Cervical Spondylotic Myelopathy

HPI

The patient is a 48-year-old gentleman who presents with progressive gait instability and dexterity problems with his hands. He also reports numbness/tingling in his b/l upper extremities. He reports at times he holds his hand out against the wall because he feels unsteady on his feet. He reports he frequently drops object. He also reports a decreased ability to hold his bladder for long periods of time, and says when he needs to urinate he needs to rush to the bathroom.

PMH

He had a prior lumbar fusion by myself for L3-4 degenertive spondylolithesis with symptoms of neurogenic claudication. He did well with surgery. He smokes 1/2 pack per day.

PE

Diffuse weakness of 4/5 in his upper extremities, most notable to finger abduction. He has a positive Hoffman sign bilaterally and a positive grip/release test. He has 2+ biceps reflexes. He lower extremity exam is unremarkable. His gait exam shows some difficult walking toe-to-heel