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Jennifer I. Stern, M.D., discusses the diagnostic challenges of degenerative cervical myelopathy (DCM).
Review the signs and symptoms of degenerative cervical myelopathy; Recognize common mimics of degenerative cervical myelopathy; Discuss when to suspect alternative etiologies of the clinical presentation
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Orthopaedic Surgery Specialty
Orthopaedic Surgery (General) Subspecialty
Mayo Clinic
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Past Notes
Thank you to the organizers for
inviting me to come speak.
Again, I'm Jen Stern.
I'm one of the neurologists in the
spine center.
And one of the things that I do in
the spine center is when people come
in with spine disease on their MRI,
try to sort out whether the symptoms
are related to what we're seeing on
imaging or whether the spine
might be asymptomatic and
the symptoms
are due to something else entirely.
So that's what I want to talk about
over the next 20 minutes, kind of
how we go about answering that
question, since the
answer would be so fundamental
for whether surgery
may benefit the patient,
I have nothing to disclose.
So are learning objectives.
I'm going to very briefly review the
signs and symptoms of degenerative
cervical my Betty and
then I'm going to talk about how to
recognize common mimics
and discuss when to suspect
alternative etiologies for the
patient's clinical presentation.
So of course, degenerative cervical.
My allopathy, like doctor said,
is cervical spinal cord
dysfunction related to spinal
stenosis and compressive injury.
And I just want to make the point
that semantically it's slightly
broader than cervical spend a lot of
my allopathy and that it's most
commonly related to spend a lot of
stress but can also be related to
other factors like say, ossification
in the posterior longitudinal
ligament.
So when a patient comes to see us
with, let's say, a gait disturbance
and spinal stenosis on their MRI,
we want to be sure not to jump to
the conclusion that the
spinal stenosis has to be
the cause of the symptoms.
And it can be a challenge sometimes
to sort that out, because
we know that patients with the same
degree of spinal stenosis on MRI
can have widely varying
presentations.
And because asymptomatic spinal cord
compression is just so common,
can also be a challenge because the
early symptoms of degenerative
cervical may lap, if it can be
nonspecific and being
so nonspecific can be mimicked by
many other neurological disorders.
And then finally, it can be a
challenge because many people who
have mild degenerative male apathy
actually have more than one common
neurologic disorder at the same
time. And so their symptoms would be
a conglomeration of more than
one etiology.
So just to briefly
review the typical early symptoms of
degenerative cervical mal apathy, of
course, often begins with the
insidious onset of a gate
disturbance. People may just
describe their gait as slow and
stiff balance impairment.
They may have falls, they may have
decline in hand dexterity.
They may have pair of speeches that
are not specific to a particular
dermatol, or they may have neck
pain related to the cervical spine
ptosis itself.
Or they may have superimposed
cervical ridicule up at these.
Of course, at the posterior columns
are involved. They may have a large
meets phenomena.
They may have frank losses,
sensation, or as the male apathy
progresses and becomes more severe,
may have frank weakness, may
have bipolar bladder disturbance,
although that tends to be late.
And in general, we'll see bladder
disturbance in less than 20% of
patients and bowel disturbance
is even less frequent.
In our typical examination,
we this is a chronic male
apathy. So we may see upper
motor neuron findings below the
level deletion, hyper reflexes,
pathological reflexes, spasticity
slowing and rapid alternating
movements. We may or may not see
frank weakness, and then at the
level of the lesion, we may see
motor neuron, lower motor neuron
findings because of anterior horn
self-involvement.
So atrophy for articulations.
And so what that means is that in
the lower extremities we'll see.
The upper motor neuron findings are
nothing but in the
upper extremities we may see a mixed
picture.
We may see frank lost sensation.
An exam will often see a gait
disturbance, and when the male
apathy is earlier mild, of course
the gait disturbance can be very
nonspecific.
We'll see often slowing
of the gait, reduced stride length.
They may be broad based and
unsteady.
