Cervical Myelopathy

Candidate:

Good morning. Thank you for the opportunity. I will start by taking a detailed history from the patient. I would inquire about their chief complaint and ask specific questions to elicit symptoms related to cervical myelopathy. For example, I would ask if the patient has experienced any sensory changes such as proprioception loss or global numbness. I would also inquire about any difficulties with fine motor activities, weakness, clumsiness, disturbances in gait, or paraesthesia in the upper limbs. Additionally, I would explore any history of neck pain.

Candidate:

After taking the history, I would proceed with a thorough physical examination. I would start by observing the patient’s gait, looking for any abnormalities such as a wide-based gait or the use of walking aids. I would also assess the patient’s posture and look for any anterior cervical dressings indicating recent surgery.

Candidate:

Thank you. Next, I would perform a neurological examination, specifically focusing on the following:

Sensory examination: I would assess for any sensory abnormalities, particularly proprioception loss and global numbness. I would test sensation in various dermatomal distributions and ask the patient to identify touch, temperature, and pinprick sensations.

Finger escape sign: I would assess the patient’s hand function by asking them to perform fine motor tasks such as buttoning up a shirt. I would observe for any difficulties or abnormalities in finger dexterity.

Grip and release test: I would ask the patient to grip an object tightly and then release it. I would assess the strength and coordination of their grip and observe for any difficulties or weakness.

Signs of upper motor neuron lesion: I would assess for signs such as hyperreflexia, clonus (more than three beats), Babinski reflex, and Hoffmann’s sign. These findings indicate upper motor neuron involvement.

Gait assessment: I would perform Romberg’s test to evaluate the patient’s balance and proprioception. I would also observe their gait for any broad-based gait or other abnormalities.

L’hermitte’s sign: I would test for L’hermitte’s sign, which is a symptom of posterior column dysfunction. I would ask the patient to flex their neck, and if they experience an electric shock-like sensation radiating down the spine or into the limbs, it would suggest posterior column dysfunction.

Candidate:

Considering the clinical findings of cervical myelopathy, I would keep the following differential diagnoses in mind:

Multiple sclerosis: This should be considered in younger patients, typically between the ages of 20 and 40 years, who present with similar symptoms. A thorough history, additional neurological findings, and imaging studies can help differentiate between cervical myelopathy and multiple sclerosis.

Amyotrophic lateral sclerosis (ALS): ALS can present with similar symptoms in a similar age group (40-60 years). However, in ALS, other findings such as tongue fasciculation, fasciculation, and atrophy of the upper limbs with diminished reflexes are typically present. Additionally, ALS is characterized by the absence of pain and sensory changes.

Candidate:

Yes, certainly. In cervical spondylotic myelopathy, the pathoanatomy involves both static and dynamic factors that lead to compression of the spinal cord in the cervical region. Static factors include congenital narrow canal, age-related disc degeneration and annular bulging, hypertrophy or folding of the ligamentum flavum, loss of cervical lordosis or development of kyphosis, and ossified posterior longitudinal ligament (OPLL). Dynamic factors include segmental instability caused by facet joint and ligamentous degeneration, as well as the development of stiff segments and compensatory hypermobile segments.

Key points to remember during the examination include:

Patients may not volunteer a clear history, so specific questions that are easy to understand are necessary to identify symptoms.
Subtle signs, such as slip-on shoes or adaptations in daily activities, should not be missed as they can provide important clues.
Surgery aims to prevent progression rather than guarantee recovery, so early intervention is often recommended.
After anterior cervical decompression surgery, hoarseness (recurrent laryngeal nerve damage) and Horner’s syndrome (sympathetic chain damage) should be monitored due to possible risks to these structures.
A kyphotic deformity with compression is best addressed through an anterior approach to address deformity and adequately decompress.
Posterior laminectomy can lead to post-operative C5 palsy, resulting in deltoid and/or biceps weakness. This usually occurs soon after surgery and has a variable recovery time. It does not occur with anterior decompressive procedures.

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Cervical Myelopathy

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