Important examination findings with cervical myelopathy may include the following. Motor signs: ● Pyramidal weakness (extensor weakness greater that flexor weakness in the upper extremities, and flexor weakness greater 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 compression. 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 delayed. 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, numbness, weakness, bladder dysfunction) and signs (fine motor dysfunction 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 symmetrically). 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. ● Neurological signs : A study by Cook et al. (2010) assessed the sensitivity and specificity of a group of examination findings to form a clinical prediction rule. They used the following findings: Babinski reflex, inverted supinator and Hoffmann sign, gait dysfunction, and age 45 or older. Patients who did not have any of these signs were unlikely to have cervical myelopathy (94% sensitivity). By contrast, the presence of at least three of the five findings was highly specific (99%) for the diagnosis of DCM. ● Imaging : Cervical MRI is the gold standard for diagnosing DCM, as it can identify the degree of spinal stenosis and amount of cord compression as well as detect intramedullary signal changes (Hilton et al., 2022). However, the degree of these findings does not necessarily correlate with the presence of cervical myelopathy, so MRI findings cannot be used as the sole reason to rule in or rule out DCM (Hilton et al., 2022). c. Carpal tunnel; cervical radiculopathy. d. Carpal tunnel, thoracic outlet syndrome.
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 myelopathy 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). Hyperreflexia 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 symptoms 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 living 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 mobility 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 myelopathy might be present. What further tests might they perform? Discussion Hyperreflexia is a distinguishing sign of degenerative cervical myelopathy. 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. Self-Assessment Quiz Question #41 With radicular conditions, reflexes are often ____________. Reflexes in clients with degenerative cervical myelopathy are often ___________.
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 degenerative cervical myelopathy were initially diagnosed in primary care as having carpal tunnel syndrome, while 35.7% were diagnosed with cervical radiculopathy.
EliteLearning.com/ Physical-Therapy
Book Code: PTNY1024
Page 58
Powered by FlippingBook