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This study aimed at determining the frequency of abnormal finger flexion, Hoffman's and extensor plantar (Babinski) response in healthy adults and to determine the sensitivity and specificity of these tests as markers of spinal cord compression in symptomatic patients.
Patients attending the neurosurgery clinic with neck related complaints formed t...
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Context 1
... sensitivity, specificity, positive and negative predictive values (PPV, NPV) of the reflexes to detect spinal cord compression in the symptomatic (case) group (n = 32) are displayed in Table 3. Irrespective of whether a single reflex or a combination of reflexes was evaluated, the specificity attained was 87.5% for all evaluations. ...Similar publications
Background and Objectives: Multiple sclerosis (MS) is a demyelinating disease which usually manifests as clinically isolated syndrome (CIS). Approximately 70% of patients with CIS progress to MS. Therefore, there is a pressing need to identify the most accurate predictive factors of CIS developing into MS, some of which could be a clear clinical ph...
Citations
... A comparative study investigated abnormal long tract signs as a screening tool for spinal cord compression; they demonstrated a high sensitivity (91.7%) and specificity (87.5%) when an abnormal finger flexor reflex, Hoffman sign, and Babinski sign were present on physical examination. 18 It is important to distinguish between pathologic conditions of the cervical cord and the brain because symptoms may overlap. The presence of a jaw jerk reflex (hyperactive jaw reflex when tapping the mandible at the chin) may indicate cranial pathologic condition and warrant further work-up. ...
Degenerative cervical myelopathy is most commonly caused by cervical spondylosis, with a predominant elderly population, and is the most common cause of spinal cord impairment. Patients typically present with gait dysfunction, hand impairment, and/or the presence of long tract signs: clonus, Hoffman sign, Babinski sign, or inverted radial reflexes. One of the key surgical strategies is deciding an approach, which is based on patient characteristics and cause of pathologic condition. Without operative intervention, there is a high rate of neurological decline. Most surgeons recommended surgical treatment given the favorable outcomes and well understood natural history of disease.
... Participants with neck pain were categorized into two groups (those with and those without clinical myelopathic signs) through the performance of four tests for clinical myelopathy signs: (i) Hoffman sign, (ii) Trömner sign, (iii) inverted supinator reflex, and (iv) Babinski sign. The test procedure and diagnostic performance of each clinical myelopathic sign are shown in Appendix A [1,8,9,34,35]. Participants who had at least one positive sign from the four clinical myelopathic tests were determined as having clinical myelopathy. Fifty-two subjects were matched on gender, age (±5 years), and BMI (±2 kg/m 2 ). ...
Patients with neck pain may experience cervical myelopathy, this may be detected by clinical myelopathic signs, although they did not have any symptom of myelopathy, except having neck pain. Decreasing physical performance is one symptom of cervical myelopathy that can lead to reduced quality of life in the elderly, however, in adult neck pain with clinical myelopathic signs have not been evaluated. Therefore, this research aimed to compare physical performance in two groups of adult patients with neck pain: those with and without clinical myelopathic signs. A total of 52 participants, gender, age, and body mass index (BMI) matched were allocated into 2 groups of 26 subjects with neck pain, those with, and without, clinical myelopathic signs. The grip and release test, nine-hole peg test, ten second step test and foot-tapping test were evaluated. The group of neck pain participants with clinical myelopathic signs exhibited greater impairment in all the tests than the group without clinical myelopathic signs (p < 0.001). Effect sizes (Cohen’s d) were grip and release test: 2.031, nine-hole peg test: 1.143, ten second step test: 1.329, and foot-tapping test: 0.798. Neck pain participants with clinical myelopathic signs demonstrated reduced physical performance. Physical performance tests may need to assessed in adult patients with neck pain who had clinical myelopathic signs.
... The Hoffmann's Sign is traditionally performed with the cervical spine in neutral and elicited by flicking the distal phalanx of the 3 rd finger downward and observing for involuntary flexion of the ipsilateral thumb or index finger [15][16][17]. Sensitivity values for screening cervical spinal cord compression range from 59% [16] to 75% [18], with a negative likelihood ratio of 0.74 [10], making it a questionable screening assessment to rule out CSM. Conversely, the presence of Hoffmann's Sign, which is more specific (0.73) than sensitive, may indicate upper motor neuron dysfunction; however, the positive likelihood ratio (4.9) makes it a questionable, stand-alone finding to implicate CSM [10]. ...
