| Mimickers of Cervical Spondylotic Myelopathy Anthony Kouri, MD Abstract Mina Tanios, MD » Many disorders present similar to cervical spondylotic myelopathy. Joseph S. Herron, MD » Mimickers can be differentiated from cervical spondylotic myelop- athy through a detailed history and physical examination. Maxwell Cooper, MD 10/24/2018 on BhDMf5ePHKbH4TTImqenVIkERnkI2IOHHF6czVEgn1G7FIdwC2JPLMvmDJbNDvUULkTCyLM7w7k= by http://journals.lww.com/jbjsreviews from Downloaded Mustafa Khan, MD » Differentiating between etiologies is aided by electrodiagnostic studies and adjunctive studies using radiographs and magnetic Downloaded resonance images. from Investigation performed at the http://journals.lww.com/jbjsreviews University of Toledo Medical Center, ervical spondylotic myelopa- upper-extremity findings3.Thisincludes Toledo, Ohio thy is a condition of neuro- the inability to grip and release the hand logic impairment resulting rapidly and the presence of the finger from the spinal canal nar- escape sign, in which the ulnar 2 digits rowing secondary to the degeneration of drift into flexion and abduction during by C BhDMf5ePHKbH4TTImqenVIkERnkI2IOHHF6czVEgn1G7FIdwC2JPLMvmDJbNDvUULkTCyLM7w7k= cervical structures. This causes spinal cord extension of the metacarpophalangeal and compression gradually. Severity varies interphalangeal joints. Severe sequelae across individuals. Progression is typically include loss of bowel and bladder func- slow and generates changes in both the cord tion, spasticity, and gait instability. Posi- and the periphery. Cervical spondylotic tive Hoffman or Babinski signs are clinical myelopathy is the most common disorder indicators of myelopathy4.TableIIdem- causing dysfunction of the spinal cord. onstrates the common signs and symp- However, patients may present with similar toms of cervical spondylotic myelopathy. symptoms caused by various other condi- Patients may experience stable tions. Pathologic conditions that affect the periods with slow, stepwise decline in func- spinal cord, or neighboring structures, tion or rapid decline4. Persistent symptoms, should not be overlooked when evaluating without transience or fluctuation, distin- patients with myelopathy. Table I provides guish cervical spondylotic myelopathy from other conditions that must be considered. other disorders. Sequelae such as sensory loss, motor weakness, or gait instability may on Cervical Spondylotic Myelopathy not be present in every patient. 10/24/2018 Cervical spondylotic myelopathy typically Diagnosing cervical spondylotic mye- presents insidiously and comprises a broad lopathy is largely reliant on history and phys- spectrum of signs and symptoms. Patients ical examination. However, other modalities may initially present with axial neck pain or are critical in making the diagnosis. Rhee et al. limitations in the neck range of motion1. performed a prospective case-control study Subtle signs such as decreased hand dex- on the prevalence of physical signs in cervical terity or mild balance impairment may spondylotic myelopathy. Thirty-nine patients go unnoticed in early disease. Difficulty with cervical spondylotic myelopathy and 37 opening jars, buttoning shirts, or writing controls were included. Twenty-one percent may be clinical indicators of cervical spon- of patients with cervical spondylotic myelop- dylotic myelopathy2. Ono et al. used the athy did not have any myelopathic signs on term myelopathy hand when describing examination2. COPYRIGHT © 2018 BY THE Disclosure: There was no source of external funding for this study. The Disclosure of Potential JOURNAL OF BONE AND JOINT Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/ SURGERY, INCORPORATED JBJSREV/A386). JBJS REVIEWS 2018;6(10):e9 · http://dx.doi.org/10.2106/JBJS.RVW.17.00176 1 | Mimickers of Cervical Spondylotic Myelopathy TABLE I Differential Diagnosis in Cervical Spondylotic Myelopathy Mimicker History and Physical Examination Diagnosis Multiple sclerosis Fatigue, diplopia, bladder disturbances, difficulty 2 lesions in the white matter, 2 episodes in the with gait, unilateral leg numbness disease course, oligoclonal bands in cerebrospinal fluid, raised IgG Amyotrophic lateral sclerosis Muscle atrophy, weakness, fasciculations, Hoffman Widespread lower motor neuron disease on EMG, sign, clonus, Babinski sign, foot drop, loss of bilateral changes within corticospinal tracts on brain dexterity, difficulty with gait MRI Parkinson disease Slowness of initiation, movement, and thought; On brain MRI, striatum and pallidum will appear postural and resting tremors; and extrapyramidal normal; on high-field T2-weighted sequences, an rigidity; symptoms will start in 1 limb and, over 2 to 5 altered nigral signal will be demonstrated; surface