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.