A brief inspired thread (@adamdobson123 / @ClementsCharl96 ) following chats about degenerative myelopathy (the most common type we see in primary/ intermediate care services) and Hoffman’s sign
1/ Degenerative cervical myelopathy (DCM) is an umbrella term for compression of the cx spinal cord secondary to degenerative processes i.e. osteophyte formation, disc protrusions, ligament hypertrophy or ossification (Hilton et.al, 2018).
2/ Other types of conditions that can cause compression include; traumatic, infectious processes spinal tumours etc
3/ It has a minimum incidence and prevalence of 41 and 606 per 1 000 000. Although these figures are thought to be much higher as they are gathered largely in orthopaedic settings
4/common symptoms for DCM include; gait disturbances, difficulty with fine motor skills, numbness/ P/N’s affecting the extremities, weakness and in more chronic disease altered bladder and bowel function (Milligan et.al, 2019)
5/Cook et.al found a cluster of tests including; gait deviation, Hoffmans, inverted supinator sign, Babinski test&age >45 yrs when clustered into 1of 5 +ve tests to rule out CSM -ve LR of 0.18 & when clustered into 3of5 +ve findings to rule in CSM +ve LR of 30.9
6/ Suspicion of the condition leads to further imaging &onward referral.Local pathways vary,our service tends to work on the premise that if there is marked compression and/or long tract neurological signs then urgent referral.
7/ If the cord is mildly compressed (would be reviewed in spinal MDT)with no imaging abnormalities of the cord and the patient does not have myelopathic ax's then the patient CAN sometimes be neuro-monitored within our service with close support of orthopaedics as needed.
8/ Surgery for DCM remains the best Rx option & is usually performed under the notion that it is to maintain the pt's current level of function therefore early detection of the condition is important.Some literature has reported improved function and OM’s post-surgery though
9/Hoffman’s sign was first postulated by a German Neurologist Johan Hoffman.The test can indicate an UMN lesion and corticospinal tract dysfunction(Munakomi, 2021).Although +ve results have also been linked to other disorders such as anxiety, MS, hyperthyroidism (barman, 2010).
10/ A SR conducted by Fogarty et.al (2018) found that Hoffman’s test has a +ve LR of 2.2 -ve LR of 0.63 and therefore a standalone +ve or -ve test is pretty poor in helping us determine if the patient has/ doesn’t have DCM. As always #contextiskey
11/ couldn’t find any hard evidence @adamdobson123 that a B/L +ve test would increase suspicion of DCM but you would think that would influence LR’s but still not to the levels that would supersede the clinical history and presentation
12/ Happy to upload some images of interesting cases I have imaged, managed and referred if people are interested.. P.s Also important to remember that most MRI scanners show a static image and this may vary dynamically
13/ finally and most importantly, the delay to dx has been reported to be be up to 6 years for some pt’s dependant on the progression of the disease. This condition can cause paralysis if left untreated and serious morbidity. Important that we safety net and recognise it
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