Self-Assessment Quiz Question #40 Most patients with degenerative cervical myelopathy are diag- nosed in their ________. This condition is considered uncom - mon before the age of ______.
Self-Assessment Quiz Question #41 With radicular conditions, reflexes are often ____________. Re- flexes in clients with degenerative cervical myelopathy are often ___________.
a. 80s; 60. b. 70s; 50. c. 50s; 40. d. 40s; 20. Signs and symptoms of cervical myelopathy
a. Hypoactive; hyperactive. b. Hypoactive; hypoactive. c. Hyperactive; hypoactive. d. Hyperactive; hyperactive.
Because of the nonspecific symptoms associated with cervical myelopathy, diagnosis can be difficult and is often delayed, and disease progression and functional deterioration can occur during this delay (Hilton et al., 2022). A study cited by Hilton et al. (2022) found that 43.1% of patients eventually diagnosed with degener- ative cervical myelopathy were initially diagnosed in primary care as having carpal tunnel syndrome, while 35.7% were diagnosed with cervical radiculopathy. Important examination findings with cervical myelopathy may in- clude the following. Motor signs: ● Pyramidal weakness (extensor weakness greater that flexor weakness in the upper extremities, and flexor weakness great- er than extensor weakness the lower extremities). ● Spasticity. ● Clonus, especially of the Achilles tendon. ● Hoffman’s sign. ● Babinski’s sign. ● Segmental weakness corresponding to the level of compres- sion. Sensory signs (limb and/or trunk): ● Pain sensation. ● Light touch. ● Deep pressure. ● Two-point discrimination. ● Vibration (Gibson et al., 2018). ● Lhermitte’s sign (electric shock sensation down the spine, or into the limbs, on neck flexion or extension). ● Gait disturbance. Self-Assessment Quiz Question #42 Diagnosis of degenerative cervical myelopathy is often de- layed. Two diagnoses frequently initially given to patients who are eventually shown to have cervical myelopathy are: a. Thoracic outlet syndrome, cervical radiculopathy. b. Cervical spondylosis, thoracic outlet syndrome. Diagnosis of degenerative cervical myelopathy is confirmed by one or more symptoms (hand clumsiness, gait imbalance, numb- ness, weakness, bladder dysfunction) and signs (fine motor dys- function of the hands, hyperreflexia, gait ataxia, sensory deficits, focal weakness) that originate from the spinal cord, as well as the finding of spinal cord compression on MRI (Milligan et al., 2019). It should be noted that cord compression can be incidentally seen on 8% to 57% of asymptomatic individuals (Milligan et al., 2019). Although diagnosis of cervical degenerative myelopathy can be difficult and is often delayed, Hilton et al. (2022) have outlined factors that can aid in the diagnosis (or differential diagnosis) of degenerative cervical myelopathy: ● Symptoms : Upper extremity motor or sensory symptoms are more likely to present bilaterally (though not necessarily sym- metrically). They also reflect neurological dysfunction of the spinal cord so do not include bulbar or cortical symptoms. They generally have a more insidious onset rather than the acute or subacute onset typically found with conditions such as cauda equina syndrome and spinal cord infarction. c. Carpal tunnel; cervical radiculopathy. d. Carpal tunnel, thoracic outlet syndrome.
The presenting symptoms of cervical myelopathy are often non- specific and include clumsiness of the hands and feet, decreased manual dexterity, and an unsteady gait. Although both lower and upper extremity symptoms may be present, typically upper ex- tremity symptoms are predominant. Patients may have difficulty doing routine tasks such as holding a coffee cup or climbing the stairs (McCartney et al., 2018). These symptoms often generate a referral to physical and occupational therapy, and clinicians should always consider whether an undiagnosed myelopathy might be present in clients with these types of symptoms. Another clinical scenario where myelopathy should at least be considered is in clients with frequent falls. Another symptom that is often associated with cervical myelop - athy is numbness and tingling in the hands and feet as well as changes in bowel and bladder function (McCartney et al., 2018). Neck stiffness is a common symptom (Davies et al., 2018). Hyper- reflexia may be present (Kalsi-Ryan et al., 2019). Pain is not always present (Manko et al., 2022). Davies et al. (2018) consider the evolution of myelopathy symp - toms to be a consistent feature. Many patients will describe symptoms that have been present but are getting worse. Rates of progression are variable, with many attributing their symptoms to getting older (Davies et al., 2018). Radiculopathy symptoms can be present with cervical myelopathy, which can confound differential diagnosis (Gibson et al., 2018). This can lead to a complicated clinical picture, as radiculopathy typically presents with hyporeflexia, while myelopathy presents with hyperreflexia (Gibson et al., 2018). The biceps reflex is most sensitive to hyperreflexia at 62%, while the brachioradialis reflex is most specific at 89%. Case Study: Florence Flynn Ms. Flynn is an 82-year-old female who was referred to home care physical therapy due to frequent falls. She lives in an assisted liv- ing facility and has had three falls in the past two months. None of these falls has resulted in significant injury, although she has bruising on her right hip. She uses a two-wheeled walker for mo- bility and has become very apprehensive about moving around her apartment, as she feels unsteady on her feet and is worried about falling. She does not have any neck pain but has a forward head posture with thoracic kyphosis. Cervical range of motion is decreased in extension, bilateral rotation, and bilateral side bend. She endorses being clumsier with both her hands and feet but feels like this is a consequence of getting old and being inactive. Question The assessing clinician is wondering if degenerative cervical my- elopathy might be present. What further tests might they per - form? Discussion Hyperreflexia is a distinguishing sign of degenerative cervical my - elopathy. The assessing clinician should include the biceps and brachioradialis reflexes, as they are the most sensitive (biceps) and most specific (brachioradialis). Other tests that might yield important information are Hoffman’s sign and Babinski’s sign.
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