What is the best course of action for a 47-year-old female with a history of L4-5 decompression and fusion (lumbar spine surgery) and C5-6 Anterior Cervical Discectomy and Fusion (ACDF) (cervical spine surgery), presenting with new onset word-finding difficulty, short-term memory problems, bilateral arm weakness, fine tremor in both hands, and impaired fine motor coordination and dexterity?

Comprehensive Neurological Physical Examination for Suspected Cervical Myelopathy

This patient requires an urgent comprehensive neurological examination focused on identifying cervical myelopathy, which her constellation of symptoms—cognitive changes, bilateral upper extremity weakness, tremor, impaired fine motor coordination, and frequent tripping—strongly suggests as a potential complication of her prior cervical spine surgery. 1, 2

Mental Status and Cognitive Assessment

Cognitive Domain Testing:

• Attention and concentration: Serial 7s, digit span forward/backward, months backward 1, 3
• Executive function: Clock drawing test, verbal fluency (animal naming in 60 seconds), trail-making test 1, 4
• Short-term memory: Three-word recall at 0,5, and 10 minutes; assess both immediate and delayed recall 1, 3
• Language function: Object naming, repetition of complex phrases, reading comprehension, writing a sentence 1
• Visuospatial function: Copy intersecting pentagons, draw a cube 1, 4

Critical Pitfall: Word-finding difficulty and short-term memory problems in a patient with prior cervical spine surgery may indicate cervical myelopathy affecting cognitive function, not just isolated cognitive decline 1, 2

Cranial Nerve Examination

CN II (Optic):

• Visual acuity using Snellen chart or near card 1
• Visual fields by confrontation testing in all four quadrants 1
• Fundoscopic examination for papilledema or optic atrophy 3

CN III, IV, VI (Oculomotor):

• Pupillary size, shape, symmetry, and direct/consensual light reflexes 1, 3
• Extraocular movements in all directions of gaze, noting any nystagmus 1, 4
• Assess for up-gaze limitation (can be normal in elderly but abnormal at age 47) 4

CN V (Trigeminal):

• Light touch sensation in all three divisions bilaterally 1, 3
• Corneal reflex bilaterally 3
• Jaw strength and masseter muscle bulk 3

CN VII (Facial):

• Facial symmetry at rest and with movement 1
• Assess nasolabial folds, forehead wrinkling, eye closure strength, smile symmetry 1, 3

CN VIII (Vestibulocochlear):

• Gross hearing assessment (finger rub or whisper test) 3, 4
• Weber and Rinne tests if hearing asymmetry noted 3

CN IX, X (Glossopharyngeal, Vagus):

• Palate elevation symmetry with "ah" phonation 3
• Gag reflex (if clinically indicated) 3
• Voice quality and dysarthria assessment 1, 3

CN XI (Spinal Accessory):

• Trapezius strength (shoulder shrug against resistance) 3
• Sternocleidomastoid strength (head turn against resistance) 3

CN XII (Hypoglossal):

• Tongue protrusion, noting deviation or fasciculations 3
• Tongue strength against cheek 3

Motor Examination

Upper Extremity Motor Testing (Critical Given Patient's Symptoms):

Strength grading (0-5 scale) for each muscle group bilaterally:

• C5 myotome: Deltoid (shoulder abduction), biceps (elbow flexion) 1
• C6 myotome: Biceps (elbow flexion), wrist extensors 1
• C7 myotome: Triceps (elbow extension), wrist flexors, finger extensors 1
• C8 myotome: Finger flexors, hand intrinsics 1
• T1 myotome: Finger abductors (interossei), thumb abduction 1

Specific fine motor testing given patient's complaint of dropping small objects:

• Finger-to-thumb opposition speed and accuracy 3, 4
• Rapid alternating movements (finger tapping, hand pronation/supination) 3, 4
• Nine-hole peg test or similar dexterity assessment 4
• Ability to pick up small objects (coin, pen, paper clip) 3

Lower Extremity Motor Testing:

• L2-L3: Hip flexion (iliopsoas) 1
• L3-L4: Knee extension (quadriceps) 1
• L4-L5: Ankle dorsiflexion, great toe extension 1
• L5-S1: Ankle plantarflexion, hip extension 1
• S1-S2: Ankle plantarflexion, knee flexion 1

Muscle tone assessment:

• Assess for spasticity in upper and lower extremities (increased tone with velocity-dependent resistance) 3, 4
• Check for rigidity (lead-pipe or cogwheel) 4
• Assess for hypotonia 3

Muscle bulk and fasciculations:

• Inspect for atrophy, particularly in hand intrinsics and thenar/hypothenar eminences 3, 4
• Observe for fasciculations at rest 3

Reflex Examination

Deep Tendon Reflexes (grade 0-4+):

• Upper extremity: Biceps (C5-C6), brachioradialis (C5-C6), triceps (C7-C8) 1, 3
• Lower extremity: Patellar (L3-L4), Achilles (S1-S2) 1, 3
• Document symmetry and any hyperreflexia suggesting upper motor neuron pathology 3, 4

Pathological Reflexes (Critical for Myelopathy Detection):

