Cervical myelopathy: diagnosing another great impostor

Abstract

Context: Cervical myelopathy, especially during the early stages of the disorder, is very difficult to diagnose. It has the ability to mimic a number of other neurologic and musculoskeletal conditions, resulting in prolonged diagnostic delay in some cases. Excessive delay can result in permanent paralysis, gait, and genitourinary dysfunction. While most common in aging populations, it can present to military clinicians at any time. Consequently, there needs to be an increased index of clinical suspicion when evaluating Soldiers.

Objective: The purpose of this clinical review is to provide an evidence-based update regarding the diagnostic utility of both common and novel clinical tools.

Data sources: English language articles published in peer reviewed journals were identified by searching the PubMed, CINAHL, and SPORTDiscus databases.

Results: Historically, clinicians have performed tests such as the Hoffmann or Babinski signs in order to rule out the presence of cervical myelopathy or other upper motor neuron disease. While there is some evidence to suggest their clinical usefulness, several other clinical tools should be considered as well. Specifically, the Trömner and the Wazir hand myelopathy signs are very sensitive for detecting myelopathy at or above the C5-6 level. There is sufficient evidence to suggest that any neurologic screen with the purpose of excluding cervical myelopathy needs to include the lower extremity tests such as the patellar tendon and Rossolimo reflexes. Analysis of the lateral cervical radiograph is an efficient and inexpensive method of evaluating for the presence of congenital cervical spine stenosis, a known risk factor for cervical myelopathy. Magnetic resonance imaging findings on T2, and especially the T1 weighted images, appear correlated with surgical outcomes.

Conclusion: Military clinicians should use the most valid clinical tools when evaluating for the presence of cervical myelopathy.