Identifying Occult Cervical Myelopathy: A Case Report Illustrating the Diagnostic Value of Dynamic Magnetic Resonance Imaging

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J Minim Invasive Spine Surg Tech. 2026;11(1):131-136

Publication date (electronic) : 2026 April 30

doi : https://doi.org/10.21182/jmisst.2025.03076

Rajeesh George, Wern Thing Hor, Ang Chee Meng, Gamaliel Tan

Department of Orthopaedics, Ng Teng Fong General Hospital, NUHS, Singapore

Corresponding Author: Wern Thing Hor Department of Orthopaedics, Ng Teng Fong General Hospital, NUHS, Singapore Email: wernthing.hor@mohh.com.sg

Received 2025 December 15; Revised 2026 January 6; Accepted 2026 January 20.

Abstract

INTRODUCTION

Cervical canal dimensions vary with neck posture, altering the degree of spinal cord compression. Traditionally, cervical myelopathy is evaluated using static magnetic resonance imaging (MRI) obtained in a neutral neck position. However, this approach may fail to detect motion-dependent stenosis. Accurate identification of dynamic compression is particularly important when considering motion-preserving posterior decompressive strategies. We describe a patient with worsening cervical myelopathy whose clinical severity was not reflected on serial static MRIs but was clearly demonstrated using dynamic MRI.

CASE PRESENTATION

A 47-year-old right-hand–dominant woman of Indian descent presented in August 2022 with neck pain and symptoms consistent with cervical myelopathy. Her medical history included cervical spondylosis, asthma, and impaired fasting glucose. She reported paraesthesia in all fingertips, reduced fine motor dexterity, and gait unsteadiness.

Neurological examination demonstrated hyperreflexia in the left upper limb and an inverted supinator reflex on the left. Mild left upper limb weakness was noted in the C6 and C7 myotomes. Upper limb sensation was preserved, and Hoffman’s sign was negative bilaterally. No clinical spasticity was observed in the lower limbs. Gait assessment revealed mild imbalance. Her modified Japanese Orthopaedic Association (mJOA) score was 17.

MRI of the cervical spine demonstrated multilevel degenerative changes with mild spinal cord compression at C2–3 and C5–6 (Figure 1). Plain radiographs demonstrated preserved cervical lordosis without instability (Figure 2). Dynamic flexion–extension radiographs confirmed maintained sagittal alignment and absence of pathological motion (Figure 3).

Figure 1.

Sagittal (A) and axial (B) T2-weighted magnetic resonance images of the cervical spine at the C5–6 level demonstrating degenerative stenosis with equivocal spinal cord compression in the neutral neck position.

Figure 2.

Anteroposterior (A) and lateral (B) radiographs of the cervical spine demonstrating preserved cervical alignment without evidence of instability or deformity.

Figure 3.

Dynamic flexion (A) and extension (B) radiographs of the cervical spine showing maintained sagittal alignment and absence of pathological motion.

Despite conservative management, the patient’s symptoms progressed between 2022 and 2025. By October 2024, she developed new left upper limb radicular pain, bilateral positive Hoffman’s signs, and inability to perform tandem gait. Her mJOA score declined to 12, although repeat static MRI showed no significant interval change.

Given the discordance between clinical and imaging findings, extensive alternative investigations were undertaken, including neurological evaluation for stiff person syndrome, autoimmune and paraneoplastic screening, cerebrospinal fluid analysis, nerve conduction studies, and psychiatric assessment, all of which were unremarkable.

1. Imaging Findings

Dynamic MRI was performed in April 2025 under direct spine surgeon supervision to ensure symptom-reproducing yet safe positioning. A wedge-shaped cushion was placed beneath the occiput for extension and under the thoracic spine for flexion. Images were acquired in neutral and extension postures. Neutral imaging demonstrated findings similar to prior scans, whereas extension imaging revealed significant multilevel spinal canal stenosis from C3–4 to C6–7 with clear spinal cord impingement (Figure 4). Flexion imaging did not demonstrate additional clinically meaningful compression, whereas extension imaging reproduced the patient’s symptomatic posture and unmasked critical canal compromise.

Figure 4.

Dynamic cervical magnetic resonance imaging comparing flexion (A) and extension (B) postures. Flexion imaging demonstrates minimal cord compression, whereas extension imaging reveals significant multilevel spinal canal stenosis with clear spinal cord impingement from C3 to C6.

Surgical options were discussed in detail. An anterior approach was not favoured due to the multilevel nature of compression, absence of focal ventral pathology, and increased morbidity associated with multilevel anterior reconstruction. Posterior laminectomy with fusion was considered but deferred given the absence of major instability, and the desire to maintain cervical range of motion considering her age. Laminoplasty was therefore selected.

2. Treatment

In September 2025, the patient underwent C3–6 French-door laminoplasty with undercutting of the C2 lamina via a standard posterior midline approach. Hinges were created on the left, with right-sided laminar screws and lateral mass plates placed from C3 to C6. Intraoperative neuromonitoring remained stable, and blood loss was minimal. Intraoperative imaging confirmed adequate decompression with well seated implants (Figure 5).

Figure 5.

Intraoperative imaging anteroposterior (A) and lateral view (B) following C3–6 French-door laminoplasty demonstrating adequate posterior decompression and stable implant positioning.

Postoperatively, right upper limb radicular pain resolved. Motor strength and sensation were full bilaterally. The surgical drain was removed on postoperative day 3. The patient ambulated independently by postoperative day 8 and was discharged on day 21. Postoperative radiographs confirmed stable implant positioning and preserved alignment (Figure 6).

Figure 6.

Postoperative anteroposterior (A) and lateral (B) cervical spine radiographs confirming appropriate laminoplasty alignment and maintained cervical lordosis.

