A 62-year-old woman comes to the office due to progressive gait unsteadiness. The patient's legs feel stiff, and she frequently stumbles and has to hold handrails while descending stairs. She also has had tingling and numbness in the hands and an occasional electric shock-like sensation in the spine. She has had no bowel or bladder incontinence. The patient has fibromyalgia and continues to have shoulder and neck pain despite a recent dosage increase in duloxetine. Other medical conditions include depression and hypothyroidism. She does not use tobacco, alcohol, or illicit drugs. Examination of the cranial nerves is normal. Upper extremity muscle strength is decreased, with mild wasting of intrinsic hand muscles. Lower extremity tone and reflexes are increased bilaterally. Sensation is grossly intact. Which of the following is the most likely cause of this patient's current condition?

Question

A 62-year-old woman comes to the office due to progressive gait unsteadiness.  The patient's legs feel stiff, and she frequently stumbles and has to hold handrails while descending stairs.  She also has had tingling and numbness in the hands and an occasional electric shock-like sensation in the spine.  She has had no bowel or bladder incontinence.  The patient has fibromyalgia and continues to have shoulder and neck pain despite a recent dosage increase in duloxetine.  Other medical conditions include depression and hypothyroidism.  She does not use tobacco, alcohol, or illicit drugs.  Examination of the cranial nerves is normal.  Upper extremity muscle strength is decreased, with mild wasting of intrinsic hand muscles.  Lower extremity tone and reflexes are increased bilaterally.  Sensation is grossly intact.  Which of the following is the most likely cause of this patient's current condition?

Quizplus · Accepted Answer

Explanation: This patient's gait unsteadiness, shock sensation in the spine, atrophy/weakness in the upper extremities, and increased tone/reflexes in the lower extremities raise suspicion for spinal cord compression (myelopathy) in the cervical spine. Myelopathy is most common in older adults who have cervical spondylosis, a degenerative condition associated with spinal canal narrowing due to the formation of osteophytes in the lateral vertebral bodies and ossification of the posterior longitudinal ligament/ligamentum flavum. In approximately 15% of patients, canal narrowing causes mechanical spinal cord compression and interruption of blood supply to the cord, resulting in cervical spondylotic myelopathy. Manifestations include insidious, progressive neurologic deficits in the upper and lower extremities due to: Damage to the cervical spine nerve roots (peripheral nervous system), which leads to neck pain that radiates to the shoulders/arms and lower motor neuron findings (eg, weakness, atrophy, reduced reflexes) in a myotome/dermatome distribution in the upper extremities Damage to the spinal cord descending tracts (central nervous system), which leads to unsteady gait (spastic, scissoring walk), a sensation of leg weakness/stiffness, and upper motor neuron signs (eg, increased reflexes, increased tone, upgoing Babinski sign) in the lower extremities An electric shock-like sensation down the spine with forward flexion of the neck (Lhermitte sign) is also commonly seen. MRI scan of the cervical spine is the first test of choice, but myelography is often required. Surgical decompression is sometimes necessary for those with moderate/severe symptoms or progressive neurologic dysfunction. (Choice A) Amyotrophic lateral sclerosis is a demyelinating polyneuropathy that typically causes both upper and lower motor neuron signs. However, most patients present with asymmetric (not symmetric) limb weakness and atrophy; in addition, Lhermitte sign is atypical, and cervical spondylotic myelopathy is far more common. (Choice B) Lumbar spinal stenosis is associated with low back pain and sensory loss/weakness in the lower extremities exacerbated by prolonged walking/standing and alleviated by sitting/lying (pseudoclaudication). Upper motor neuron signs are absent, and the upper extremities are unaffected. (Choice C) Spinal cord inflammation from multiple sclerosis can cause Lhermitte sign and upper motor neuron findings; however, lower motor neuron symptoms are absent because the disease does not affect the peripheral nervous system. In addition, most cases arise in young adults. (Choice D) Polymyositis is an inflammatory myopathy associated with symmetric, proximal skeletal muscle weakness. Spasticity and increased reflexes would not be seen. Educational objective: Cervical spondylotic myelopathy is common in older adults and generally presents with progressive neck pain, gait disturbances, lower motor neuron signs in the upper extremities (eg, weakness, diminished reflexes), and upper motor neuron signs in the lower extremities (eg, increased reflexes, spasticity).

A 62-Year-Old Woman Comes to the Office Due to Progressive