Then, as the male apathy progresses,
we'll start to see a more frank
spastic gait.
And if the posterior columns are in
fact, we may see a sensory taxi
and a positive Romberg affecting the
gate.
Of course the clinical exact
clinical presentation depends on the
region, the spinal cord involved.
So I just put in the handout some of
the the classic spinal
cord syndrome is based on location.
So when a person patient
comes to see us with, again, say,
a gate disturbance and
spinal stenosis on the MRI, one of
the first things that we can think
about is, does the patient actually
have my allopathy or do they have
something else that looks similar?
Because again, many non-male
empathic disorders have symptoms
in common with early male apathy.
So what are some of the common
mimics that we should be thinking
about?
Well, Parkinson's disease can
look a lot like degenerative
mile up at sea because they have
a lot of features in common.
So people with Parkinson's disease
can have this slow, stiff gait, but
the insidious onset, reduced
stride length, they can have
difficulty with balance.
They'll have decreased dexterity in
the hands.
And they often complain about a
sensation of weakness in the legs.
And that's when you examine them.
You'll see it's not actually
weakness. It's more trouble with
coordination or trouble with
initiation of movements.
But they often describe it as
weakness, and then both conditions
can cause urinary symptoms.
So when we're trying to sort it out,
it can be very helpful to look for
signs that are not referable to the
spinal cord.
So in Parkinson's disease, people
will have like a mast face,
reduced facial expression.
They may have type of bonia.
So just a soft, weak voice.
They'll have cochlea, rigidity, an
examination, and they may have a
rest tremor. And if they do, that's
going to be very helpful.
As far as sorting things out,
they're not going to have numbness
and the gait itself is actually
somewhat different.
People with Parkinson's tend to have
more trouble initiating the gait in
the first place. Standing from the
chair, taking the first few steps,
they can have braces where they're
in the middle of walking and
suddenly they can't take another
step.
Or they can have what we call a
fascinating gait where they're
walking and all of a sudden they
speed up and speed up and kind of
almost lose control of the rhythm
of their walking.
Normal pressure. Hydrocephalus is
another condition that will
sometimes see come through the spine
center because it can sometimes
look like degenerative male apathy.
And just as a brief preview of the
kind of classical symptomatic
triad, a normal pressure
hydrocephalus is gait disturbance
and bladder urgency or incontinence
and cognitive decline.
Although in practice, the cognitive
decline comes late.
And so what that means is when they
see us in the office at any given
point of time, they may or may not
have it, but both
and and my allopathic can
again have that chronic progression
of a gait disorder, trouble
with balance and a sense of
heaviness in the lower extremities,
and both can have bladder symptoms.
So when we're trying to look outside
the spinal cord to see if more is
going on, if the patients
have cognitive decline, that can be
helpful.
People with MPH are not going to
have difficulty with hand dexterity.
They're not going to have difficulty
with numbness.
And they did suffer slightly
different and often quite a bit more
extreme in MPH.
They may have a magnetic gait where
their steps are very tiny
and they're not lifting up their
feet off the ground, almost like
their feet are magnetize to the
ground. Or they may have a frank
apraxia gait.
And of course, if the picture's not
clear, it can always help to look
outside the court, look for
things like dilated ventricles out
of proportion to the cell sigh and
other signs so we can see in normal
pressures hydrocephalus.
And less can sometimes be confused
with degenerative male allopathy
because patients
with ALS will have a progressive
weakness, though often
have decline in hand dexterity.
In this case, it tends to be more
related to the two weakness
and atrophy of the small muscles
of the hands.
They may have upper motor neuron
findings and multiple limbs and may
have lower motor neuron findings in
the upper extremities.
So when we're trying to look for
signs that are not referable, the
spinal cord is sorted out.
It can be very helpful if they have
ballpark signs, disorder, three
or just fascia.
And also remember that even though
cervical my allopathic can cause
atrophy in particular patients in
the upper extremities because of
anterior horn cell involvement,
you'll never see it outside the
upper extremities.