Background:
Neurologic clustering of findings is recommended with Cervical Spondylotic Myelopathy (CSM). Hoffmann's Sign and Reverse Lhermitte's Sign have been associated with CSM, which, however, have not been discussed as the only objective findings that may cause clinical uncertainty.
Case description:
This case report describes how sensitizing Hoffmann's Sign following a Reverse Lhermitte's Sign guided reasoning, with a 66-year-old male presenting with a right lumbar radiculopathy diagnosis. Local lumbar symptoms and impairments were identified, however, a Reverse Lhermitte's Sign with cervical extension was the only finding that reproduced right lower extremity (LE) pain. Hoffmann's Sign, the only abnormal neurologic finding, became exaggerated when performed in cervical extension. Concern of an early presenting CSM accounting for right LE pain was considered. A neurosurgical consultation was initiated with concurrent guideline-based lumbar spine treatment and continued monitoring of neurologic status.
Outcomes:
Seven weeks after evaluation, sudden worsening of right LE symptoms, hand numbness, ataxia, and grip weakness occurred. Cervical magnetic resonance imaging demonstrated C3-6 cord compression. A multi-level cervical decompression surgery was performed.
Discussion:
Using a sensitized Hoffmann's Sign-in response to a Reverse Lhermitte's Sign aided differential diagnosis of an early presenting CSM with reports of LE pain. The diagnostic utility of a sensitized Hoffmann's Sign is unknown.
... The neurological examination can be challenging, even in experienced hands, with signs often in fact incidental. 47,48 Specialists often tailor their assessment to the specific neurological differential, without consensus on a minimum and standard assessment. 42 In a retrospective study of patients presenting with DCM to a single center, Hilton et al (2018) demonstrated the assessment was different between primary care, secondary care, and spinal surgery 49 ; in particular primary care focusing on peripheral limb strength, whereas secondary care and spinal surgery long-tract signs. ...
Study Design
Literature Review (Narrative)
Objective
To introduce the number one research priority for Degenerative Cervical Myelopathy (DCM): Raising Awareness.
Methods
Raising awareness has been recognized by AO Spine RECODE-DCM as the number one research priority. This article reviews the evidence that awareness is low, the potential drivers, and why this must be addressed. Case studies of success from other diseases are also reviewed, drawing potential parallels and opportunities for DCM.
Results
DCM may affect as many as 1 in 50 adults, yet few will receive a diagnosis and those that do will wait many years for it. This leads to poorer outcomes from surgery and greater disability. DCM is rarely featured in healthcare professional training programs and has received relatively little research funding (<2% of Amyotrophic Lateral Sclerosis or Multiple Sclerosis over the last 25 years). The transformation of stroke and acute coronary syndrome services, from a position of best supportive care with occasional surgery over 50 years ago, to avoidable disability today, represents transferable examples of success and potential opportunities for DCM. Central to this is raising awareness.
Conclusion
Despite the devastating burden on the patient, recognition across research, clinical practice, and healthcare policy are limited. DCM represents a significant unmet need that must become an international public health priority.
... A high risk of bias resulted in 12 articles being excluded from further analysis. [33][34][35][36][37][38][39][40][41][42][43][44][45] Consequently, 19 articles from 10 countries were included in the present analysis [1][2][3]5,20,[46][47][48][49][50][51][52][53][54][55][56][57][58][59] (Table 1). ...
Study Design
Systematic review and meta-analysis.
Objectives
Cervical spinal cord compression (SCC) due to degenerative changes of the spine is a frequent finding on magnetic resonance imaging (MRI). While most people remain asymptomatic, a proportion develop symptoms of degenerative cervical myelopathy (DCM). DCM is an often-progressive neurological disease that can cause quadriplegia. The epidemiology of SCC and DCM is poorly understood. We sought to estimate the prevalence of degenerative cervical SCC and DCM from cross-sectional cohorts undergoing MRI.
