Cervical Myelopathy

History

  1. Symptoms:
    • Difficulty in fine motor tasks (e.g., dropping things, clumsiness with buttons, using utensils).
    • Walking difficulty, especially gait abnormalities (e.g., shuffling, broad-based, ataxic).
    • Urinary or bowel issues.
    • Neck or back pain.
    • Radicular symptoms (pain radiating down the limbs).
    • Are these symptoms progressive?
    • Any systemic symptoms like weight loss?
    • Any past treatment for similar episodes?
    • Headaches?
  2. Past Medical History (PMH):
    • History of cancers, strokes, cardiovascular disease.
  3. Social History (SH):
    • Smoking history.
    • Home circumstances.
    • Support network.

Examination

Look

  1. Ask the patient to expose fully to examine both upper and lower limbs.
  2. Walking Aids:
    • Note if the patient uses walking aids and their type.
  3. Front, Side, and Back:
    • Check for scars, deformities, and muscle wasting.
  4. Rhomberg’s Test:
    • Observe balance with eyes closed.
  5. Stand on Heels:
    • Test for proprioception and gait stability.
  6. Stand on Toes:
    • Check for strength and balance.
  7. Heel-Toe Walk:
    • Assess coordination and gait pattern.
  8. Hands for Intrinsic Wasting:
    • Look for muscle atrophy in the hands.
  9. Feet and Legs for Wasting and Clawing:
    • Inspect for muscle wasting and foot drop.
  10. Gait:
    • Shuffling, broad-based, ataxic, unsteady, prolonged stance, reduced cadence.

Feel

  1. Pain:
    • Check for neck or back pain.
  2. Sensory Examination:
    • Test dermatomes and peripheral nerves.
    • Offer pin prick, soft touch, 2-point discrimination, and vibration testing.

Move

  1. Neck & Upper Limb:
    • Assess neck movements (flexion, extension, rotation).
    • Lhermitte’s Sign:
      • Flex neck to provoke electric shock sensation down the spine.
    • Spurling’s Test:
      • Compression of the cervical spine to elicit radicular symptoms.
    • Shoulder Abduction Relief Sign:
      • Positive if symptom relief with shoulder shrug.
    • Tone:
      • Check for spasticity.
    • Motor Power – Myotomes:
      • Test key muscle groups (C5, C6, C7, C8, T1).
    • Reflexes – Hyper-reflexia:
      • Check for exaggerated DTRs (e.g., biceps, triceps, brachioradialis).
    • Signs of Myelopathy – UMN Signs:
      • Scapulohumeral Reflex:
        • Brisk humeral abduction on percussion of scapula spine.
      • Hofman’s Test:
        • Flicking the nail bed to elicit finger flexion.
      • Inverted Radial Reflex Sign:
        • Flexion of fingers when pressing on the radial styloid.
      • Ulna Finger Escape Sign:
        • Flexion of fingers with resistance during extension.
  2. Lower Limb Examination:
    • Same steps as above for sensory, tone, power, and reflexes.
    • Tests for UMN Lesions in Lower Limb:
      • Babinski Sign:
        • Positive if there’s an up-going plantar response.
      • Clonus:
        • 5 beats is abnormal.
      • Hyper-reflexia:
        • Exaggerated reflexes in the lower limb.

Finishing

  1. Offer to do PR (Per Rectum) and assess perianal sensation if indicated.
  2. Vascular Examination:
    • Check for signs of vascular compromise.
  3. X-Rays:
    • Full spine in neutral, flexion, and extension views.
  4. MRI Scan:
    • To confirm diagnosis and assess for cord compression and neural involvement.

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