Degenerative cervical myelopathy (DCM) is the most common cause of spinal cord dysfunction in adults worldwide and results from progressive compression of the cervical spinal cord secondary to degenerative changes such as intervertebral disc degeneration, osteophyte formation, hypertrophy of the ligamentum flavum, and facet joint arthropathy ^[1,2]. Patients commonly present with gait instability, hand clumsiness, upper limb weakness, paresthesia, and upper motor neuron signs, leading to progressive functional impairment if left untreated ^[2,3].

Magnetic resonance imaging (MRI) is the gold standard for diagnosing DCM because it accurately demonstrates the level and severity of spinal cord compression, associated intramedullary signal changes, and other pathological abnormalities that guide surgical planning ^[1,3]. Surgical decompression is recommended for patients with moderate-to-severe or progressive myelopathy, as it prevents further neurological deterioration and improves long-term functional outcomes ^[1].

Posterior cervical decompression and fusion (PCDF) is an established surgical option for patients with multilevel cervical spondylotic myelopathy, particularly in the presence of preserved cervical lordosis. It provides effective decompression of the spinal cord while maintaining cervical stability through instrumented fusion ^[4,5]. Although neurological recovery after surgery is generally favorable, post-operative C5 nerve root palsy remains a recognized complication that requires early identification and appropriate rehabilitation ^[6,7].

We present a case of multilevel cervical spondylotic myelopathy managed with PCDF, highlighting the clinical presentation, radiological findings, surgical management, post-operative C5 palsy, and functional recovery in the context of current literature ^[8].

A 66-year-old female presented with a 5-month history of progressive gait instability, recurrent falls, bilateral hand paresthesia, and right upper limb weakness. She also complained of difficulty with fine motor activities, including buttoning clothes and writing. There was no history of trauma or bowel and bladder dysfunction. Her medical history was significant for hypertension, type 2 diabetes mellitus, and hypothyroidism.

On neurological examination, the patient had a spastic gait, grade 4/5 power in the right upper limb, hyperreflexia in both upper and lower limbs, bilateral Hoffmann’s sign, and extensor plantar responses, consistent with cervical myelopathy.

Laboratory investigations revealed the following:

• Hemoglobin: 10.5 g/dL
• Erythrocyte sedimentation rate: 150 mm/h
• Hemoglobin A1c: 7.1%
• Thyroid-stimulating hormone: 6.33 μIU/mL.

MRI of the cervical spine demonstrated severe spinal canal stenosis and spinal cord compression at the C5–C6 level, with focal intramedullary T2 hyperintensity suggestive of chronic compressive myelopathy (Fig. 1).

Axial T2-weighted imaging at the same level demonstrated a posterior disc-osteophyte complex causing severe central canal stenosis with marked flattening of the spinal cord and near-complete effacement of the surrounding cerebrospinal fluid space (Fig. 2).

Based on the clinical and radiological findings, a diagnosis of DCM secondary to cervical spondylosis was established. After medical optimization, the patient underwent PCDF from C3 to C7 using lateral mass screw-and-rod fixation.

Post-operative radiographs demonstrated satisfactory placement of the instrumentation with maintained cervical alignment and a stable posterior fusion construct (Fig. 3).

During the post-operative period, the patient developed weakness of shoulder abduction and elbow flexion, consistent with C5 nerve root palsy. She was managed conservatively with physiotherapy and rehabilitation.

The surgical wound healed uneventfully without evidence of infection (Fig. 4).

Clinical photograph demonstrating a well-healed posterior cervical surgical incision without evidence of wound infection, dehiscence, or implant-related complications during follow-up.

At subsequent follow-up, the patient demonstrated gradual improvement in gait, upper limb strength, and hand function with continued physiotherapy.

DCM is the most common cause of spinal cord dysfunction in adults and results from progressive compression of the cervical spinal cord due to degenerative changes such as intervertebral disc degeneration, osteophyte formation, facet joint arthropathy, and hypertrophy of the ligamentum flavum. The natural history of DCM is characterized by gradual neurological deterioration, making early diagnosis and timely surgical intervention essential to prevent irreversible spinal cord injury and functional disability ^[1,2].

Our patient presented with progressive gait instability, bilateral hand paresthesia, and upper limb weakness, which are characteristic clinical manifestations of DCM. MRI demonstrated severe spinal cord compression at the C5–C6 level with intramedullary T2 hyperintensity, indicating chronic cord injury. These findings align with previous studies by Kalsi-Ryan et al. and Badhiwala et al., who emphasized that MRI is the imaging modality of choice for confirming the diagnosis, assessing the severity of cord compression, and guiding surgical management ^[2,3].

The patient underwent PCDF, which is an established surgical procedure for multilevel cervical spondylotic myelopathy, particularly in patients with preserved cervical alignment. Posterior decompression effectively relieves spinal cord compression, while instrumented fusion provides immediate stability, maintains cervical alignment, and reduces the risk of post-operative deformity. Edwards et al. reported that appropriate patient selection and surgical planning are critical determinants of successful neurological recovery following posterior cervical surgery ^[4]. Similarly, Hirabayashi and Satomi demonstrated favorable long-term neurological improvement following posterior decompression procedures in patients with multilevel cervical myelopathy ^[5].

A recognized complication following posterior cervical decompression is post-operative C5 nerve root palsy, which typically presents with weakness of shoulder abduction and elbow flexion. The reported incidence ranges from approximately 5% to 10%, although rates vary depending on the surgical technique and patient characteristics ^[6,7]. The exact pathophysiology remains uncertain, with proposed mechanisms including posterior migration of the spinal cord following decompression, traction injury to the C5 nerve root, reperfusion injury, and pre-existing foraminal stenosis ^[6,7]. In the present case, the patient developed post-operative C5 palsy but showed gradual neurological improvement with conservative management, including physiotherapy and structured rehabilitation, without requiring revision surgery.

Overall, this case highlights the importance of correlating clinical findings with MRI. These findings agree with current evidence supporting surgical decompression as the standard of care for patients with progressive DCM ^[1,4,8]. Recent studies have also demonstrated favorable neurological recovery in patients with post-operative C5 palsy managed with structured rehabilitation and close follow-up ^[9,10].

DCM is a progressive neurological disorder in which early diagnosis and timely surgical intervention are essential to prevent irreversible spinal cord injury and improve functional outcomes. This case demonstrates that PCDF is an effective treatment for multilevel cervical spondylotic myelopathy, providing adequate spinal cord decompression and stable fixation. Although post-operative C5 nerve root palsy remains a recognized complication, prompt diagnosis, appropriate rehabilitation, and close follow-up can result in satisfactory neurological recovery.

Careful patient selection, meticulous surgical technique, and early recognition of complications such as C5 nerve root palsy are critical for achieving favorable neurological and functional outcomes.

Post-operative C5 palsy remains a recognized complication after PCDF, even when surgery is technically satisfactory. Anticipation of this complication, meticulous surgical planning, early identification of post-operative deltoid and biceps weakness, exclusion of structural causes, and timely rehabilitation are critical for favorable neurological and functional outcomes.