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). 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%
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., 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 assessment to quantify upper limb impairment and to aid in 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 involved
Special tests for differential diagnosis of cervical myelopathy Hoffman’s sign For this test, the patient is seated with the head in a neutral
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). 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.
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