Methods
We conducted a systematic review and meta-analysis of MRI reports on human subjects older than 16 years with degenerative SCC. A predetermined search strategy was used to identify relevant literature on MEDLINE. Title and abstract screenings were followed by full text screening. Data was extracted and analyzed by fixed or random-effects models.
Results
The present search returned 1506 publications. Following our exclusion criteria, 19 studies were included. Subgroup analysis of 3786 individuals estimated the prevalence of asymptomatic SCC in a healthy population as 24.2% with a significantly higher prevalence of SCC in older populations compared with younger populations and American/European populations compared with Asian populations. Subgroup analysis of 1202 individuals estimated the prevalence of DCM in a healthy population as 2.3%.
Conclusions
We present the first estimates of the prevalence of asymptomatic SCC and DCM. Studies investigating the epidemiology of SCC are heterogeneous in methodology and results. These data indicate the need for more studies into the epidemiology of SCC and DCM performed with consistent methodologies.
... Therefore, testing of a single reflex is insufficient to detect early DCM. However, a combination of Hoffmann's reflex, extensor plantar reflex, and finger flexion reflex may be used as a rapid screening tool [30]. When tested together, these reflexes have been shown to have a sensitivity of 91.67% and specificity of 87.5% in determining if a patients symptoms are due to cervical spinal cord compression. ...
Introduction
Degenerative Cervical Myelopathy [DCM] often presents with non-specific symptoms and signs. It progresses insidiously and leads to permanent neurological dysfunction. Decompressive surgery can halt disease progression, however significant delays in diagnosis result in increased disability and limit recovery. The nature of early DCM symptoms is unknown, moreover it has been suggested incomplete examination contributes to missed diagnosis. This study examines how DCM is currently assessed, if assessment differs between stages of healthcare, and whether this influences patient management.
Study design
Retrospective cohort study.
Methods
Cervical MRI scans (N = 1123) at a tertiary neurosciences center, over a single year, were screened for patients with DCM (N = 43). Signs, symptoms, and disease severity of DCM were extracted from patient records. Patients were considered at 3 phases of clinical assessment: primary care, secondary care, and surgical assessment.
Results
Upper limb paraesthesia and urinary dysfunction were consistently the most and least prevalent symptoms respectively. Differences between assessing clinicians were present in the reporting of: limb pain (p<0.005), objective limb weakness (p = 0.01), hyperreflexia (p<0.005), Hoffmann reflex (p<0.005), extensor plantar reflex (p = 0.007), and lower limb spasticity (p<0.005). Pathological reflexes were least frequently assessed by primary care doctors.
Conclusion
DCM assessment varies significantly between assessors. Reporting of key features of DCM is especially low in primary care. Incomplete assessment may hinder early diagnosis and referral to spinal surgery.
... De meest voorko- mende klinische aanwijzingen die, elk afzonderlijk, kunnen wijzen op cervicaal myelumlijden zijn hyper- reflexie (94%), een (bilaterale) Hoffmannreflex (81%) en teken van Babinski (53%) (24). De sensitiviteit (91,67%) en specificiteit (87,5%) van de combinatie van deze drie testen zijn bij symptomatische patiën- ten hoger dan voor elke test apart en maakt de com- binatie dus uiterst geschikt en betrouwbaar om cer- vicaal myelumlijden vast te stellen (25). ...
