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Correlation of Cord Signal Change With Physical Examination Findings in Patients With Cervical Myelopathy

Nemani, Venu M. MD, PhD*; Kim, Han Jo MD*; Piyaskulkaew, Chaiwat MD; Nguyen, Joseph T. MPH*; Riew, K. Daniel MD

doi: 10.1097/BRS.0000000000000659
Cervical Spine

Study Design. Retrospective case series.

Objective. To determine whether cord signal change (CSC) visualized on magnetic resonance imaging (MRI) correlates with level-specific physical examination findings as well as other signs of cervical myelopathy.

Summary of Background Data. Although CSC is often used as a marker for severe cervical spine pathology, it is not known whether CSC detected on MRI actually translates clinically into level-specific findings detected on physical examination.

Methods. A consecutive series of patients with CSC evident on MRI operated on by a single surgeon from 2010 to 2012 were retrospectively analyzed. Patients' preoperative reflex examination (biceps, brachioradialis, and triceps) including abnormal reflexes (Hoffman sign, inverted radial reflex, clonus, and Babinski) were recorded. Patients were deemed to have an examination consistent with the level of CSC if they had normal reflexes cranial to the level of CSC, were hypo-reflexic at the affected level, and hyper-reflexic caudal to the level of CSC.

Results. Forty-three patients with CSC were identified during the study period (Table 1). Isolated T2 CSC was present in 35 patients, and concomitant T1 and T2 CSC was present in 8 patients. Interestingly, the reflex examination correlated poorly with the cranio-caudad level of CSC, with only 11 of 43 patients (26%) having a concordant examination. In patients with CSC, 16% had clonus, 67% had Hoffman sign, 44% had Romberg sign, and 60% had a gait abnormality.

Conclusion. CSC visualized on MRI correlates poorly with the upper extremity reflex examination in patients with cervical myelopathy. Of the pathological reflexes, Hoffman sign has the strongest association with CSC, but still was only positive in 67% of cases. More sensitive clinical measures need to be developed to more accurately associate CSC detected on MRI to the clinical severity of cervical spondylotic myelopathy.

Level of Evidence: 4

Although cord signal change is often used as a radiographical indicator of cervical myelopathy, it is unclear whether the presence of this finding translates into positive findings on physical examination. We show that cord signal change correlates poorly with pathological reflexes and level-specific physical examination findings in patients with myelopathy.

*Spine and Scoliosis Service, Hospital for Special Surgery, Weill Cornell Medical College, New York, NY; and

Department of Orthopaedic Surgery, Washington University School of Medicine, St Louis, MO.

Address correspondence and reprint requests to Venu M. Nemani, MD, PhD, Spine and Scoliosis Service, Hospital for Special Surgery, Weill Cornell Medical College, 535 E 70th St, New York, NY 10021; E-mail:

Acknowledgment date: May 22, 2014. First revision date: August 15, 2014. Second revision date: September 16, 2014. Acceptance date: September 20, 2014.

The manuscript submitted does not contain information about medical device(s)/drug(s).

No funds were received in support of this work.

No relevant financial activities outside the submitted work.

Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.