Summary

Cervical spondylotic myelopathy (CSM), also known as degenerative cervical myelopathy (DCM), is the most common cause of spinal cord dysfunction in adults over 55 years. It results from compression of the spinal cord due to age-related degenerative changes in the cervical spine, including disc herniation, osteophyte formation, ligamentum flavum hypertrophy, and ossification of the posterior longitudinal ligament (OPLL). The clinical presentation is insidious, with characteristic findings of clumsy hands, gait disturbance, and a combination of upper (legs) and lower (arms) motor neurone signs. Diagnosis is confirmed with MRI cervical spine. Surgical decompression is the mainstay of treatment for established myelopathy, as the natural history is one of progressive decline. Conservative management is only appropriate for mild, stable disease with close monitoring.

Key Facts

• Epidemiology: Most common cause of spinal cord dysfunction in elderly worldwide
• Aetiology: Degenerative changes causing cervical spinal stenosis and cord compression
• Mean age of onset: 50-60 years; increases with age
• Pathophysiology: Mechanical compression + ischaemia → myelopathy
• Classic presentation: Clumsy hands + spastic gait + mixed UMN/LMN signs
• Key sign: Hoffman's sign (UMN lesion above C5/6)
• Imaging: MRI is gold standard; T2 hyperintensity indicates cord signal change
• Natural history: Progressive deterioration (~20-60% deteriorate without surgery)
• Treatment: Surgical decompression (ACDF, laminectomy, laminoplasty)
• Prognosis: Surgery stabilises/improves in majority; recovery inversely related to duration

Clinical Pearls

"Button Trouble": Difficulty with fine motor tasks like buttoning shirts is a classic early symptom. Ask specifically about hand dexterity — patients often attribute it to arthritis or aging.

"Scissor Legs, Numb Hands": CSM typically causes UMN signs in the legs (spastic paraparesis) and LMN or mixed signs in the arms (wasting at level of compression + UMN below).

"Hoffman's = CSM Until Proven Otherwise": A positive Hoffman's sign (flick middle fingernail → thumb flexes) in a patient with gait problems and hand clumsiness is highly suggestive of cervical myelopathy.

"The Window Closes": Recovery from myelopathy depends on duration. Longer symptom duration before surgery = worse outcomes. Early neurosurgical referral is essential.

"Stepwise Deterioration": CSM often follows a stepwise course — periods of stability punctuated by episodes of decline. Trauma, even minor, can precipitate sudden worsening.

Why This Matters Clinically

CSM is common, underdiagnosed, and treatable. Many elderly patients with gait problems and hand clumsiness are dismissed as having "age-related decline" when they actually have a surgically correctable condition. Recognising the clinical pattern (clumsy hands + spastic gait + UMN signs) and performing the relevant clinical tests (Hoffman's, reflexes, gait) enables timely diagnosis via MRI and referral for surgical consideration.[1,2]

Structured Neurological Examination

Upper Limbs:

• Inspection: Wasting (intrinsic hand muscles, C5 wasting)
• Tone: May be normal, spastic, or hypotonic (at level)
• Power: Test each myotome (C5-T1)
• Reflexes: Biceps (C5-6), Triceps (C7), Supinator (C5-6)
• Hoffman's sign: Flick middle fingernail distal phalanx; positive if thumb flexes
• Finger escape sign: Patient extends fingers; small finger abducts
• Sensory: Light touch, pinprick, C5-T1 dermatomes

Lower Limbs:

• Tone: Increased (spastic)
• Power: Hip flexors (L1-2), Knee extension (L3-4), Ankle dorsiflexion (L4-5), Plantarflexion (S1)
• Reflexes: Knee (L3-4), Ankle (S1) — hyperreflexia; sustained clonus
• Plantars: Upgoing (Babinski positive)
• Romberg's test: May be positive (posterior column involvement)

Gait:

• Observe walking: Spastic, stiff-legged, broad-based
• Heel-toe walk: Difficult
• Tandem walking: Impaired

Special Tests

Natural History

Surgical Outcomes

Prognostic Factors

Key Guidelines

Landmark Studies

Fehlings et al. — AOSpine North America (2013)

• Prospective study of surgical outcomes for DCM
• n=278 patients; 280 surgical patients
• 80% improved with surgery; predictors of outcome identified
• PMID: 23334673

Kadanka et al. — RCT Surgical vs Conservative (2002)

• RCT comparing surgery vs conservative for mild CSM
• No significant difference at 2-3 years for MILD disease
• Does NOT apply to moderate/severe myelopathy
• PMID: 12415118

Tetreault et al. — Predictors of Outcome (2015)

• Systematic review of prognostic factors
• Duration of symptoms, baseline severity predict outcome
• Supports early surgery for better outcomes
• PMID: 25299038

Evidence Strength

What is Cervical Spondylotic Myelopathy?

