CERVICAL SPONDYLOTIC

MYELOPATY

Professional Chiropractic Practice 1 (CHIR13008)

Term 1, 2020

By: Georgia Evrat, Caitlin Briggs and Edward Atkins

(Edward Atkins): There is a large diversity among patients in regard to characteristics,
presentations, severity and onset when dealing with different conditions. Understanding
this substantial diversity allows for more effective and efficient treatment and diagnosis
(Windgassen et al., 2018). Clustering is a method in which this multiplicity can be better
understood. It describes a set of methods or system that seek to classify data, techniques or
groups. It's relevant to research in all scientific disciplines because in some way they all rely
on classification (Leonard & Droege., 2008). It combines certain subgroups or analysis tools
with similar characteristics or diagnostic results, its ultimate goal is to produce an effective
and reliable diagnostic criteria tailored to the condition or issue in question. In regards to
chiropractic, such a tool can be used to group testing techniques for specific conditions,
allowing practitioners to have several means by which they can confirm or negate possible
conditions when trying to determine the underlying pathology affecting their patient.
However, the specificity, sensitivity and likelihood ratios of the tests used within the cluster
must first be analysed to ensure they are effective and accurate.

In the following video Caitlin, Georgia and I will create and scrutinise a cluster of testing
procedures used in the diagnosis of Cervical Spondylotic Myelopathy (CSM). CSM is a
characteristic pattern of neurological signs and symptoms that occur due to damage to the
cervical spinal cord, it is often associated with age-related degenerative changes within the
cervical spine that compress or squash the spinal cord (Alli, Anderson & Khan., 2017).

One of the most common signs of CSM is hyperreflexia, 94% of subjects in Chikuda et al.
(2010) and 85% of subjects in Harrop et al. (2010) studies were found to have it present.
Hyperreflexia is often caused by an upper motor neuron lesion, which refers to pathologies
above the pyramidal decussation of the later corticospinal tract. Which is the most
important descending motor pathway of the body and is responsible for the movement of
the limbs (Blumenfeld, 2010. p. 232). In regard to CSM, this upper motor neuron lesion is
caused by the compression, pinching or any other causes of interference of the spinal cord
within the cervical region. To confirm the presence of an upper motor neuron lesion the
reflexes should be tested in both upper and lower extremities. 
The first examination of the cluster for CSM is the Hoffman’s test. If there is any flexion of
the index finger and thumb it is considered to be a positive Hoffman’s sign (Glaser et al.,
2001). This test elicits reactions from the flexor pollicis brevis (thumb flexion) and flexor
digitorum superficialis (second finger flexion), through the provocation of the profundus
muscle in the third digit. All muscles involved are innervated by the median nerve of the
arm, which is made up by lateral cords which come from the nerve roots of C5-C7 and the
medial cord which comes from C8 and T1. All of which meet to form the median nerve after
leaving the brachial plexus (Blumenfeld, 2010) (Moore, Dalley & Agur., 2014). A positive
test, therefore, suggests possible neurological issues within the area of the spine
responsible for the passage of motor neurons used in these muscles.

The second test in the cluster is the Ankle Clonus test. If clonus is present there with be a
series of involuntary, rhythmic, muscular contractions and relaxations against the pressure
of the hand, giving the test a positive result (Zimmerman & Hubbard., 2019). This
examination tests the muscles responsible for dorsiflexion of the foot which includes the
tibialis anterior, fibularis tertius as well as extensor digitorum and hallucis longus all of
which are innervated by the deep fibular nerve which arises from L4-L5. It also stretches the
foot’s plantarflexes such as the gastrocnemius and soleus which are innervated by the tibial
nerve which arises from S1-S2. As well as the tibialis posterior which is also innervated by
the tibial nerve but from the branch that arises from L4-L5. All nerves mentioned exit the
spine via the lumbar plexus which motor functions are also supplied via the lateral
corticospinal tract. Therefore, a positive test can indicate some pathology related to this
neural pathway (Moore, Dalley & Agur. 2014., p. 591, 597-598).

(Caitlin Briggs): Thank you Eddie. Here I will demonstrate gait analysis in a patient with CSM
and the typical features that present with this condition. Patients with CSM will have a
characteristic broad-based, slow paced gait and will often complain of difficulty maintaining
balance when walking, and often describes their gait as clumsy and uncoordinated. Upon
further investigation, the doctor will notice that the patient has reduced cadence, shorter
stride lengths, decreased knee flexion, and a longer double-support duration, which would
be expected when considering the patient’s loss of balance (Malone et al., 2012). The
symptoms of gait deviation are attributed to cervical spinal cord compression as a result of
the spondylosis of the cervical spine.

Upon examination of the patient’s history, be sure to listen carefully for any mention of
recent falls or loss of balance while walking, as gait changes are often a primary symptom of
CSM. The patient may describe their walking as staggering or clumsy. An important question
to ask the patient is, “Have you found that you’re having trouble walking over uneven
surfaces or had any loss of balance when you’re walking?”. The answer to that question may
be an important indication to consider CSM as a likely diagnosis.

It is important for clinicians to monitor high-risk patients for CSM as it is a potentially

devastating condition the further it progresses. One such risk factor for CSM is an age over
45 years. Spondylosis is mostly attributed to dehydration of the intervertebral discs as we
age, resulting in increased fibrocartilage. As a result of this, the articular surfaces of the
vertebrae approximate, and in most cases, osteophytes ensue. These degenerative disc
changes and osteophytes are responsible for the pain and stiffness many patients may
experience. Subsequently, cervical myelopathy is ultimately a result of spondylosis in the
cervical spine due to compression on the spinal cord and spinal nerve roots. This may give
rise to upper and lower motor neuron symptoms indicative of CSM. It is important,
however, to never rule out a patient under the age of 45 years from the diagnosis of CSM, as
symptoms may appear as early as 20 years old. Over to you, Georgia.

