import { HighYieldBox, ExamCheatSheet, Tabs, Tab, ComparisonTable, VivaScenario, ContentSection, SpecialTestCard , MedicalImage} from '@/components/content' # 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 ## Understanding Myelopathy **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:** | 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 | ## Clinical Presentation **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 **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 **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 **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 **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 **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 **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):** - 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 ## Summary Presentation ## Examination Sequence 1. **Gait**: Walking, tandem, Romberg, turning 2. **Hoffman's**: Both sides, look for asymmetry 3. **Finger escape sign**: Sustained finger extension 4. **Grip and release**: 10-second count 5. **Upper limb reflexes**: Biceps, brachioradialis, triceps 6. **Lower limb reflexes**: Knee, ankle 7. **Clonus**: Ankle (sustained = abnormal) 8. **Plantar response**: Both sides (Babinski) 9. **Sensation**: Proprioception, vibration, pinprick 10. **Sphincter**: Ask about bladder/bowel function ## Examiner Tips