What are the red flag signs in cervical myelopathy?

Red Flag Signs in Cervical Myelopathy

The most critical red flag signs in cervical myelopathy include gait instability, decreased hand dexterity, hyperreflexia, Hoffmann's sign, Babinski sign, and bladder/bowel dysfunction, which warrant immediate referral for surgical evaluation. 1, 2

Key Clinical Red Flags

Motor Dysfunction

• Upper extremity symptoms:
  • Decreased hand dexterity and fine motor control
  • Grip weakness
  • Difficulty with buttons, writing, or handling small objects
  • Diffuse hand numbness and paresthesias

Gait Abnormalities

• Wide-based, unsteady gait
• Spastic gait pattern
• Falls or near-falls
• Difficulty with balance, especially in dark environments

Pathological Reflexes

• Hyperreflexia (especially in lower extremities)
• Hoffman's sign (flicking the distal phalanx of middle finger causes thumb flexion)
• Inverted supinator sign (tapping brachioradialis causes finger flexion instead of supination)
• Babinski sign (upgoing plantar response)
• Ankle or wrist clonus

Sensory Changes

• Sensory loss below level of compression
• Loss of position and vibration sense (posterior column dysfunction)
• Dissociated sensory loss (preservation of light touch with loss of pain/temperature)
• "Numb, clumsy hands" syndrome

Autonomic Dysfunction

• Bladder dysfunction (urgency, frequency, or incontinence)
• Bowel incontinence
• These autonomic symptoms indicate advanced disease 3

Disease Progression Red Flags

• Stepwise deterioration in neurological function
• Rapid progression of symptoms (days to weeks)
• Development of new neurological deficits despite conservative management
• Worsening myelopathy scores (mJOA score ≤12) 1

Imaging Red Flags

• Severe spinal canal stenosis on MRI
• T2 hyperintensity within spinal cord (myelomalacia)
• Multiple levels of compression
• Evidence of spinal cord compression with corresponding clinical symptoms 1

Diagnostic Algorithm

1. Screen for red flags in any patient with neck pain or radicular symptoms

2. Perform targeted neurological examination:

   • Test for pathological reflexes (Hoffman's, Babinski, clonus)
   • Assess gait (tandem walking, Romberg test)
   • Evaluate hand dexterity (rapid finger tapping, grip strength)
   • Check sensory function (position, vibration, pin-prick)

3. If red flags present:

   • Obtain MRI cervical spine without contrast (preferred) 1
   • Consider CT myelography if MRI contraindicated

4. Management decision based on severity:

   • Mild myelopathy (mJOA >12): Consider surgical decompression or short-term (3 years) nonoperative therapy 1
   • Moderate-severe myelopathy (mJOA ≤12): Surgical decompression recommended 1

Important Caveats

• Lower extremity symptoms may occur without upper extremity involvement, leading to misdiagnosis 3
• Sensory symptoms in a glove-and-stocking distribution can be misdiagnosed as peripheral neuropathy 4
• Diagnostic delay is common due to subtle initial symptoms and incomplete neurological examinations 5
• Long periods of severe stenosis can lead to irreversible white and gray matter damage 1
• The presence of EMG abnormalities or clinical radiculopathy in patients with cervical stenosis without myelopathy increases risk of developing symptomatic CSM 1

Urgency of Referral

Patients with suspected cervical myelopathy should be promptly referred to a spine surgeon, as delayed diagnosis and management can result in permanent neurological deficits and long-term disability 2. The natural history of cervical myelopathy typically involves a slow, stepwise decline, but periods of rapid deterioration can occur 1.