CSM is a condition where age-related changes in the neck bones put pressure on the spinal cord. This can affect the nerves that control your arms, legs, and bladder.

Why does it happen?

As we age, the discs between the neck bones wear out, bone spurs can form, and the ligaments can thicken. In some people, these changes narrow the space around the spinal cord enough to cause pressure on the cord.

What are the symptoms?

• Clumsy hands — difficulty with buttons, writing, or picking up small objects
• Unsteady walking — feeling off balance, stiff legs
• Numbness or tingling in hands
• Weakness in arms or legs
• In advanced cases, bladder problems

How is it treated?

Treatment depends on how severe your symptoms are:

• Mild symptoms: Careful monitoring, physiotherapy, avoiding risky activities
• Moderate to severe symptoms: Surgery to take pressure off the spinal cord (decompression)

Surgery can be done from the front of the neck (removing the disc and fusing the bones) or from the back (opening up the bone covering the cord).

What to expect?

With surgery, most people stop getting worse and many improve. Recovery depends on how severe the symptoms were before surgery and how long they were present. Earlier treatment generally leads to better outcomes.

When to seek help urgently

Seek immediate medical attention if you notice:

• Rapid worsening of weakness or numbness
• Loss of bladder or bowel control
• Sudden difficulty walking
• Any of these symptoms after a fall or neck injury

High-Yield Exam Topics

Sample Viva Questions

Q1: A 65-year-old presents with difficulty buttoning shirts, unsteady gait, and numb hands. How do you assess him?

Model Answer: This presentation is highly suggestive of cervical spondylotic myelopathy. I would take a detailed history (duration, progression, bladder symptoms, neck pain, trauma) and perform a full neurological examination. Key examination findings to elicit: Hoffman's sign (UMN above C5/6), inverted biceps reflex (LMN at C5-6 with UMN below), hyperreflexia and upgoing plantars in legs, spastic gait. I would also assess finger escape sign and check for a sensory level. Investigation of choice is MRI cervical spine looking for cord compression and T2 signal change. If confirmed, I would refer urgently to a spinal surgeon for consideration of decompression.

Q2: What is Hoffman's sign and what does it indicate?

Model Answer: Hoffman's sign is elicited by flicking the distal phalanx of the middle finger. A positive response is reflex flexion of the thumb and/or index finger. It indicates an upper motor neurone lesion affecting the corticospinal tract above the level of C5-6 (where the finger flexor reflex arc is located). In the context of a patient with gait disturbance and hand clumsiness, a positive Hoffman's sign strongly suggests cervical myelopathy and should prompt MRI of the cervical spine.

Q3: Compare anterior and posterior surgical approaches for CSM.

Model Answer: Anterior (ACDF, corpectomy):

• Addresses ventral pathology (disc, osteophytes)
• Good for 1-3 level disease
• Requires fusion with graft/cage and plate
• Risks: Dysphagia, recurrent laryngeal nerve injury

Posterior (laminectomy, laminoplasty):

• Indirect decompression; cord "falls back"
• Good for multi-level stenosis
• Laminoplasty preserves motion; laminectomy + fusion for instability
• Requires preserved lordosis (kyphotic spine → consider anterior)
• Risks: C5 palsy, post-laminectomy kyphosis, neck pain

Choice depends on: Number of levels, location of compression, cervical alignment, surgeon experience.

Common Exam Errors

Last Reviewed: 2025-12-24 | MedVellum Editorial Team

Medical Disclaimer: MedVellum content is for educational purposes and clinical reference. Clinical decisions should account for individual patient circumstances. Always consult appropriate specialists.