Review Question - QID 4607

This patient’s clinical presentation is concerning for cervical myelopathy. The inability to preform a tandem gait, intrinsic wasting, a positive Hoffmann's sign, and a finger escape sign(the two ulnar digits drift into abduction and flexion within 30 seconds) are all signs of myelopathy. Obtaining a cervical spine MRI is necessary to confirm the diagnosis and initiate treatment.

Cervical myelopathy is a disease caused by compression of the spinal cord and is associated with a constellation of symptoms including difficulty with gait and clumsiness of the hands. It can be graded using the modified Japanese Orthopedic Association Scale. (Illustration A)

Emery et al. reviewed the natural history, pathogenesis, diagnosis and management of cervical spondylotic myelopathy. The natural history of cervical myelopathy is slow, stepwise deterioration over time, with variable periods of stable neurologic function. Surgical intervention is indicated to alter the natural history and prevent further progression.

Rao et al. discuss the pathophysiology, natural history, and clinical evaluation of cervical myelopathy. The clinical presentation of myelopathy is described as highly variable. Diffuse numbness in the hands is often misdiagnosed as carpal tunnel syndrome and requires a high index of suspicion given the progressive deterioration in patients with cervical myelopathy.

Rhee et al. compared the physical exam findings of 39 patients with myelopathy to 37 without, and while he found a significant increase in myelopathic signs on physical exam in the myelopathy group, 21% of patients in the myelopathy group had no myelopathic signs of physical exam. Individual tests were even less reliable, with a Hoffmann sign only present in 59%, Babinski in 13%, and clonus in 13%.

Illustration A is the modified Japanese Orthopedic Association Scale. Illustrations B and C show the sagittal and axial T2-weighted MRI sequences from the patient in this scenario. There is extensive cervical spondylosis and cord compression.

Incorrect Answers:
Answer 1: Reassurance and observation is inappropriate in cervical myelopathy; the nature of this process is progressive deterioration
Answer 2: Night splinting is an appropriate first line treatment in carpal tunnel syndrome, not cervical myelopathy
Answer 3: Carpal tunnel corticosteroid injections are not appropriate treatment in patients with cervical myelopathy
Answer 4: EMG studies may show evidence of cervical radiculopathy, but they are not the appropriate next step in this patient’s management