So people with ALS will often have
atrophy and poor situations in the
tongue or the lower extremities, and
that can make it easier to sort out.
Not often have a pseudo barber
effect and we can think of sit up
affect almost like an incontinence
of emotions where they laugh
and cry too easily and often
inappropriately.
They tend to have minimal, if any,
sensory disturbance, but they can
sometimes have. Paresthesia are very
mild sensory complaints.
So if they do complain a pair of
stations, it doesn't rule out the
possibility.
And then finally, I want to say a
few words about functional gait
disorder, because that's something
that we're all going to see in our
office from time to time.
And a lot of times people with a
functional gait disorder will have a
bizarre gait.
And in that case, it's going to be a
lot easier to sort out.
But it's not always bizarre.
So one of the most common functional
patterns is when the patient's
standing on a narrow base where
their feet are pretty close together
and but they're flailing their arms
and swinging their trunk as if
they're about to fall.
And that's not really consistent
with organic neurologic disease in
the sense that it's actually quite a
bit harder to maintain your balance
if you're kind of swaying back and
forth compared to if you're actually
standing still.
They may have excessive slowness and
stiffness and they may have kind of
a sudden buckling at the knees, but
they rarely fall.
Functional gait disorders often
improve with distraction and often
fluctuate throughout the visit.
So we might, for instance, see
someone who has a lot of trouble
walking on examination, but then
when the visit is over, they're able
to walk to the door on their way
home.
So let's say we're
comfortable that our patient in the
office has email apathy
and that we're not suspecting one of
the nine male Patrick mimics.
Now, the next thing we can think
about is, are other disorders
contributing to the clinical
picture?
Because there are a lot of common
superimposed disorders that can
exaggerate one or more of the
symptoms and deficits that we
typically attribute to my allopathy.
And so, in effect, they're going to
make a mildly symptomatic my
allopathy appear worse than it
actually is.
And there are many different
disorders that can do so, which I
have in the handout.
And I'm going to go through just a
few of them.
Peripheral neuropathy is commonly
superimposed on
cervical by allopathy, in part
because the populations are really
fairly similar.
And there's many different kinds of
peripheral neuropathy, of course.
But just the typical length
dependent
neuropathy can exaggerate distal
numbness and pair of stations in
the lower extremities or even in
the hands of. It's severe,
and if it involves the large fibers,
it can exaggerate balance difficulty
as well.
So it can be very helpful to ask
about progressive numbness and pain
in the feet.
It can be very helpful to look for
the typical stacking glove pattern
of sensory loss and exam.
I just want to bring up a few
comments that can be helpful to keep
in mind when we're wondering
whether a peripheral neuropathy is
superimposed on the clinical
picture, EMG can be
helpful, but EMG only shows
large fiber neuropathy is not small
fiber.
And so what that means in practice
is that a normal EMG is not going to
rule out the possibility of
neuropathy.
So we wanted to bring up the point
that some neuropathies can mask
the hyper reflexes that we normally
see in my allopathy and so
somebody can come in with
otherwise frank my allopathy with
no reflexes but up
going toes, let's say.
And then finally large fibers,
sensory loss can look similar to a
posterior column deficit.
Lumbar spinal stenosis, of course,
is also commonly superimposed on
cervical by allopathy and in fact
causes lumbar reticular
apathy that can exaggerate weakness
and numbness in the lower
extremities.
If it's severe, it can exaggerate
bipolar bladder deficit.
So it can be very helpful to ask
about radiating low back pain,
neurogenic coordination,
to look for signs of lumbar ridicule
up at apathy, an examination.
And of course, there's many common
superimposed disorders that can
affect hand dexterity, carpal
tunnel syndrome, ulnar neuropathy,
S.A.T. one reticular.
But these intracranial disorders
generally have other symptoms
involved as well, although very
rarely they don't have to.
So now let's say our patient in the
office, we're comfortable that they
have mild apathy and were not
suspecting superimpose conditions.