Samenvatting Deze leidraad biedt de verzekeringsarts ondersteuning bij de verzekeringsgeneeskundige controle en begeleiding naar werkhervatting van de verzekerde na aangifte van arbeidsongeschiktheid door de gevolgen van een whiplashtrauma zonder objectiveerbare afwijkingen (WAD I/II). Het gebruik van deze leidraad helpt de verzekeringsarts om, op basis van de huidige stand van de wetenschappelijke kennis over WAD I/II, te anticiperen op mogelijke probleemsituaties, chronifi-catie van klachten te vermijden, en een snelle re-integratie in het arbeidscircuit te bewerkstelligen teneinde langdurig werkverzuim en blijvende arbeidsongeschiktheid te voorkomen. Een stroomdiagram werd ontwikkeld als hulpinstrument om de arts de mogelijkheid te bieden om tot een snelle en accurate classificatie te komen, alarmsignalen te herkennen, en op basis van deze gegevens een probleemgestuurde anamnese, klinisch onderzoek en risicoanalyse uit te voe-ren met behulp van specifieke meetinstrumenten en klinische testen om, indien nodig, de verze-kerde via zijn huisarts naar gespecialiseerde hulp te verwijzen en een snellere arbeidsre-integratie te bekomen. In de huidige tijdsgeest van evidence-based medicine en arbeidsre-integratie kunnen niet alleen slachtoffers en artsen voordeel halen uit deze interactieve relatie maar kan de ganse maatschappij profiteren van de anticiperende rol van de verzekeringsarts die niet alleen letselschade vaststelt maar ook menselijke en economische schade probeert te voorkomen. Inleiding Whiplash is de verzamelnaam geworden voor een aantal symptomen die het gevolg zijn van een plotse hyperextensie-hyperflexiebeweging van de cervicale wervelkolom die op haar beurt meestal het gevolg is van een acceleratie-deceleratiemechanisme. De term verwijst naar het ongevalmechanisme en niet naar de diagnose. We spreken van "whiplash associated disor-der" (WAD) graad I/II wanneer na een whiplash trauma geen objectiveerbare afwijkingen aanwezig zijn, maar wel klachten zoals pijn, stijfheid en gevoeligheid van de nek en musculoskeletale klachten (1) Indien er wel objectief vastgestelde schade aanwe-zig is (zoals fracturen of dislocaties) spreekt men van WAD III/IV. Dat ligt buiten de beschouwing van deze richtlijn (1). De incidentie van whiplashtrauma's is de laatste decennia sterk gestegen en varieert van 16 tot 2.000 per 100.000 inwoners, afhankelijk van de geografische ligging en het gangbare verzekeringssysteem (2, 3). De totale kost van deze traumagerelateerde nekpijn bedraagt in Europa meerdere miljarden euro per jaar (2). Ondanks de classificatie van WAD I/II als mineur letsel gaat deze pathologie gepaard met aanzienlijke morbiditeit, kosten en productieverlies (2, 3). Weten-schappelijke informatie over arbeidsgerelateerde effecten zoals ziekteverzuim en arbeidsongeschikt-heid is schaars, en afhankelijk van de lokale uitke-ringswetgeving.
... However, like the symptoms, combinations of examination findings may improve diagnostic accuracy. Tejus et al. showed that a combination of the finger flexion, Hoffman's and plantar reflexes could be used effectively as a marker of cervical spinal cord compression in patients with neck-related complaints, with a sensitivity of 91.7% and a specificity of 87.5%, and their absence had a negative predictive value of 77.8% [45]. Whilst examination findings would be limited to professional use, they could be a helpful addition to diagnostic algorithms, and their predictive power with symptoms requires further assessment. ...
BACKGROUND
Degenerative cervical myelopathy (DCM) is a common debilitating condition resulting from degeneration of the cervical spine. While decompressive surgery can halt disease progression, existing spinal cord damage is often permanent, leaving patients with lifelong disability. Early surgery improves the likelihood of recovery, yet the average time from the onset of symptoms to correct diagnosis is over 2 years. The majority of delays occur initially, before and within primary care, mainly due to a lack of recognition. Symptom checkers are widely used by patients before medical consultation and can be useful for preliminary triage and diagnosis. Lack of recognition of DCM by symptom checkers may contribute to the delay in diagnosis.
OBJECTIVE
The aims of this study were to investigate whether Web-based symptom checkers were able to recognize relevant symptoms of DCM, to characterize the DCM differential they returned , and to evaluate the diagnostic performance of recognized DCM symptoms.
METHODS
We pooled classical DCM symptoms from leading review articles. These symptoms were entered into the algorithms used by the top 20 symptom checker websites (N=4; Google Search). The most widely cited symptom checker, WebMD, was used to characterize the differential diagnosis for DCM symptoms.
