Do I Need Neck Surgery? A Simple Guide for Patients

Introduction 

If an MRI shows pressure on your spinal cord in your neck (called cervical spinal cord compression or stenosis) but you don’t have symptoms like weakness or numbness, it can be confusing and scary. You might worry about needing surgery right away to avoid serious problems like paralysis. However, surgery is usually not needed unless specific issues arise. This article explains when surgery might be necessary and why a cautious, non-surgical approach is often the best choice.

The Challenge of Asymptomatic Compression 

Sometimes, an MRI done for something else, like neck pain or a head injury, shows significant pressure on your spinal cord, even though you feel fine. Doctors might warn you about the risk of paralysis, which can be frightening. However, most people with this condition don’t need urgent surgery. The key is understanding when surgery is truly necessary and when it’s safe to monitor the condition instead.

What Are the Risks of Not Having Surgery? 

The main concern with pressure on your spinal cord is the chance of developing myelopathy (a condition where the spinal cord is damaged, causing symptoms like hand numbness, trouble walking, or weakness) or a spinal cord injury and paralysis, especially after an accident. Here’s what studies tell us:

• A study from Czechoslovakia followed 66 people with spinal cord compression but no symptoms:

  • After 1 year, 8% developed myelopathy.

  • After about 3.5 years, about 23% developed myelopathy.

• A Japanese study found that people with narrowed spinal canals (stenosis) have a higher risk of spinal cord injury after trauma, but the actual chance of this happening is very low Only about 0.017% of patients with cervical stenosis avoid spinal cord injury if they have prophylactic surgery. A surgeon would have to operate on ~60,000 patients to prevent one from spinal cord injury and paralysis. This means the risk of sudden paralysis is extremely small, and surgery is usually only needed if you start showing clear signs of myelopathy, like worsening weakness or numbness.

  
  

Does Surgery Help?

Surgery to relieve pressure on the spinal cord (called decompression) can help people who already have myelopathy symptoms. A study showed that people with severe myelopathy improved the most after surgery, while those with mild or no symptoms didn’t see much benefit. Another study found that for people with mild myelopathy, surgery didn’t work better than non-surgical treatments (like physical therapy or pain management) over 10 years. Surgery also comes with risks, like trouble swallowing or infections, which happen in about 6-18% of cases. For people without symptoms, these risks often outweigh the benefits.

When Is Surgery Needed? 

Doctors use a tool called the modified Japanese Orthopaedic Association (mJOA) score to check for myelopathy. It looks at:

• How well you move your arms and legs.

• If you have numbness or tingling.

• Problems with bladder or bowel control.

Surgery is usually only recommended if your mJOA score shows worsening (moderate or severe) myelopathy, meaning you’re developing symptoms like difficulty walking or hand weakness.

What Do Guidelines Say? Experts from the AO Spine group recommend against surgery for people with spinal cord compression but no myelopathy symptoms. Instead, they suggest:

• Explaining the low risk of problems to ease your worries.

• Teaching you to watch for signs of myelopathy, like numbness, weakness, or trouble with balance.

• Regular checkups to monitor your condition. Surgery is only needed if myelopathy symptoms are moderate/severe or get worse.

  
  

Special Situations

1. Neck Pain and Compression: Neck pain alone isn’t a reason for surgery. If you have pain, it might be from something else, like pinched nerves. Surgery is only considered if myelopathy develops.

2. MRI Changes: If your MRI shows changes in your spinal cord (like swelling), it’s concerning but doesn’t automatically mean surgery. Doctors will monitor you closely.

3. Pinched Nerves (Radiculopathy): If you have nerve pain (like arm pain or tingling) along with spinal cord compression, you might try treatments like steroid injections first. Surgery may be needed if symptoms don’t improve, or myelopathy worsens.

4. Other Spine Surgery: If you’re having surgery on another part of your spine (like your lower back), doctors will take extra care to protect your neck during the procedure and monitor your spinal cord, but they won’t operate on your neck unless myelopathy is worsening.

   
   

A Practical Plan for You Here’s a simple approach if you have spinal cord compression but no or mild symptoms:

1. Get a Thorough Checkup: Your doctor will do a detailed exam to look for signs of myelopathy.

2. Learn About Your Condition: Understand that the risk of sudden paralysis after an accident is very low (0.017%). Watch for signs like hand numbness, trouble walking, or weakness.

3. Regular Monitoring: Visit your doctor every 6–12 months for checkups, including mJOA score tests to catch any changes early.

4. Avoid High-Risk Activities: Stay away from activities like contact sports that could worsen the compression.

5. Make Decisions Together: Talk openly with your doctor to avoid unnecessary fear and focus on what’s best for you.

If you have mild symptoms or nerve pain, treatments like physical therapy or injections might help, especially for older patients. Surgery is only considered if symptoms get worse.

Conclusion 

If your MRI shows pressure on your spinal cord but you don’t have symptoms like weakness or numbness, you likely don’t need surgery. Studies and guidelines support a cautious approach with regular checkups and patient education. Surgery is only necessary if you develop clear signs of myelopathy. If a doctor says you need surgery to prevent paralysis, but you feel fine, consider getting a second or third opinion to make sure it’s the right choice for you.