Spondylotic degeneration of the cervical spine is associated with ageing and is often asymptomatic,1 but 10-15% of people with the condition might develop symptoms of compression of the nerve roots (radiculopathy) or spinal cord (myelopathy).2 Many factors have been implicated in the tendency to develop radiculopathy or myelopathy, including advanced age, disability at presentation, cord diameter, cord area, altered cord signal on magnetic resonance imaging (T2 and T1 weighted images),3 increased cervical spinal mobility,4 5 and the presence of a congenitally narrow spinal canal. These factors might also influence any improvement with an operation, either positively—factors such as increased cervical mobility—or negatively, as a result of advanced age or a congenitally narrow spinal canal.

The natural course of symptomatic cervical degenerative disease is unclear, mainly because no good quality, prospective cohort studies of untreated patients have been conducted. However, the available observational data show that progressive disability is not inevitable, that symptoms might remain static, and patients with apparent disability might improve without surgery.6 7 8 9 Patients with radicular symptoms do not necessarily progress to develop overt myelopathy, and in one study at five years, 75% had improved spontaneously.10 A small randomised controlled trial also found that outcomes after surgery might be similar to those of conservative management.11 Possible complications of surgery include oesophageal perforation, carotid or vertebral artery injury, and permanent damage to nerve roots.12 Damage to the spinal cord might carry a risk of paraplegia.