Focused examination for cervical spondylotic myelopathy including upper motor neuron signs, Hoffman's test, gait assessment, and differentiation from other neurological conditions.
Cervical myelopathy examination requires systematic assessment of upper motor neuron signs in both upper and lower limbs. Examiners expect you to perform Hoffman's test, test for hyperreflexia, assess gait, and understand that this is a clinical diagnosis representing cord compression - a surgical urgency.
High-Yield Exam Summary
Definition: Cervical myelopathy is spinal cord dysfunction due to compression, typically from:
Clinical Pattern:
Natural History:
Myelopathy vs Radiculopathy:
| Feature | Radiculopathy | Myelopathy |
|---|---|---|
| Pattern | Single root (dermatomal) | Below lesion level |
| Motor | LMN at level | UMN below, LMN at level |
| Reflexes | Decreased at level | Increased below |
| Sensory | Dermatomal | Below level, may be patchy |
| Gait | Usually normal | Spastic, broad-based |
| Urgency | Usually not | YES - surgical urgency |
Upper Limb Symptoms:
Lower Limb Symptoms:
Bowel/Bladder (Late and Severe):
Myelopathic Gait Features:
Specific Tests:
Tandem Gait (Heel-to-Toe):
Romberg Test:
Quick Walking Turn:
Upper motor neuron lesion (cervical myelopathy)
Flexion of thumb and/or index finger in response to flicking
Upper motor neuron lesion - hyperreflexia from loss of cortical inhibition
Ability to detect true positives
Ability to exclude false positives
Hoffman's Sign Interpretation:
Cervical cord compression at C5-6
Finger flexion (FDP activation) instead of elbow flexion
Cervical myelopathy at C5-6 level - LMN at C6 (absent brachioradialis) + UMN below (hyperreflexic finger flexors)
Ability to detect true positives
Ability to exclude false positives
Myelopathy with intrinsic weakness
Little finger (and possibly ring) abducts spontaneously
Cervical myelopathy - intrinsic weakness allows unopposed EDM/EDC
Ability to detect true positives
Ability to exclude false positives
Hand function in myelopathy
Less than 20 complete grip-release cycles in 10 seconds
Cervical myelopathy - slow alternating movements due to cord dysfunction
Ability to detect true positives
Ability to exclude false positives
Description:
Assessment:
Upper motor neuron lesion
Extension (dorsiflexion) of great toe ± fanning of other toes
Upper motor neuron lesion - corticospinal tract dysfunction
Ability to detect true positives
Ability to exclude false positives
Upper motor neuron hyperreflexia
Sustained clonus (greater than 3 beats of rhythmic contractions)
Upper motor neuron lesion - loss of descending inhibition
Ability to detect true positives
Ability to exclude false positives
Test Bilaterally:
Grading:
Myelopathy Pattern:
Posterior Column:
Spinothalamic Tract:
Pattern in Central Cord Syndrome:
Assessment:
Nurick Grade:
| Grade | Description |
|---|---|
| 0 | Symptoms only, no deficit |
| 1 | Signs present, gait normal |
| 2 | Gait abnormal, still employed |
| 3 | Gait abnormal, unable to work |
| 4 | Requires assistance for walking |
| 5 | Chair/bed bound |
Modified Japanese Orthopaedic Association (mJOA):
| condition | onset | pattern | reflexes | special |
|---|---|---|---|---|
| Cervical Myelopathy | Gradual | UMN below lesion | Increased | Hoffman's +, gait disturbance |
| Cervical Radiculopathy | Variable | Single dermatomal | Decreased at level | Spurling's +, no gait changes |
| Motor Neuron Disease (ALS) | Gradual | Mixed UMN + LMN | Increased | Fasciculations, bulbar signs |
| MS | Relapsing | Variable | Increased | Optic neuritis, sensory symptoms |
| B12 Deficiency | Gradual | Posterior columns + UMN | May be increased | Anemia, peripheral neuropathy |
| Thoracic Cord Lesion | Variable | UMN in legs only | Increased legs | Sensory level on trunk |
"65-year-old man with 6-month history of progressive difficulty walking and clumsiness with his hands."
High-Yield Exam Summary