• Hoffman sign: Flick distal phalanx of middle finger and observe for thumb flexion/adduction 1, 2
• Babinski sign: Stroke lateral plantar surface and observe for great toe extension with fanning of other toes 1, 3
• Clonus: Rapid dorsiflexion of ankle and observe for sustained rhythmic contractions 3, 4
• Jaw jerk: Increased response suggests lesion above pons 3

Superficial Reflexes:

• Abdominal reflexes (T8-T12) 3
• Cremasteric reflex (L1-L2) if applicable 3

Sensory Examination

Primary Sensory Modalities:

• Light touch: Test with cotton wisp or fingertip in dermatomal distribution C2-S1 1, 3
• Pinprick: Use safety pin to assess pain sensation in dermatomal distribution 1, 3
• Temperature: Use cold tuning fork if light touch or pinprick abnormal 3
• Vibration: 128 Hz tuning fork at bony prominences (distal interphalangeal joints, malleoli, patella, iliac crest) 3, 4
• Proprioception: Joint position sense at distal interphalangeal joints of fingers and great toes 3, 4

Cortical Sensory Function:

• Graphesthesia: Number writing on palm 3, 4
• Stereognosis: Object identification by touch 3, 4
• Two-point discrimination: Particularly in fingertips 3, 4
• Extinction to double simultaneous stimulation: Touch both sides simultaneously 1, 3

Sensory Level Assessment:

• Carefully map any sensory level, particularly in thoracic dermatomes, which would indicate spinal cord pathology 1, 3

Coordination and Cerebellar Testing

Upper Extremity:

• Finger-to-nose testing: Assess for dysmetria, intention tremor 1, 3
• Rapid alternating movements: Hand pronation/supination, finger tapping 3, 4
• Rebound phenomenon: Test arm recoil after sudden release of resistance 3

Lower Extremity:

• Heel-to-shin testing: Assess for ataxia 1, 3
• Foot tapping: Assess speed and rhythm 3

Scoring limb ataxia (0-2 scale):

• 0 = No ataxia 1
• 1 = Ataxia in one limb 1
• 2 = Ataxia in two or more limbs 1

Tremor Characterization (Critical Given Patient's Complaint)

Tremor Assessment:

• Rest tremor: Observe hands at complete rest in lap 4
• Postural tremor: Arms outstretched, hands pronated 4
• Kinetic/intention tremor: During finger-to-nose testing 4
• Task-specific tremor: During writing or holding objects 4

Tremor characteristics to document:

• Frequency (low <4 Hz, medium 4-7 Hz, high >7 Hz) 4
• Amplitude (fine vs coarse) 4
• Distribution (unilateral, bilateral, symmetric, asymmetric) 4
• Alleviating/exacerbating factors 4

Gait and Station Assessment

Static Balance:

• Romberg test: Feet together, eyes open then closed for 30 seconds 3, 4
• Sharpened Romberg: Tandem stance (heel-to-toe) with eyes open then closed 4
• Single-leg stance: Time ability to stand on each leg 4

Dynamic Gait Assessment (Critical Given Patient's Tripping):

• Normal gait: Observe base, stride length, arm swing, posture, turning 3, 4
• Tandem gait: Heel-to-toe walking in straight line 1, 3
• Toe walking: Tests S1 strength and cerebellar function 3
• Heel walking: Tests L4-L5 strength 3
• Gait with eyes closed: Assess proprioceptive contribution 4

Specific gait patterns to identify:

• Spastic gait (scissoring, circumduction) suggesting myelopathy 1, 3
• Ataxic gait (wide-based, unsteady) suggesting cerebellar or proprioceptive dysfunction 3, 4
• Steppage gait (foot drop) suggesting L5 radiculopathy or peroneal neuropathy 3
• Parkinsonian gait (shuffling, reduced arm swing, festination) 4

Special Myelopathy Tests (Highest Priority Given Clinical Context)

Lhermitte Sign:

• Neck flexion producing electric shock sensation down spine or into extremities 1, 2

Grip and Release Test:

• Rapid fist opening/closing for 10 seconds; <20 repetitions suggests myelopathy 1, 2

Inverted Radial Reflex:

• Tapping brachioradialis produces finger flexion instead of elbow flexion 1, 2

Scapulohumeral Reflex:

• Tapping medial scapular border produces shoulder elevation/arm abduction 1

Critical Clinical Correlation

This examination must specifically assess for cervical myelopathy given:

• Prior C5-6 ACDF with potential adjacent segment disease 1, 2
• Bilateral upper extremity symptoms (weakness, tremor, fine motor impairment) 1, 2
• Gait disturbance (frequent tripping) 1, 2
• Cognitive changes (may reflect myelopathy affecting higher function) 1, 2

Red flags requiring urgent imaging:

• Hyperreflexia with pathological reflexes (Hoffman, Babinski, clonus) 1, 2
• Sensory level 1, 3
• Spastic gait pattern 1, 3
• Progressive motor weakness 1, 2
• Impaired proprioception or vibration sense 3, 4

The natural history of cervical spondylotic myelopathy shows 55-70% of patients experience progressive deterioration without intervention, making timely diagnosis critical. 2