What are the myelopathy signs associated with neck pain upon extension?

Myelopathy Signs Associated with Neck Pain Upon Extension

Myelopathy presents with a constellation of upper motor neuron signs including hyperreflexia, positive Hoffman and Babinski signs, spasticity, gait disturbance, and hand clumsiness—these findings distinguish it from radiculopathy and require urgent neurosurgical evaluation. 1, 2, 3

Cardinal Clinical Signs of Cervical Myelopathy

Upper Motor Neuron Signs (Most Specific)

• Hyperreflexia in upper and/or lower extremities is present in 92% of myelopathy cases and represents the most consistent finding 3
• Positive Hoffman reflex (bilateral) indicates corticospinal tract involvement and is highly specific for cervical cord compression 3
• Positive Babinski sign occurs in 55% of symptomatic thoracic disc herniation cases with myelopathy 1
• Spasticity and increased muscle tone in the lower extremities, distinguishing myelopathy from peripheral nerve disorders 1, 4

Motor Dysfunction Patterns

• Hand clumsiness and loss of fine motor coordination (difficulty with buttons, writing, or manipulating small objects) 5, 6
• Progressive bilateral leg weakness that may present without upper extremity symptoms in atypical cases 7
• Gait disturbance with wide-based, unsteady walking pattern 1, 5
• Sudden weakness, paralysis, or fatigability affecting trunk, arms, and legs while sparing the head 4

Sensory Abnormalities

• Paresthesias, numbness, or "deadness" in the hands and lower extremities 4, 5
• Dysesthesias (unpleasant abnormal sensations) 4
• Torso dysesthesia may occur with cervical cord involvement 3

Autonomic Dysfunction

• Bladder dysfunction occurs in 24% of symptomatic thoracic disc herniation cases with myelopathy 1
• Neurogenic urinary incontinence represents advanced myelopathy requiring urgent intervention 7
• Bowel incontinence in severe cases 7

Critical Distinguishing Features from Radiculopathy

The key distinction is that myelopathy involves central nervous system pathology affecting trunk, arms, and legs simultaneously, whereas radiculopathy follows a single nerve root distribution. 2, 4

Myelopathy-Specific Findings

• Hyperreflexia (versus normal or diminished reflexes in radiculopathy) 2, 3
• Bilateral symptoms (versus unilateral dermatomal pattern) 2
• Gait disturbance and lower extremity involvement (not typical of cervical radiculopathy) 1, 2
• Negative Spurling's test (which is specific for radiculopathy, not myelopathy) 8

Neck Pain Upon Extension: Specific Considerations

Extension maneuvers narrow the spinal canal and may exacerbate cord compression, particularly in patients with:

• Ossification of posterior longitudinal ligament (OPLL) causing position-dependent cord compression 1
• Cervical spinal stenosis from degenerative changes, herniated discs, or ligamentum flavum hypertrophy 1, 5
• Spondylotic changes with osteophytes causing anterior compression of the dura and spinal cord 1

Red Flags Requiring Urgent MRI

Any patient with suspected myelopathy requires immediate MRI cervical spine without contrast—this is a neurosurgical emergency. 1, 8

Examination Findings Mandating Urgent Imaging

• Any combination of hyperreflexia, positive Hoffman sign, or positive Babinski sign 2, 3
• Progressive neurological deficits or severe myelopathic symptoms 1, 2
• Gait disturbance with upper motor neuron signs 1, 2
• Bladder or bowel dysfunction 1, 7

Additional Red Flags

• Constitutional symptoms (fever, unexplained weight loss, night sweats) suggesting infection or malignancy 1, 8
• Elevated inflammatory markers (ESR, CRP) 1, 8
• History of malignancy, immunosuppression, or IV drug use 1, 8
• Intractable pain despite conservative therapy 8

Common Diagnostic Pitfalls

Do not miss myelopathy masquerading as radiculopathy—always test for hyperreflexia, Babinski sign, and gait disturbance in any patient with neck pain and neurological symptoms. 2

Critical Errors to Avoid

• Misdiagnosing myelopathy as radiculopathy or carpal tunnel syndrome when upper motor neuron signs are present 3
• Failing to examine lower extremities in patients presenting with neck pain and hand symptoms 7
• Assuming lumbar pathology is responsible for lower extremity symptoms without evaluating the cervical spine 7
• Delaying imaging when myelopathic signs are present—these patients require urgent neurosurgical evaluation, not conservative management 6, 3

Natural History and Urgency

Myelopathic patients are unlikely to show significant improvement without surgery and typically demonstrate stepwise deterioration—surgical decompression should be considered urgently. 6

• 75-90% of cervical radiculopathy resolves with conservative therapy, but myelopathy does not 9
• Myelopathy represents a surgical indication, whereas most neck pain and radiculopathy can be managed conservatively 6
• Delayed diagnosis and treatment of myelopathy leads to irreversible spinal cord damage 3, 7