RESULTS
A total of 31 classical DCM symptoms were identified, of which 45% (14/31) listed DCM as a differential and 10% (3/31) placed DCM in the top third of the differential. The mean differential rank for motor symptoms was significantly better than that for arthritic symptoms (P=.01) and the average differential rank for all symptoms (P=.048). The symptom checker WebMD performed best at recognizing DCM, placing the condition nearer to the top of the differential list (mean rank of 5.6) than either Healthline (rank of 12.9, P=.02) or Healthtools.AARP (rank of 15.5, P=.001). On WebMD, only one combination of symptoms resulted in DCM as the primary differential: neck, shoulder, and arm pain with hand weakness. Moreover, 151 differential diagnoses for DCM symptoms were recorded on WebMD. Multiple sclerosis and peripheral neuropathy were the most common differentials, shortlisted for 52% (16/31) and 32% (10/31) of the DCM symptoms, respectively.
CONCLUSIONS
DCM symptoms are poorly identified by Web-based symptom checkers, which leads to a large differential of many other common conditions. While a diagnosis becomes more likely as the number of symptoms increases, this represents more advanced disease and will not support much-needed earlier diagnosis. Symptom checkers remain an attractive concept with potential. Further research is required to support their optimization.
... However, like the symptoms, combinations of examination findings may improve diagnostic accuracy. Tejus et al. showed that a combination of the finger flexion, Hoffman's and plantar reflexes could be used effectively as a marker of cervical spinal cord compression in patients with neck-related complaints, with a sensitivity of 91.7% and a specificity of 87.5%, and their absence had a negative predictive value of 77.8% [47]. Whilst examination findings would be limited to professional use, they could be a helpful addition to diagnostic algorithms, and their predictive power with symptoms requires further assessment. ...
Background:
Degenerative Cervical Myelopathy (DCM) is a common debilitating condition resulting from degeneration of the cervical spine. Whilst decompressive surgery can halt disease progression, existing spinal cord damage is often permanent, leaving patients with lifelong disability. Early surgery improves the likelihood of recovery, yet the average time from onset of symptoms to correct diagnosis is over 2 years. The majority of delays occur initially, before and within primary care, mainly due to a lack of recognition. Symptom checkers are widely used by patients before medical consultation and can be useful for preliminary triage and diagnosis. Lack of recognition of DCM by symptom checkers may contribute to the delay in diagnosis.
Objective:
The present study sought to investigate whether online symptom checkers are able to recognise relevant symptoms of DCM, to characterise the DCM differential returned, and to evaluate the diagnostic performance of its recognised symptoms.
Methods:
Classical DCM symptoms were pooled from leading review articles. These symptoms were entered into the algorithms used by the top 20 symptom checker websites (N=4) (Google Search). The most widely cited symptom checker, WebMD, was used to characterise the differential diagnosis for DCM symptoms.
Results:
31 classical DCM symptoms were identified, of which 14 (45%) listed DCM as a differential and 3 (10%) placed DCM in the top third of the differential. The mean differential rank for motor symptoms was significantly better than for arthritic symptoms (P = .0093) and the average differential rank for all symptoms (P = .048). The symptom checker WebMD performed best at recognising DCM, placing it nearer the top of the differential list (average rank of 5.6) than both Healthline (rank of 12.9, P = .015) and Healthtools.AARP (rank of 15.5, P = .0014). On WebMD, only one combination of symptoms resulted in DCM as the primary differential: neck, shoulder and arm pain with hand weakness. 151 differential diagnoses for DCM symptoms were recorded on WebMD. Multiple sclerosis and peripheral neuropathy were the most common differentials, shortlisted for 52% and 32% of DCM symptoms respectively.
Conclusions:
DCM symptoms perform poorly in online symptom checkers and lead to a large differential of many other common conditions. Whilst a diagnosis becomes more likely as the number of symptoms increases, this will not support much needed earlier diagnosis. Symptom checkers remain an attractive concept with potential. Further research is required to support their optimisation.
... Healthy volunteers were selected as controls. 22 The Hoffman was performed independently by a physiotherapist and a neurosurgeon. It was considered positive if it was present on either side, on at least two out of the three attempts. ...
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 exam 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 1 January 1947 to 1 March 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 non-degenerative type of cervical myelopathy, and/or no evaluation with MRI.
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 3 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 (LR) of 2.2 (95% CI 1.5-3.3) and a negative LR 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 to the gold standard test (MRI). 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.