(Georgia Evrat): Thank you, Caitlin. The Babinski test is also included in Cook’s cluster for
indicating Cervical Spondylotic Myelopathy. The patient is relaxed in the supine position.
Using the pointed end of the reflex hammer or a pointed object, the examiner swipes along
the plantar surface of the lateral aspect of the foot from the heel towards the great toe in a
forward and medial motion across the ball of the foot. In regard to the anatomy of the
tissue being challenged, the Babinski test stimulates a response from the nociceptive fibres
in the S1 dermatome (Cook et al., 2010, p. 175-180). The detection of this stimulation will
travel up the tibial and sciatic nerve to S1 in the spine and synapse with the anterior horn
cells. A normal response from the test will result in either a neutral response or plantar
flexion as this motor response is mediated through the S1 root and tibial nerve (Aninda et
al., 2019).
A positive indication for the Babinski test will result in the contraction of toe extensors,
being the extensor hallucis longus and extensor digitorum longus via the deep peroneal
nerve which displays as dorsiflexion and fanning of the other toes (Aninda et al., 2019). This
may indicate a spread in the sensory input beyond the S1 myotome to L4 and L5. This can
potentially suggest loss of integrity of the corticospinal tract and an upper motor neuron
lesion (Aninda et al., 2019). Back to you, Caitlin.

(Caitlin Briggs): Thank you Georgia. Clustering in Cervical Spondylotic Myelopathy brings
with it a host of benefits and limitations. This is due to the complexity of the condition that
can manifest itself differently in almost every patient.

Firstly, I will discuss the benefits of clustering in CSM. Considering the diverse nature of
CSM, it is important to identify a cluster of tests that accommodates for each symptom and
sign. The cluster that we have identified demonstrates the ability to evoke a response from
the broad range of symptoms. There are multitudes of tests that could be performed to get
a diagnosis, so this cluster of tests accurately narrow down the diagnosis, saves the
practitioner a lot of time, and, according to Brown et al., has the ability to, “Overcome the
weakness of stand-alone tests” (Cook et al., 2010). Cook et al. claim that this cluster of tests
are necessary to, “Suspect and rule in CSM, then MRI can confirm the diagnosis” ( Cook et al,
2010). That is to say, these tests carry heavy weight in diagnosing the condition.

Opposingly, the main limitation in clustering for CSM is the possible late presentation of
symptoms. Therefore, it is likely that false negative responses are evoked from a patient
when this cluster is performed. There is controversy over the reliability of a specific cluster
of tests used to diagnose CSM, limiting its validity. One such argument explains that the
tests performed are highly specific, such as Babinski’s and Hoffmann’s tests, verses highly
sensitive. This may result in a high number of false negative results (Cook et al., 2009). The
same study from Brown et al. suggests that no cluster of tests has proven more beneficial in
identifying CSM than stand-alone tests. Back to you, Georgia.
(Georgia Evrat): The incorporation of clusters in chiropractic practice provides multiple
benefits in regard to the practicality in reaching an accurate diagnosis in clinic. A cluster of
predictive clinical tests can serve as a consistent and efficient systematic evaluation for each
presenting patient through performing the least amount of testing for the most amount of
information. Performing the same cluster of tests for patients presenting with the same
clinical pathology makes it much easier for the chiropractor to quickly identify discrepancies
between these patients (Chad et al., 2011, p. 539-546). A primary example of this is Cook’s
cluster, five clinical findings that can be performed very easily and quickly can provide a
highly specific diagnosis for CSM whereby, the patient can then receive the appropriate
management of care in less time (Cook et al., 2010, p. 175-180). This highly supports the fit
of clusters in chiropractic practice due to their ability to confirm diseases earlier in the stage
of the condition or rule out the condition in this screening.

The creation of a cluster is a combination of tests with the strongest likelihood ratio from
research with the highest quality (Chad et al., 2011, p. 539-546). As seen to the side of me,
this table displays the sensitivity, specificity, positive likelihood ratio and negative likelihood
ratio percentages of the tests which pose value to identifying myelopathies. Five clinical
tests being, gait deviation, a positive Hoffman’s test, inverted supinator sign, positive
Babinski test, an age greater than 45 and alternatively some other forms of hyperreflexia
testing demonstrate the capacity when clustered, to rule out cervical spine myelopathy if
there is one or none of the five tests revealing positive (Cook et al., 2010, p. 175-180). This
has a negative likelihood ratio of 0.18, 95%. When clustered into three out of the five tests
revealing positive, indicating a CSM, it has a positive likelihood ratio of  30.9, 95%. Cook et
al. (2010) highlights in this table that when combinations of these tests are clustered, they
increase the specificity and likelihood ratios of ruling in and ruling out CSM compared to
these stand-alone tests. These clusters may be useful in identifying patients with this
complex diagnosis in similar patient populations.
 (Cook et al., 2010, p. 175-180)

Overall, when these tests are used alone, they are not overtly diagnostic and may lead to
multiple false negatives and even on some occasions, false positives (Chad et al., 2011, p.
539-546). Therefore, we combine appropriate and complimenting tests together that are
more reflective of comprehensive examination findings and provide a more accurate
diagnosis without unnecessary costs or invasive procedures.
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