Symptoms of Cervical Myelopathy
Cervical myelopathy presents with a characteristic combination of upper extremity dysfunction (hand numbness, clumsiness, weakness), gait disturbance, lower extremity symptoms (weakness, spasticity), and upper motor neuron signs (hyperreflexia, increased tone), though presentation can be variable and symptoms often progress insidiously over time. 1, 2
Core Clinical Manifestations
Upper Extremity Symptoms
- Hand dysfunction is the hallmark: numbness, paresthesias, and loss of fine motor dexterity (difficulty with buttons, writing, picking up small objects)
- Distal upper extremity weakness
- Hand clumsiness is often an early complaint 3, 2
Lower Extremity and Gait Abnormalities
- Gait disturbance is a cardinal feature—patients describe difficulty walking, imbalance, or feeling unsteady 1, 4
- Lower extremity weakness (objective weakness found in 58% of cases) 3
- Spasticity in the legs
- Disequilibrium 2
Sensory Disturbances
- Paresthesias in limbs (tingling, pins-and-needles sensation) 5, 2
- Pain (though not always present)
- Sensory level abnormalities—may have discernible midthoracic pin level, loss of sensation from upper leg/genital area downward, or isolated perineal/upper thigh sensory loss 3
Motor Signs on Examination
- Hyperreflexia (exaggerated deep tendon reflexes) 1
- Increased muscle tone/spasticity 1
- Muscle weakness in both upper and lower extremities 2
- Positive Hoffman's sign, Babinski sign (upper motor neuron signs)
Additional Symptoms
- Neck pain and stiffness 2
- Decreased cervical range of motion 2
- Bladder control difficulties (urgency, frequency, or retention) 2
- Functional deficits in activities of daily living 2
Critical Clinical Pitfalls
Atypical presentations occur in approximately 1% of cases: Some patients present with cervical myelopathy without any upper extremity symptoms, manifesting only with lower extremity weakness, gait difficulty, and sensory changes perceived from the trunk, waist, perineum, or legs downward 3. These patients typically have compression at C5-6 or C6-7 levels and often have concurrent lumbar degenerative disease (83% in one series), which can mislead clinicians 3.
Natural History and Progression Patterns
The disease typically follows one of three patterns 6:
- Episodic progression (75%): New symptoms appear in discrete episodes with intervening quiescent periods, during which 2/3 of patients show deterioration
- Slow steady progression (20%): Gradual worsening without stepwise decline
- Rapid onset with plateau (5%): Acute symptom onset followed by prolonged stability
Important caveat: Symptoms often present late in the disease course, when significant spinal cord damage has already occurred 5. The majority of conservatively managed patients remain stable over several years, though deterioration is more common in females and those with increased cervical range of motion 6.
Severity Stratification
Clinical severity is commonly graded using the modified Japanese Orthopedic Association (mJOA) score 1:
- Mild myelopathy: mJOA 15-17
- Moderate myelopathy: mJOA 12-14
- Severe myelopathy: mJOA ≤11
As the disease progresses, symptoms become more obvious and pronounced 2. Without treatment, cervical myelopathy can significantly impair quality of life and in severe cases cause disability or quadriplegia 5.