Can cervical myelopathy cause bilateral feet paresthesia at the soles?

Can Cervical Myelopathy Present Initially with Bilateral Feet Paresthesia at the Soles?

Yes, cervical myelopathy can absolutely present with bilateral feet paresthesia at the soles as an initial symptom, though this presentation mimics peripheral polyneuropathy and represents a specific clinical subtype that requires high clinical suspicion. 1

The "Pseudo-Polyneuropathy" Presentation

Cervical spondylotic myelopathy can manifest with a distinctive pattern of sensory disturbances affecting all four distal limbs in a distribution that mimics peripheral polyneuropathy, including paresthesias at the soles of the feet. 1 This presentation occurs in approximately 16% of cervical myelopathy cases (10 out of 61 patients in one series). 1

Key Clinical Features to Recognize:

• Bilateral distal sensory symptoms affecting both feet and hands, with objective superficial sensory deficits documented on examination 1
• Lower extremity symptoms can predominate initially, with vibration sense particularly affected in the lower limbs 1
• Pin-prick sensation is typically more diminished in the upper limbs than lower limbs, creating an atypical pattern 1
• Motor impairment is often mild at presentation, which can mislead clinicians toward a peripheral neuropathy diagnosis 1
• Preserved triceps reflexes despite other myelopathic signs 1

Anatomical Basis

The pathophysiological substrate for this presentation involves compression at the mid-to-low cervical level (typically C4/5 and C5/6), causing a combination of dorsal horn/anterior commissure lesions affecting the upper limbs and anterolateral funiculi lesions affecting the lower limbs. 1 This explains why bilateral feet paresthesia can be the presenting complaint.

Critical Diagnostic Pitfalls to Avoid

The most dangerous error is assuming bilateral distal paresthesias automatically indicate peripheral polyneuropathy. 1 Several features distinguish cervical myelopathy from true polyneuropathy:

• Normal nerve conduction studies and F-wave latencies despite prominent sensory symptoms 1
• Somatosensory evoked potentials show delayed N13 and P14 peaks after median/ulnar nerve stimulation, indicating central rather than peripheral pathology 1
• EMG may show only mild chronic denervation in C5-C7 innervated muscles 1
• Hyperreflexia or preserved reflexes rather than the areflexia expected in polyneuropathy 2

Broader Clinical Context

Cervical myelopathy commonly presents with lower extremity symptoms that can overshadow upper extremity findings. 3 In one case report, a 38-year-old patient with severe C6-C7 stenosis presented exclusively with progressive bilateral leg weakness, numbness, and urinary incontinence without any upper extremity neurological changes. 3 This emphasizes that cervical spine imaging must be considered even when symptoms are confined to the lower extremities. 3

The classic presentation includes gait involvement in 100% of cases, with paresthesias and proprioceptive changes in a pattern that may not subside between episodes. 2

Immediate Diagnostic Algorithm

When encountering bilateral feet paresthesia:

1. Examine for upper motor neuron signs: hyperreflexia, Babinski sign, clonus, spasticity 2
2. Test proprioception and vibration sense in both upper and lower extremities to identify the characteristic pattern 1
3. Assess gait and balance for ataxia or spasticity 2
4. Order cervical spine MRI if any upper motor neuron signs are present or if nerve conduction studies are normal despite prominent symptoms 2, 1
5. Do not rely on symptom distribution alone—the absence of hand symptoms does not exclude cervical myelopathy 3, 1

Urgent Differential Consideration

Before attributing bilateral ascending paresthesias to cervical myelopathy, immediately exclude Guillain-Barré syndrome, which presents with rapidly progressive bilateral weakness starting in the legs, accompanied by paresthesias and areflexia. 4 GBS requires urgent immunotherapy and represents a medical emergency. 5 The key distinguishing feature is that GBS causes areflexia or hyporeflexia, while cervical myelopathy typically causes hyperreflexia. 4

Imaging Recommendations

MRI of the cervical spine without and with contrast is the definitive imaging modality for evaluating suspected cervical myelopathy, providing superior visualization of the spinal cord, canal stenosis, and intramedullary signal changes. 2 The ACR Appropriateness Criteria designate cervical spine MRI as "usually appropriate" for acute or chronic myelopathy evaluation. 2

Intramedullary T2 signal changes on MRI represent myelomalacia and gliosis, serving as prognostic factors for surgical outcomes. 2 Compression is most commonly at C5-C6 and C4-C5 levels in this presentation pattern. 1