Gibson et al. (2018) looked at the sensitivity and specificity of individual myelopathy signs on physical examination with results as follows: Hyperreflexia has a sensitivity of 72% and a specificity of 43%, with biceps being most sensitive at 62% and brachioradialis most specific at 89%. Hoffman sign has 59% sensitivity and 81% specificity. Inverted brachioradialis reflex has sensitivity 51% and specificity 81%. Clonus has a sensitivity of 13% and a specificity of 100%. And Babinski reflex has sensitivity of 13% and specificity of 100%.
Finding
Sensitivity Specificity
Hyperreflexia
72%
43%
Biceps reflex
62%
Brachioradialis
89%
Hoffman's sign
59%
84%
Inverted brachioradialis reflex
51%
81%
Clonus
13%
100%
Babinski’s reflex
13%
100%
Special tests for differential diagnosis of cervical myelopathy Hoffman’s sign
assessment to quantify upper limb impairment and to aid in the diagnosis of cervical myelopathy. The GRASSP-M tool measures palmar sensation, prehension/dexterity, and upper extremity strength and was shown to objectively quantify hand impairment and to aid in more accurately diagnosing cervical myelopathy. Finger escape sign The finger escape sign can be highly indicative of cervical cord dysfunction. For this test, the patients holds their fingers extended and closed together (adducted). If the ulnar digits drift into flexion or abduction, cervical cord dysfunction may be present (Milligan et al., 2019). Romberg’s test This test assesses proprioceptive ability, which is often affected in cervical myelopathy. The patient stands with both feet together and without shoes on. The examiner instructs the patient to cross the arms in front of the body and close their eyes. Balance is assessed. This test is positive if there is a loss of balance with eyes closed (Forbes & Cronovich, 2022). Heel/toe walking Having the client walk on their heels and then their toes may be an effective way to elicit difficulties with gait and mobility (McCartney et al., 2018). An MRI can confirm the diagnosis of DCM (Hilton et al., 2019), so referral to a physician for follow-up is indicated. Surgery is the only evidence-based treatment and has been show to halt disease progression and result in improvement in many areas. Few patients make a complete recovery (Hilton et al., 2019). involved compressive structures, expanding the spinal canal by removal or manipulation of the posterior lamina of the vertebrae (Gibson et al., 2018). Decompression of the spinal cord and stabilization of the spine can be achieved through both anterior and posterior surgical approaches (Nouri et al., 2020). Patients are often referred to physical therapy after surgical treatment to address ongoing musculoskeletal and neurological deficits. NEXUS Criteria for cervical spine fractures This test involves five clinical criteria, all of which must be fulfilled to rule out a cervical spine fracture (Garg et al., 2020): ● No midline tenderness. ● The absence of a focal neurologic deficit. ● A normal level of alertness. ● No evidence of intoxication. ● Absence of clinically apparent pain that might distract the patient from the pain of a cervical spine injury. This tool has a sensitivity of 99% and a specificity of 12.9%, with a positive likelihood ratio of 2.7% and a negative likelihood ratio of 99.8% (Garg et al., 2021). According to Garg et al. (2020), one of the greatest advantages of NEXUS is its ease of application, while its high subjectivity and the lack of clear definitions for the clinical criteria are important drawbacks.
For this test, the patient is seated with the head in a neutral position while the examiner flicks the distal phalanx of the middle finger (Flynn et al., 2016). The test is positive if this maneuver causes involuntary flexion movement of the thumb and/or index finger. A positive Hoffman’s sign indicates the presence of an upper motor neuron lesion and corticospinal pathway dysfunction (Whitney et al., 2022). Inverted supinator sign For this test, the patient is in a seated position and the therapist puts the patient’s slightly pronated and fully relaxed forearm on their forearm. The therapist then applies a series of quick strikes near the styloid process of the radius at the attachment of the brachioradialis tendon. A positive test (abnormal response) occurs if the elbow extends or the fingers flex. A normal response occurs if the wrist pronates and/or the elbow flexes. Babinski sign This test is used to assess upper motor neuron reflexes to determine the presence of a central nervous system disorder (Flynn et al., 2016). For this test, the patient is supine and the examiner strokes the plantar surface of the foot with an instrument from posterior lateral toward the ball of the foot. The test is positive if the big toe extends and the other toes fan out (Flynn et al., 2016). Manual dexterity assessment Assessment of the subtle changes in manual dexterity with cervical myelopathy can be difficult. A study by Kalsi-Ryan et al. (2019) was designed to develop and validate a clinical Treatment In patients presenting asymptomatically with cord compression, the incidence of developing symptomatic myelopathy is approximately 8% at one-year and 23% at four-year follow- up (Gibson et al., 2018). Surgical outcomes are considered good, so surgery is nearly universally recommended at the earliest possible opportunity to prevent progression and allow for maximum recovery (Gibson et al., 2018). Surgery typically involves decompressing the spinal canal by removing the Cervical spine fractures Fractures to the cervical spine can be sustained during low- energy events such as a fall or high-energy events such as a motor vehicle crashes (Beeharry et al., 2021). In the U.S., 29.3% of cervical spine fractures are caused by car crashes (Beeharry et al., 2021). Levels C2 and C7 are most frequently involved (Beeharry et al., 2021). Sometimes the presence of a cervical spine fracture is not readily apparent and when this type of injury is not recognized, it can lead to catastrophic neurological disability and possible mortality (Garg et al., 2020). The literature identifies two algorithms or clinical decision- making rules for adequate clearance for cervical spine fractures. One is NEXUS, which stands for National Emergency X-radiography Utilization Study. The other is the Canadian
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Book Code: PTNY1024
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