3. Outcome and Follow-up

At 3-month follow-up, the patient demonstrated sustained neurological improvement without recurrence of symptoms. Postoperative dynamic MRI confirmed a capacious cervical spinal canal from C3 to C6 with no residual cord compression (Figure 7).

Figure 7.

Postoperative dynamic cervical magnetic resonance imaging demonstrating a capacious cervical spinal canal in neutral (A), extension (B), and flexion (C) from C3 to C6 with adequate decompression and no residual cord compression.

DISCUSSION

Degenerative cervical myelopathy (DCM) is a progressive disorder caused by chronic spinal cord compression arising from both static and dynamic factors. Pathophysiological contributors include congenital canal narrowing, intervertebral disc degeneration, osteophyte formation, facet arthropathy, and hypertrophy or infolding of the ligamentum flavum, ultimately resulting in spinal cord ischemia and neuronal loss [1,2]. Clinically, DCM presents with hand clumsiness, gait instability, sensory disturbance, and upper motor neuron signs, with progression that may be subtle and heterogeneous.

MRI is the diagnostic gold standard for evaluating cervical myelopathy, allowing assessment of soft tissues, canal dimensions, and intramedullary signal changes that correlate with prognosis [3,4]. However, conventional MRI is routinely performed in a neutral neck position and may underestimate the severity of spinal cord compression in patients with motion-dependent pathology. This limitation becomes particularly relevant when clinical deterioration is disproportionate to static imaging findings, resulting in diagnostic uncertainty and delays in definitive management.

Dynamic MRI has emerged as a valuable adjunct for evaluating cervical spinal canal behaviour during physiological motion. Cervical extension predictably reduces canal dimensions through posterior buckling of the ligamentum flavum, increased disc protrusion, and facet joint overlap, whereas flexion typically enlarges the canal and reduces cord compression [5,6]. Muhle et al. [3] demonstrated that approximately 27% of patients with cervical spondylotic myelopathy exhibited more severe spinal cord compression in extension compared with neutral positioning. Liu et al. [5] further showed that extension MRI correlates more closely with neurological deficits than static imaging alone. Zeng et al. [7] introduced the concept of “hidden” ligamentum flavum hypertrophy, which may only become apparent on dynamic imaging and escape detection on routine neutral MRI.

In the present case, serial static MRI scans demonstrated only mild spinal cord compression despite progressive neurological deterioration over several years. This marked clinical-radiological discordance prompted extensive alternative investigations, including neurological, autoimmune, paraneoplastic, and psychiatric evaluations, all of which were unrevealing. Dynamic MRI performed under direct spine surgeon supervision ultimately revealed severe multilevel spinal canal stenosis from C3 to C6 during extension, reproducing the patient’s symptomatic posture and providing decisive diagnostic clarity. These findings directly altered clinical management by identifying a surgically remediable cause for deterioration and preventing further diagnostic delay.

Dynamic MRI should not be considered a routine investigation for all patients with cervical myelopathy, particularly in view of cost and resource considerations. Its value lies in carefully selected patients with progressive neurological symptoms that are inadequately explained by static imaging. In such cases, the incremental diagnostic yield of dynamic MRI may outweigh additional costs by expediting appropriate surgical intervention and reducing the risk of irreversible neurological decline [2,8,9].

Once multilevel dynamic compression was established, surgical strategy required careful consideration. An anterior approach was not favoured because of the multilevel nature of compression, absence of focal ventral pathology, and the increased morbidity associated with multilevel anterior reconstruction [10]. Posterior laminectomy with instrumented fusion was considered; while it provides reliable decompression and prevents postoperative kyphosis, it alters cervical biomechanics, restricts range of motion, and is associated with adjacent segment degeneration and hardware-related complications [11,12].

Laminoplasty was selected as the optimal surgical strategy in this case due to preserved cervical lordosis, absence of instability on dynamic radiographs, and the desire to maintain physiological cervical motion. Multiple studies have demonstrated that laminoplasty provides effective multilevel decompression while preserving motion and reducing adjacent segment stress compared with posterior fusion [11,13,14]. Additionally, laminoplasty has been associated with lower rates of C5 palsy and favourable long-term functional outcomes in appropriately selected patients [15-17]. In this context, dynamic MRI played a critical role not only in establishing the diagnosis but also in supporting a motion-preserving posterior decompressive strategy.

This report has several limitations inherent to its design. As a single-case report, the findings may not be generalizable to all patients with cervical myelopathy. The follow-up period of 3 months is relatively short, and long-term outcomes such as maintenance of cervical alignment, durability of neurological recovery, and risk of adjacent segment degeneration cannot yet be assessed. Furthermore, standardized protocols for dynamic MRI, including optimal extension angles and positioning techniques, remain lacking. Larger prospective studies with standardized kinematic imaging protocols are required to better define the role of dynamic MRI in diagnostic and surgical decision-making algorithms for cervical myelopathy.

CONCLUSION

DCM is a progressive condition in which delayed diagnosis and treatment may result in irreversible neurological impairment. While static MRI remains the cornerstone of diagnostic evaluation, it may underestimate clinically significant spinal cord compression in selected patients with motion-dependent pathology.

This case illustrates that dynamic MRI, particularly in cervical extension, can reveal occult multilevel compression in the setting of clinical-radiological discordance and may provide additional diagnostic insight that influences surgical decision-making. However, as a single-case observation, these findings should be interpreted cautiously and are not intended to support routine use of dynamic MRI in all patients with cervical myelopathy.

Dynamic MRI should be considered a complementary, problem-solving tool in carefully selected patients with progressive neurological symptoms that are inadequately explained by conventional imaging. Larger, prospective studies with standardized imaging protocols are required to define its diagnostic value, cost-effectiveness, and impact on long-term clinical outcomes.

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