Synopsis
Detect degenerative cervical cord dysfunction before irreversible hand, gait and sphincter disability, distinguish it from radiculopathy and peripheral disease and expedite specialist decompression assessment.
- Degenerative cervical myelopathy results from static and dynamic cord compression by discs, osteophytes, ligament thickening, facet change or ossification within a developmentally narrow canal.
- Early symptoms are often loss of hand dexterity, dropping objects, difficulty with buttons or handwriting, bilateral paraesthesia and an unsteady or stiff-legged gait rather than severe neck pain.
- Examination may show hyperreflexia below the lesion, Hoffmann sign, inverted supinator response, ankle clonus, extensor plantars, impaired tandem gait and proprioceptive loss.
- A cervical radiculopathy can coexist and produce focal lower-motor-neurone weakness or reduced arm reflexes at the compressed level while the legs remain brisk.
- Bladder urgency or retention and severe imbalance are later or high-risk features; their absence does not exclude clinically important early myelopathy.
- MRI cervical spine is the principal investigation, but degenerative cord indentation is common in asymptomatic adults and becomes myelopathy only when clinical cord dysfunction correlates.
- Cord T2 signal change supports injury and may affect prognosis, yet its absence does not make progressive clinical myelopathy safe to observe without specialist review.
- NICE referral guidance treats gait disturbance, clumsy or weak hands or legs, brisk reflexes, extensor plantars and new sphincter change as reasons not to manage a presumed radiculopathy routinely.
- Surgical decompression aims mainly to stop further neurological decline; improvement may occur but established disability, especially after long delay, can persist.
- Avoid high-velocity cervical manipulation in suspected myelopathy and provide individual falls, driving, work and activity advice while definitive assessment proceeds.
Key red flags
Buttons, coins, keys, handwriting, cutlery and phone use become slow or unreliable, objects are dropped and both hands may feel numb or stiff despite little neck pain.
The legs feel heavy or stiff, balance worsens, tandem walking fails and falls occur, with brisk knees, clonus or extensor plantar responses below the cervical lesion.
Segmental arm weakness, wasting or a reduced reflex coexists with hyperreflexic legs and gait disturbance, indicating cervical cord compression plus radiculopathy rather than an isolated root lesion.
Urinary urgency, hesitancy or retention, bowel dysfunction and major transfer difficulty indicate substantial cord involvement after urological and medication causes are considered.
Investigation priorities
Demonstrate cord compression, level, canal reserve, intramedullary signal and alternative tumour, infection or inflammatory disease.
Management branches
Hand clumsiness, gait change or bilateral symptoms accompany brisk reflexes, plantars or mixed arm and leg signs.
- Document dexterity, segmental strength, all limb reflexes, plantar responses, sensory modalities, gait and bladder or bowel symptoms and ask how quickly function is changing.
- Arrange urgent cervical MRI and specialist spinal referral; use emergency pathways for rapid decline, trauma, loss of walking or new sphincter dysfunction.
- Avoid cervical manipulation and unsafe high-impact activity, assess falls and driving and give explicit return instructions while the patient awaits review.