Anteroposterior cervical spine radiograph of an 85-year-old man with a 4-month history of severe right upper extremity pain shows multilevel degenerative changes.
Lateral cervical spine radiograph of the patient.
An 85-year-old man presents with a 4-month history of severe right upper extremity pain. He denies prior injury to the neck or shoulder. The pain is worse over the right scapula and posterior arm and seems to radiate to the ulnar side of the forearm. Conservative treatment with ice and nonsteroidal anti-inflammatory drugs has not provided relief. He has also been feeling unstable with gait, and his balance seems off. Anteroposterior and lateral radiographs of his cervical spine show multilevel degenerative changes. There is significant degenerative disk disease, with disk height loss and anterior and posterior osteophyte formation at C5-6 and C6-7. Magnetic resonance imaging shows significant bilateral foraminal stenosis that is worse on the right side than on the left and is most pronounced at C5-6 and C6-7.
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Cervical myelopathy is a compressive injury to the spinal cord that most commonly occurs as a result of degenerative spondylosis in people aged more than 50 years. With aging, desiccation of the cervical disks occurs and height is lost. Hypertrophy of the ligamentum flavum occurs, osteophytes form, and ossification of the posterior longitudinal ligament may occur. This degenerative cascade leads to compression of the cord.
Symptoms may vary considerably and usually do not follow a dermatomal pattern like cervical radiculopathy. Subtle changes in gait and balance are often the first signs of early myelopathy. Complaints of neck pain, loss of fine motor control of the upper extremity or “clumsy hands” and paresthesias are common. Patients often complain of increasing difficulty with hand writing over a few weeks to months. The proximal motor groups of the legs are more commonly affected than the distal motor groups in cervical myelopathy, which is opposite to the findings of lumbar stenosis. Changes is bowel and bladder function rarely occur in those with cervical myelopathy.1,2
There are several tests of the hands to screen for cervical myelopathy. For the finger escape sign, the patient is asked to extend and adduct the fingers. If the small and ring fingers flex and abduct after 30 to 60 seconds, cervical myelopathy is considered. Slow or clumsy hands may be evident by asking the patient to continuously make a fist and release 20 times in 10 seconds. Other upper motor neuron signs are often present in patients with moderate to severe cervical myelopathy, including hyperreflexia, positive Hoffman sign, sustained clonus, and positive Babinski sign. Hoffman sign involves snapping the distal tip of the extended middle finger, which leads to spontaneous flexion of the other fingers in those with cervical myelopathy.1,2
Dagan Cloutier, MPAS, PA-C, practices in a multispecialty orthopedic group in the southern New Hampshire region and is editor-in-chief of the Journal of Orthopedics for Physician Assistants (JOPA).
- Emery SE. Cervical spondylotic myelopathy: diagnosis and treatment. J Am Acad Orthop Surg. 2001;9:376-388.
- Rao R. Neck pain, cervical radiculopathy, and cervical myelopathy: pathophysiology, natural history, and clinical evaluation. J Bone Joint Surg Am. 2002;84-A:1872-1881.