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Cervical Spondylotic Myelopathy: A Common Cause of Spinal Cord Dysfunction in Older Persons part-2

WILLIAM F. YOUNG, M.D.,
Temple University Hospital, Philadelphia, Pennsylvania
 

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Clinical History

Common complaints of patients with cervical spondylotic myelopathy include neck stiffness, crepitus in the neck with movement, brachialgia, a dull "achy" feeling in the arm, and numbness or tingling in the hands.

Patients with CSM will generally have these symptoms: neck stiffness; unilateral or bilateral deep, aching neck, arm and shoulder pain; and possibly stiffness or clumsiness while walking (Table 1). CSM usually develops insidiously. In the early stages of CSM, complaints of neck stiffness are common because of the presence of advanced cervical spondylosis.10 Other common complaints include crepitus in the neck with movement; brachialgia, which is characterized as a stabbing pain in the pre- or postaxial border of the arm, elbow, wrist or fingers; a dull "achy" feeling in the arm; and numbness or tingling in the hands.

Pain following a stereotypical dermatomal distribution is referred to as a radiculopathy rather than a myelopathy. For example, in patients with a disc herniation between the sixth and seventh vertebrae, pain radiates into the shoulder, upper arm, elbow, and index and middle fingers. It is typically unilateral. Numbness and weakness follow the same distribution. Some patients will exhibit signs and symptoms of radiculopathy and myelopathy.

The hallmark symptom of CSM is weakness or stiffness in the legs.10,11 Patients with CSM may also present with unsteadiness of gait. Weakness or clumsiness of the hands in conjunction with the legs is also characteristic of CSM. Symptoms may be asymmetric particularly in the legs. Loss of sphincter control or frank incontinence is rare; however, some patients may complain of slight hesitancy on urination.

TABLE 1
Clinical Presentation of Cervical Spondylotic Myelopathy

Common symptoms
Clumsy or weak hands
Leg weakness or stiffness
Neck stiffness
Pain in shoulders or arms
Unsteady gait

Common signs
Atrophy of the hand musculature
Hyperreflexia
Lhermitte's sign (electric shock-like sensation down the center of the back following flexion of the neck)
Sensory loss

Physical and Neurologic Examination

The physical and neurologic examination is used to confirm the presence of spinal cord dysfunction. Flexion of the neck may cause a generalized "electric shock-like" sensation down the center of the back,10referred to as Lhermitte's sign (Table 1). Atrophy of the hands, particularly the intrinsic musculature, may be present.

Sensory abnormalities have a variable pattern on examination. Loss of vibratory sense or proprioception in the extremities (especially the feet) can occur. Superficial sensory loss may be asymmetric and persons are variably affected. The sensory examination may be confounded by the presence of diabetes mellitus and a concurrent peripheral neuropathy.

A characteristic physical finding of CSM is hyperreflexia. The biceps and supinator reflexes (C5 and C6) may be absent, with a brisk triceps reflex (C7). This pattern is almost pathognomonic of cord compression because of cervical spondylosis at the C5-C6 interspace.12 Ankle clonus and Babinski's sign (pathologic extension of the great toe elicited by stroking the foot) in the feet may also be revealed. Hoffmann's sign (a reflex contraction of the thumb and index finger after nipping the middle finger) is a subtle indicator of spinal cord dysfunction. A stiff or spastic gait is also characteristic of CSM in its later stages.

When cervical spondylosis is isolated to the C6-7, C7-T1 spinal levels, the arm reflexes may be normal. A hyperactive pectoralis muscle reflex elicited by tapping the pectoralis tendon in the deltopectoral groove causing adduction and internal rotation of the shoulder is a sign of cord compression in the upper cervical spine (C2-3, C3-4 spinal levels).13 The "dynamic" Hoffmann's sign (when a typical Hoffmann's sign is elicited after having the patient flex and extend the neck multiple times) may be an indicator of early CSM.14 Hyperreflexia may be absent in CSM patients who have concurrent diabetes, causing a peripheral neuropathy (Table 1).

 

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