Use Caution, It Might Be Worse 

I have likely seen hundreds of patients with referred pain that translates to the arms, legs, or thoracic region. Pain can be caused by a number of structures and can involve multiple diagnoses.

Did you know that one of these diagnoses is progressive, destructive, and can be debilitative over time?

In this clinical platform, we'll take a closer look at cervical myelopathy to better understand both common characteristics and the challenges clinicians face during testing.


Cervical myelopathy and cervical radiculopathy are two diagnoses associated with referred pain to the arms and thoracic region. While both conditions involve debilitating neurological symptoms, cervical myelopathy is less common and is the only condition that affects the lower extremity. If inappropriately treated, these conditions may lead to advanced disability.

Pathophysiology of Cervical Spine Myelopathy :

Cervical spine myelopathy is a clinical diagnosis made with imaging confirmation. This condition is hallmarked by the neurological changes caused by the stenotic encroachment of the cervical spinal cord. Encroachment, which may lead to structural and vascular changes, originates from sagittal narrowing of the spinal canal. This narrowing can compress the spinal cord, and often stems from:
Osteophytes secondary to degeneration of intervertebral joints
Stiffening of connective tissues, such as the ligamentum flavum, at the dorsal aspect of the spinal canal, which can impinge on the cord by "buckling" when the spine is extended.
Degeneration of intervertebral discs together with subsequent bony changes.

Other degenerative connective tissue changes :

Non-degenerative, structural-based conditions may be associated with one of the following:


1.Arachnoid cyst
3.Epidural lipomatosis
4.Unique Myelopathy Characteristics :Cervical myelopathy is different from cervical radiculopathy in a number of ways. 
Myelopathy generally affects motor before sensory and is:

  • Bilateral
  • Hyper-reflexic
  • Progressive
  • Destructive

Myelopathy is characterized by a variable distribution pattern. As the disease progresses, it may involve subsequent gait-related changes, weakness of the legs, and spasticity. Advanced cases may involve loss of ambulation and transfer capacity, pain, and loss of coordination.

The onset of symptoms is slow and the condition can vary by patient, despite being labeled with the same ICD-10 diagnosis. 

Myelopathy is the most prevalent spinal cord condition in older adults affecting 90% of individuals between the ages of 60 and 69.

Lack of Sensitivity in Testing:

Differential diagnosis can be very tricky. Most measures for clinical tests are "sub-threshold" and fail to identify symptoms. As a result, cervical myelopathy tests tend to be "specific" and lack the sensitivity needed to rule out the condition. This creates a conundrum for myelopathy as most clinicians seek to rule out the condition prior to intervening at the neck.

Clinical Prediction Rule :

In 2014, A clinical prediction rule for cervical spine myelopathy. The rule was designed to improve sensitivity (negative likelihood ratios) and specificity (positive likelihood ratios) in order to rule out the condition early in an examination.


There are five tests associated with the clinical prediction rule:

1. Age
2. Gait
3. Hoffmann's Sign
4. Inverted Supinator Sign
5. Babinski Test

Clustering the tests together expands upon the limitation of stand-alone findings and improves the likelihood of truly ruling out the condition.


In conclusion, diagnosing cervical myelopathy can be challenging as clinical tests can fail to rule out the condition. The prediction rule can increase testing sensitivity and specificity, which enables clinicians to more confidently diagnose myelopathy.

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