So the next thing we might think
about is, is the male apathy caused
by the cord compression that we're
seeing on MRI or is it caused
by something else?
The question itself, it's not really
a stretch because asymptomatic
cervical spinal stenosis is so
common and so statistically,
many people who have other male
apathy may have this finding on
their MRI.
So what are some red flags that
should make us suspect a different
cause of male apathy?
Because there are many different
categories and other causes of male
apathy.
Well, if symptoms are out of
proportion to MRI, that can be
a helpful sign, although we have to
keep in mind that people can still
have surfshark on my Allopathy
related to dynamic factors,
an unusual time course can be
helpful, and it's kind of an extreme
example of that, that relapsing
remitting course of multiple
sclerosis is going to influence
and that, you know, this
is not a degenerative my allopathy
picture tracks
specific clinical presentations
or track specific MRI findings
can be very helpful.
And one of the most common causes of
this would be a B12 deficiency,
which I'm going to talk a little bit
more about in a minute.
And then if the male apathy is
just one component of a broader
spectrum of symptoms, let's
say it's a component of a broader
one component of broad neurologic
deficits like, say, in the spinal
cerebellar ataxia,
or one part of a widespread
syndrome, including medical problems
like Garcia, a stark void,
male apathy that can be a clue.
And of course, historical risk
factors for specific male apathy,
like risk of metastases in people
with cancer can be helpful.
Family history of my lab, but they
can clue us and that maybe they have
a hereditary male apathy
and of course, atypical imaging.
If we see something else, it's going
to be a slam dunk.
Now when the male apathy is
confined to the lower extremities,
of course we think about
the possibility that it's in the
thoracic ward.
And I wanted to just bring up a
couple of factors that can be
that can complicate the picture a
little bit.
And the first is that signs and
symptoms of early cervical male
apathy tend to be worse in the lower
extremities and the upper
extremities.
And the second complicating factor
is that a cervical male apathy can
cause a thoracic sensory level,
because, remember, a lesion in the
cord can cause the sensory level at
that level, but
it can also cause a sensory level
anywhere below that level.
And then finally, I wanted to say a
few words about vitamin B12
deficiency because
it's so prevalent.
A recent statistics showed that
anywhere between six and 14%
of older adults have B12 deficiency
and copper deficiency can be
absolutely identical to B12
deficiency.
And so what will often see is
a chronic, insidious, progressive
male apathy that looks a lot like
degenerative male apathy.
It tends they tend to cause post
or lateral syndromes, and they may
be associated with other factors
like cognitive dysfunction in Europe
at the macro acidic anemia,
in some cases an optic neuropathy.
So MRI may or may not show
a T2 hyper intensity that's
restricted to the dorsal columns,
but when it does, that can be
exceedingly helpful.
Sometimes it'll show a
longitudinally extensive signal.
Risk factors malabsorption
and gastric bypass are risk factors
for B12 and copper deficiency.
Pernicious anemia, of course, for
B12.
And then zinc toxicity is really a
very common cause of copper
deficiency.
And one of the most common causes, a
zinc toxicity is denture cream.
So sometimes older people will be
swallowing little bits of their
denture cream, giving them some same
toxicity, and then potentially
at risk for copper deficiency
by allopathy.
So I think the bottom line is just
to have a low threshold to check B12
levels since B12 deficiency is so
common to check metal malartic
acid and to check copper studies.
So just to put it all together, you
know, there are many different clues
that the clinical presentation may
not be caused by degenerative
cervical may a lot, but that it may
be attributable to something else
instead, whether it's a clinical
presentation where the male apathy
is just one part of a constellation
of other symptoms, whether
it's an unusual time course
or historical feature suggesting
a different cause, a family
history suggesting,
you know, a genetic cause
or atypical imaging features.
And I think the bottom line is just
keeping in mind that there may be
mimics. Keeping in mind that there
may be superimposed conditions
can be very helpful.
And in cases that are not clear,
involving a neurologist in the case
can often be very helpful.
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