Cervical Myelopathy Examination
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.
Quick Reference One-Pager
Upper Limb UMN Signs
- Hoffman's sign (flicking DIP)
- Inverted brachioradialis reflex
- Finger escape sign
- Grip and release test (less than 20/10s)
- Myelopathy hand (intrinsic wasting + spasticity)
Lower Limb UMN Signs
- Hyperreflexia (knee, ankle)
- Sustained clonus (greater than 3 beats)
- Babinski (upgoing plantar)
- Spastic gait
Gait Assessment
- Wide-based, spastic gait
- Romberg test
- Tandem walking difficulty
- Balance disturbance
Key Points
- Below level of lesion = UMN signs
- At level = LMN signs (segmental)
- Myelopathy is surgical urgency
- MRI essential for diagnosis
Understanding Myelopathy
Pathophysiology
Definition: Cervical myelopathy is spinal cord dysfunction due to compression, typically from:
- Cervical spondylosis (most common)
- Disc herniation
- OPLL (ossification of posterior longitudinal ligament)
- Tumor or trauma
Clinical Pattern:
- ABOVE the lesion: Normal
- AT the lesion: Lower motor neuron signs (segmental)
- BELOW the lesion: Upper motor neuron signs
Natural History:
- Progressive stepwise deterioration in most
- Rarely improves spontaneously
- Surgical decompression prevents progression
Myelopathy vs Radiculopathy:
- Radiculopathy
- Single root (dermatomal)
- Myelopathy
- Below lesion level
- Radiculopathy
- LMN at level
- Myelopathy
- UMN below, LMN at level
- Radiculopathy
- Decreased at level
- Myelopathy
- Increased below
- Radiculopathy
- Dermatomal
- Myelopathy
- Below level, may be patchy
- Radiculopathy
- Usually normal
- Myelopathy
- Spastic, broad-based
- Radiculopathy
- Usually not
- Myelopathy
- YES - surgical urgency
Clinical Presentation
Symptom Patterns
Upper Limb Symptoms:
- "Clumsy hands" - difficulty with fine motor
- Dropping objects
- Difficulty with buttons, writing
- Numbness, tingling (non-dermatomal)
Lower Limb Symptoms:
- Gait disturbance (unsteady, spastic)
- Balance problems
- Feeling "drunk" without alcohol
- Weakness, stiffness
Bowel/Bladder (Late and Severe):
- Urinary urgency or hesitancy
- Incontinence (very late sign)
- Constipation
Gait Examination
Gait Assessment
Myelopathic Gait Features:
- Wide-based stance
- Slow, deliberate steps
- Stiff (spastic) quality
- Difficulty turning
- May drag toes (foot drop from spasticity)
Specific Tests:
Tandem Gait (Heel-to-Toe):
- Walk in straight line, heel to toe
- Tests balance and coordination
- Very sensitive for myelopathy
Romberg Test:
- Stand with feet together, eyes open, then closed
- Positive = falls or sways significantly with eyes closed
- Tests proprioception (posterior column)
Quick Walking Turn:
- Walk 10m, turn quickly
- Instability on turning is early sign
Upper Limb UMN Signs
Special test
Hoffman's Sign
Upper motor neuron lesion (cervical myelopathy)
Technique
- 1Hold patient's middle finger, letting hand hang relaxed
- 2Flick (quickly extend) the DIP joint of middle finger
- 3Observe thumb and index finger
Positive Sign
Flexion of thumb and/or index finger in response to flicking
Indicates
Upper motor neuron lesion - hyperreflexia from loss of cortical inhibition
Diagnostic Accuracy
Ability to detect true positives
Ability to exclude false positives
Hoffman's Sign Interpretation:
- Must be ASYMMETRIC or associated with other signs to be meaningful
- Bilateral Hoffman's in a young person may be normal (hyperreflexia)
- Look for other UMN signs to confirm pathology
- Indicates cord compression when combined with other findings
Special test
Inverted Brachioradialis Reflex
Cervical cord compression at C5-6
Technique
- 1Tap brachioradialis tendon at radial styloid
- 2Observe for finger flexion instead of normal response
Positive Sign
Finger flexion (FDP activation) instead of elbow flexion
Indicates
Cervical myelopathy at C5-6 level - LMN at C6 (absent brachioradialis) + UMN below (hyperreflexic finger flexors)
Diagnostic Accuracy
Ability to detect true positives
Ability to exclude false positives
Special test
Finger Escape Sign (Wartenberg)
Myelopathy with intrinsic weakness
Technique
- 1Patient extends and adducts all fingers
- 2Hold position for 30-60 seconds
- 3Observe especially the little finger
Positive Sign
Little finger (and possibly ring) abducts spontaneously
Indicates
Cervical myelopathy - intrinsic weakness allows unopposed EDM/EDC
Diagnostic Accuracy
Ability to detect true positives
Ability to exclude false positives
Special test
Grip and Release Test
Hand function in myelopathy
Technique
- 1Patient makes fist then fully opens hand
- 2Repeat as fast as possible for 10 seconds
- 3Count complete cycles
Positive Sign
