis.
Kadanka and Mares et al. provide a prospective, randomized study comparing conservative and operative treatment of mild and moderate forms of spondylotic cervical myelopathy. At the 3-year follow-up period, there were no significant differences between the surgical and conservative treatment groups.
Figure A shows a lateral radiograph with loss of cervical lordosis and mild degenerative changes at C5-6, C6-7. Figures B shows a sagittal MRI with mild stenosis and loss of cervical lordosis. Figure C shows the axial MRI with left-sided foraminal stenosis at C5-6.
Answers 1-4: non-operative management is recommended in this situation.