years, will involve both limbs EMG can be helpful in determining the frequency and amplitude of a tremor Carpal tunnel syndrome Pain in hand, decreased sensation in median nerve Based on history and physical examination, in distribution, reduced grip strength, night equivocal cases, electrodiagnostic studies are symptoms, clumsiness, thenar atrophy in late stages helpful Cubital tunnel syndrome Decreased sensation in the ulnar nerve distribution, Based on history and physical examination, in intrinsic weakness and weakness of the small and equivocal cases, electrodiagnostic studies are ring finger flexor digitorum profundus, Wartenberg helpful; on electrodiagnostic studies, ulnar nerve sign velocity must be ,50 m/s at elbow level HIV Lower-extremity weakness, vague discomfort in SpinalMRIshows extensivecentral high-signalareas legs, gait ataxia, erectile dysfunction (men), bowel or on T2, mainly cervicodorsal bladder disturbance HTLV-1 Slowly progressive chronic spastic paraparesis, HTLV-1 antibodies in serum and cerebrospinal fluid spastic bladder Syphilis Incoordination, pain, absent ankle jerks, impaired High signal on T2 MRI with enhancement of the vibratory sensation, impotence, Romberg sign, spinal surface that disappears Argyll-Robertson pupils, autonomic dysfunction Guillain-Barre´ syndrome Rapidly progressive distal weakness that spreads Illness 7 to 10 days prior; clinical diagnosis, but EMG proximally, severe weakness in shoulder abduction and nerve conduction study demonstrate severe and elbow extension, urinary retention, ileus, sinus neuropathy; cerebrospinal fluid may have raised tachycardia, hyporeflexia, and areflexia protein content Acute transverse myelitis Flaccidparaparesis of lowerextremities that can also Focal and central high-signal areas in T2 sequences, involve the arms, well-defined sensory level occupying more than two-thirds of the spinal cord axially, and extending over 3 to 4 segments Vitamin B12 deficiency Diminished proprioception, decreased vibration Vitamin B12 serum levels; MRI shows T2 sensation, motor weakness, hyperreflexia, gait hyperintense signal alterations usually confined to disturbance, intellectual impairment, impaired posterior columns, but may involve lateral columns vision or brain stem Syringomyelia Intrinsic weakness, cape-like sensory loss, loss of MRI demonstrating syrinx pain and temperature sensation, hyperreflexia, gait disturbance, diplopia, dizziness Radiation damage Lhermitte sign, Brown-Sequard-type symptoms, Spinal cord segment in irradiated zone, .6- ascending sensorimotor disturbance, tetraplegia month latency period, normal cerebrospinal fluid and paraplegia, local amyotrophy analysis, local spinal edema, and contrast enhancement on T2 for at least 8 months after latency period Paraneoplastic etiology Insidiously progressive myelopathy; may occur prior Increased protein concentration in cerebrospinal to cancer diagnosis fluid; longitudinally extensive, symmetric, tract- specific signal changes on MRI Vascular etiology Asymmetric leg weakness, worse with walking or Flow voids on MRI, engorged draining medullary standing for long periods veins and feeding arteries within cerebrospinal fluid Hepatic etiology Progressive pure motor spastic paraparesis, minimal Diagnosis of exclusion; decompensated liver sensory deficit disease, post-liver transplant, post-shunt surgery Alcoholic etiology Paresthesias of feet with progressive spastic Alcoholism without substantial liver disease paraparesis, sometimes bladder dysfunction 2 OCTOBER 2018 · VOLUME 6, ISSUE 10 · e9 Mimickers of Cervical Spondylotic Myelopathy | Amyotrophic lateral sclerosis is a TABLE II Clinical Presentation of Cervical Spondylotic term that encompasses several adult- Myelopathy onset conditions characterized by pro- Common symptoms gressive motor neuron degeneration. Clumsy or weak hands Amyotrophic lateral sclerosis is also a 11 Leg weakness or stiffness term for one specific disease . Amyo- Neck stiffness trophic refers to the lower motor neuron Pain in shoulders or arms disease signs and symptoms. These Unsteady gait include the muscle atrophy, weakness, Common signs and fasciculations seen with this disease. Weakness of the hand musculature Lateral sclerosis refers to corticospinal Hyperreflexia tract hardening from gliosis causing Lhermitte sign (electric shock-like sensation down the center of the upper motor neuron signs, including back following flexion of the neck) overactive tendon reflexes, the Hoffman 12 Sensory loss sign, clonus, and the Babinski sign . Lower motor neuron loss causes sub- stantial weakness. Often, the weakness Magnetic resonance imaging In .33% of patients with multiple from lower motor neuron loss is more (MRI) is the imaging