Less than 20 complete grip-release cycles in 10 seconds
Indicates
Cervical myelopathy - slow alternating movements due to cord dysfunction
Diagnostic Accuracy
Ability to detect true positives
Ability to exclude false positives
Myelopathy Hand
Description:
- Loss of finger adduction power (interossei)
- Difficulty with rapid finger movements
- Intrinsic wasting with spasticity
- "Numb clumsy hand" pattern
Assessment:
- Finger spread (interossei weakness)
- Finger adduction (can't hold paper between fingers)
- Rapid finger movements impaired
- Fine motor tasks difficult
Lower Limb UMN Signs
Special test
Plantar Response (Babinski Sign)
Upper motor neuron lesion
Technique
- 1Stroke lateral plantar surface from heel to little toe
- 2Continue medially across ball of foot
- 3Observe great toe
Positive Sign
Extension (dorsiflexion) of great toe ± fanning of other toes
Indicates
Upper motor neuron lesion - corticospinal tract dysfunction
Diagnostic Accuracy
Ability to detect true positives
Ability to exclude false positives
Special test
Clonus (Ankle)
Upper motor neuron hyperreflexia
Technique
- 1Flex patient's knee slightly
- 2Quickly dorsiflex ankle and hold
- 3Count rhythmic contractions
Positive Sign
Sustained clonus (greater than 3 beats of rhythmic contractions)
Indicates
Upper motor neuron lesion - loss of descending inhibition
Diagnostic Accuracy
Ability to detect true positives
Ability to exclude false positives
Lower Limb Reflexes
Test Bilaterally:
- Knee jerk (L3-4): Hyperreflexic in myelopathy
- Ankle jerk (S1): Hyperreflexic in myelopathy
- Compare sides for asymmetry
Grading:
- 0: Absent
- 1+: Diminished
- 2+: Normal
- 3+: Brisk (may be normal)
- 4+: Clonus
Myelopathy Pattern:
- Hyperreflexia BELOW level of cord compression
- May have hyporeflexia AT level (LMN segment)
Sensory Examination
Sensory Patterns in Myelopathy
Posterior Column:
- Vibration sense (128Hz tuning fork)
- Proprioception (joint position sense)
- Test in great toe and fingers
- Romberg relies on this
Spinothalamic Tract:
- Pain (pinprick)
- Temperature
- May have sensory level
Pattern in Central Cord Syndrome:
- "Cape-like" distribution
- Upper limbs worse than lower
- Sacral sparing
Assessment:
- Light touch
- Pinprick (compare sides)
- Vibration
- Proprioception
- Look for sensory level
Severity Assessment
Myelopathy Grading (Nurick/mJOA)
Nurick Grade:
- Description
- Symptoms only, no deficit
- Description
- Signs present, gait normal
- Description
- Gait abnormal, still employed
- Description
- Gait abnormal, unable to work
- Description
- Requires assistance for walking
- Description
- Chair/bed bound
Modified Japanese Orthopaedic Association (mJOA):
- Motor dysfunction upper limb (0-5)
- Motor dysfunction lower limb (0-7)
- Sensory upper limb (0-3)
- Sphincter dysfunction (0-3)
- Total: 0-18 (18 = normal)
- Mild: 15-17, Moderate: 12-14, Severe: less than 12
Differential Diagnosis
- onset
- Gradual
- pattern
- UMN below lesion
- reflexes
- Increased
- special
- Hoffman's +, gait disturbance
- onset
- Variable
- pattern
- Single dermatomal
- reflexes
- Decreased at level
- special
- Spurling's +, no gait changes
- onset
- Gradual
- pattern
- Mixed UMN + LMN
- reflexes
- Increased
- special
- Fasciculations, bulbar signs
- onset
- Relapsing
- pattern
- Variable
- reflexes
- Increased
- special
- Optic neuritis, sensory symptoms
- onset
- Gradual
- pattern
- Posterior columns + UMN
- reflexes
- May be increased
- special
- Anemia, peripheral neuropathy
- onset
- Variable
- pattern
- UMN in legs only
- reflexes
- Increased legs
- special
- Sensory level on trunk
Summary Presentation
“65-year-old man with 6-month history of progressive difficulty walking and clumsiness with his hands.”
Examination Sequence
Systematic Approach
- Gait: Walking, tandem, Romberg, turning
- Hoffman's: Both sides, look for asymmetry
- Finger escape sign: Sustained finger extension
- Grip and release: 10-second count
- Upper limb reflexes: Biceps, brachioradialis, triceps
- Lower limb reflexes: Knee, ankle
- Clonus: Ankle (sustained = abnormal)
- Plantar response: Both sides (Babinski)
- Sensation: Proprioception, vibration, pinprick
- Sphincter: Ask about bladder/bowel function
Examiner Tips
Do
- Test Hoffman's correctly (flick DIP, observe response)
- Assess gait thoroughly (tandem, Romberg)
- Check reflexes bilaterally (compare sides)
- Test for clonus (sustained greater than 3)
- Ask about bladder function
Don't
- Miss bilateral nature of findings
- Forget to assess gait
- Accept isolated Hoffman's as pathological (needs other signs)
- Miss the inverted brachioradialis reflex
- Forget to mention MRI and surgical urgency