A 58-year-old man comes to the physician because of a 5-month history of progressive clumsiness in his hands and an unsteady gait. He frequently drops small objects and has difficulty fastening buttons. He has no history of trauma, fever, or preceding illness. Vital signs are normal. Neurological examination reveals decreased bulk and tone in the intrinsic muscles of both hands. Biceps and brachioradialis reflexes are 1+ bilaterally. In contrast, knee and ankle jerks are 3+ bilaterally, and sustained ankle clonus is present. Babinski sign is present bilaterally. Sensory examination shows decreased vibration and position sense in the toes. Which of the following is the most appropriate next step in management?
- Magnetic resonance imaging of the cervical spineCevap
- BComputed tomography scan of the head
- CElectromyography and nerve conduction studies
- DLumbar puncture with cerebrospinal fluid analysis
- EReferral for physical therapy and outpatient observation
Cevap
Magnetic resonance imaging of the cervical spine
The patient presents with progressive neurological decline characterized by a distinct combination of lower motor neuron (LMN) signs in the upper extremities and upper motor neuron (UMN) signs in the lower extremities. The LMN signs (muscle atrophy, hyporeflexia in the biceps and brachioradialis) indicate damage at the level of the nerve roots in the cervical spine. The UMN signs (hyperreflexia, clonus, positive Babinski sign) indicate compression of the descending corticospinal tracts. The diminished vibratory and position sense indicates involvement of the ascending dorsal columns. This constellation of findings is classic for cervical spondylotic myelopathy (CSM), the most common cause of non-traumatic spinal cord compression in older adults. The correct diagnostic approach is magnetic resonance imaging of the cervical spine to visualize the extent of cord compression and to plan for appropriate neurosurgical decompression.
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Anahtar Kavram
Cervical Spondylotic Myelopathy