Review Question - QID 211839

Myelopathy hand refers to the characteristic hand findings in a patient with cervical spondylotic myelopathy (CSM). All of these may be evidence with the exception of intrinsic plus posturing.

Due to the insidious nature of CSM, often including periods of quiescence with intermittent and progressive neurologic decline, recognition of exam findings suggestive of myelopathy is important. Changes in hand dexterity and coordination are among the earliest signs, and these may be present in otherwise asymptomatic individuals. Progressive cervical cord compression may result in intrinsic atrophy, weakness in grip and pinch, small finger escape, impaired ability to perform rapid alternating movement (dysdiadochokinesia), and hyperreflexia (Hoffman’s sign, inverted radial reflex).

Lebl et al. review the pathophysiology, presentation and treatment CSM. The authors discuss the characteristic clinical findings of diminished hand dexterity, ataxia, and weakness. They conclude that thorough history and physical exam is important given the often asymptomatic but progressive nature of CSM.

Stark et al. performed an electromyographic study evaluating hand wasting in the setting of CSM. The authors noted that the lower cervical nerve roots (C8 and T1) were most severely effected, and that the upper roots (C5 and C6) were relatively spared. They concluded that the gradation of neurologic impairment was consistent with stagnant hypoxia secondary to venous congestion.

Incorrect answers:
Answer 1: Dysdiadochokinesia, or the impaired ability to perform rapid, alternating movement, is often present in myelopathy. This can be evaluated and objectively quantified with the 10-second grip-release test.
Answer 3: This describes Hoffman’s sign, which occurs due to hyperreflexia associated with cervical myelopathy.
Answer 4: This describes Wartenberg’s sign. Cervical myelopathy is associated with intrinsic weakness. The small finger may drift into extension under the pull of the extensor digiti minimi due to a weakened palmar interossei.
Answer 5: Intrinsic atrophy is a characteristic hand manifestation of cervical myelopathy.