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A Systematic Review of the Utility of the Hoffmann Sign for the Diagnosis of Degenerative Cervical Myelopathy

Fogarty, Alexandra, MD; Lenza, Eric, MD; Gupta, Gaurav, MD, FRCPC; Jarzem, Peter, MD, FRCSC; Dasgupta, Kaberi, MD, MSc, FRCPC; Radhakrishna, Mohan, MD, FRCPC

doi: 10.1097/BRS.0000000000002697

Study Design. Systematic review.

Objective. To determine the validity of the Hoffmann sign for the detection of degenerative cervical myelopathy (DCM) for patients presenting with cervical complaints.

Summary of Background Data. While physical examination maneuvers are often used to diagnose DCM, no previous review has synthesized diagnostic accuracy data.

Methods. Medline, Embase, and HealthStar were searched for articles from January 1, 1947 to March 1, 2017 using the following terms: Spinal Cord Diseases, Spinal Cord Compression, Cervical Vertebrae, Signs and Symptoms, Physical Examination, Epidemiologic studies, Epidemiologic Research Design, Predictive Value of Tests, and Myelopathy. The Quality Assessment of Diagnostic Accuracy Studies (QUADAS) checklist was applied to determine the level of evidence. Articles included were published in English or French language, rated as QUADAS level 3 or higher with a minimum 10 patients presenting with cervical complaints having undergone the Hoffman sign. Excluded studies recruited patients with a nondegenerative type of cervical myelopathy, and/or no evaluation with magnetic resonance imaging.

Results. A total of 589 articles were selected for review. Following the application of inclusion and exclusion criteria, 45 articles were analyzed using the QUADAS checklist. Only of three articles were of QUADAS quality 3 or higher. Analysis of combined data from 2/3 studies indicated that the Hoffman sign has a positive likelihood ratio of 2.2 (95% CI 1.5–3.3) and a negative likelihood ratio of 0.63 (95% CI 0.5–0.8).

Conclusion. A positive Hoffman alone is unlikely to lead to more than a small change in estimated probability of DCM as compared with the gold standard test (magnetic resonance imaging). Variability in results across individual studies may result from differences in study design. There are insufficient data to support use of the Hoffman sign alone to confirm or refute a diagnosis of DCM.

Level of Evidence: 1

McGill University Health Centre, Montreal General Hospital Site, Montréal, Québec, Canada.

Address correspondence and reprint requests to Mohan Radhakrishna, MD, FRCPC, McGill University Health Centre, Montreal General Hospital Site, 1650 Cedar Avenue, Room L7-510, Montréal, Québec, H3G 1A4, Canada; E-mail:

Received 17 January, 2018

Revised 24 February, 2018

Accepted 09 April, 2018

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

No funds were received in support of this work.

Relevant financial activities outside the submitted work: grants, payment for lecture.

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