Review Question - QID 214055

This patient's MRI images demonstrate cervical spine compression, which is concerning for cervical myelopathy. Patients with cervical myelopathy will demonstrate upper motor neuron signs, such as sustained clonus.

Cervical myelopathy is a common degenerative condition caused by compression of the spinal cord and is most commonly characterized by clumsiness in the hands and gait imbalance. Degenerative cervical spondylosis is the most common etiology of cervical myelopathy. Symptoms of cervical myelopathy include neck stiffness and pain, extremity parasthesias, weakness, clumsiness, and gait instability. On examination, UMN signs such as weakness, positive finger escape sign, difficulty with grip and release, hyperreflexia, inverted radial reflex, Hoffmann's sign, sustained clonus, positive Babinski's sign, and a positive Romberg test may be evident. Surgical intervention is commonly needed to effectively manage these patients.

Gibson et al. reviewed degenerative cervical myelopathy (DCM). He reports that the diagnosis of DCM is based on clinical examination, with a positive Hoffmann's sign and hand numbness typically appearing in the upper limbs, and gait abnormalities such as difficulty with tandem gait serving as sensitive diagnostic findings. They conclude that non-operative management has a limited role in treatment, while surgical management has been shown to both be safe and effective for halting disease progression and improving neurological function.

Nemani et al. retrospectively reviewed cord signal change (CSC) visualized on MRI and correlated the findings with level-specific physical examination findings as well as other signs of cervical myelopathy. In patients with CSC, 16% had clonus, 67% had Hoffman sign, 44% had Romberg sign, and 60% had a gait abnormality. They concluded that CSC visualized on MRI correlates poorly with the upper extremity reflex examination in patients with cervical myelopathy and that of the pathological reflexes, Hoffman's sign has the strongest association with CSC.

Tejus et al. reviewed the frequency of abnormal finger flexion, Hoffman's and Babinski response in healthy adults to determine the sensitivity and specificity of these tests as markers of symptomatic spinal cord compression. They found that the frequency of the reflexes in healthy controls for finger flexion, Hoffman's, and Babinski's signs were 1%, 0.3% and 0%, respectively. None of the controls with positive reflexes had any abnormality on MRI. They concluded that a combination of the three reflexes had a sensitivity of 91.7%, specificity of 87.5%, PPV of 95.7% and NPV of 77.8% in detecting spinal cord compression.

Figure A is the sagittal T1 MRI image demonstrating severe spinal canal stenosis noted from C4 to C7 secondary to degenerative disc bulges and congenitally narrow spinal canal which results in complete effacement of the CSF and spinal cord compression at these levels. Figure B shows high T2 signal noted within the cord due to either edema or myelomalacia. Figure C is the axial T1 image demonstrating foraminal narrowing. Illustration A is a video demonstrating a positive Hoffmann's sign, inverted radial reflex, and sustained clonus.

Incorrect Answers:
Answer 1: Cervical myelopathy is an UMN condition and would demonstrate increased reflexes.
Answer 2: Muscular atrophy is a sign of lower motor neuron injury.
Answer 3: Cervical myelopthy would demonstrate a positive Babinksi sign.
Answer 5: Tongue fasiculations are a sign of lower motor neuron injury.