What type of gait is expected in a patient with cervical spondylotic myelopathy who has weakness of the left upper and lower extremities but normal strength in the right upper and lower extremities?

Hemiplegic Gait Pattern in Unilateral Cervical Spondylotic Myelopathy

This patient will exhibit a hemiplegic (spastic hemiparetic) gait pattern, characterized by circumduction of the left lower extremity with the leg held in extension, foot in equinovarus position, and reduced arm swing on the left side. 1

Pathophysiology of Unilateral Presentation

• Cervical spondylotic myelopathy typically causes bilateral upper motor neuron signs with spastic weakness in lower extremities, increased tone, and hyperreflexia 2, 3
• However, asymmetric or unilateral cord compression can produce predominantly hemiplegic presentations when the corticospinal tract is compressed more severely on one side 1
• The left-sided weakness pattern indicates unilateral impairment of the corticospinal tract descending through the cervical spinal cord 1

Specific Gait Characteristics to Observe

Lower Extremity Features:

• Circumduction pattern - the left leg swings outward in a semicircular arc during the swing phase because the patient cannot flex the hip and knee adequately 1
• Spastic extension - the left leg is held stiffly in extension with increased tone 2
• Equinovarus foot position - the left foot is plantar-flexed and inverted, with toe dragging during swing phase 1
• Reduced stride length on the affected side 1

Upper Extremity Features:

• Diminished or absent arm swing on the left side 1
• The left arm may be held in a flexed, adducted position at the elbow and wrist due to spasticity 1

Overall Gait Pattern:

• Asymmetric motor activity with clear left-right differences 1
• Slow, effortful ambulation with reduced fluidity of motion 1
• Narrow to normal base width (unlike the wide-based ataxic gait seen in bilateral myelopathy) 1

Critical Diagnostic Confirmation

• Hyperreflexia and pathologic reflexes (Babinski sign, clonus) should be present on the left side, confirming upper motor neuron pathology rather than peripheral nerve injury 2, 3
• Preserved or increased reflexes distinguish this from lower motor neuron causes of weakness 3
• MRI of the cervical spine is mandatory to confirm cord compression and assess for asymmetric compression explaining the unilateral presentation 3, 4

Common Pitfall to Avoid

Do not mistake this for a stroke-related hemiparesis. The key distinguishing features are:

• Gradual, insidious onset over months rather than acute presentation 4, 5
• Neck pain or radicular symptoms may be present 6
• Hand clumsiness and fine motor deterioration on the affected side 6
• Sensory level or proprioceptive loss at the cervical level 3

Urgency of Management

• Prompt referral to spine surgery is mandatory for any patient with demonstrable myelopathy and spinal cord compression 4, 5
• Delaying surgery risks permanent neurological deficit, as the natural history involves stepwise deterioration 4, 7
• Even with unilateral presentation, progressive cord compression can lead to bilateral involvement if left untreated 7