During a routine primary care visit, a 68-year-old woman describes a six-month history of steadily worsening balance and difficulty performing fine motor tasks, such as fastening the buttons on her clothing. She mentions that her hands feel increasingly 'clumsy,' leading to frequently dropping objects, and she has fallen twice while navigating her kitchen. Her medical background includes long-standing type 2 diabetes mellitus, hypertension, and osteoarthritis. Neurologic evaluation reveals intact cranial nerves and 4/5 strength in the intrinsic muscles of both hands. Which of the following physical examination findings would specifically support the most likely diagnosis of her condition? (Select all that apply)
- Flexion of the thumb and index finger upon flicking the distal phalanx of the middle fingerCevap
- Electric shock-like sensations radiating down the spine with forward neck flexionCevap
- Extension of the great toe and fanning of the other toes upon stroking the lateral plantar surfaceCevap
- DSymmetrical diminution of the patellar and Achilles deep tendon reflexes
- EDysmetria on finger-to-nose testing and a wide-based, irregular gait
Cevap
The correct findings are flexion of the thumb and index finger upon flicking the middle finger (Hoffmann sign), electric shock-like sensations radiating down the spine with neck flexion (Lhermitte sign), and extension of the great toe upon stroking the lateral plantar surface (Babinski sign).
The patient's presentation of progressive gait instability, hand clumsiness, and intrinsic hand muscle weakness in the context of osteoarthritis is highly suspicious for cervical spondylotic myelopathy (CSM). CSM typically presents with lower motor neuron signs at the level of the compression (e.g., intrinsic hand weakness) and upper motor neuron (UMN) signs below the lesion. The correct options represent specific maneuvers testing for UMN lesions and cervical cord irritation. Flicking the middle finger to elicit thumb and index flexion is Hoffmann's sign (a UMN sign of the upper extremity). Electric shock-like sensations with neck flexion describe Lhermitte's sign (indicating cervical cord irritation). Extension of the great toe with plantar stimulation is Babinski's sign (indicating UMN corticospinal tract involvement). Together, these specific findings strongly support the diagnosis.
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Cervical spondylotic myelopathy presents with a constellation of lower motor neuron signs at the level of compression (upper extremities) and upper motor neuron signs below the level of compression (lower extremities).
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