Bilateral Hand Clumsiness and Unsteady Gait
A 57-year-old right-handed woman reports 8 months of bilateral hand numbness and clumsiness - she drops coins, cannot fasten buttons, and has twice burned herself while cooking. Over the same period she has developed progressive unsteadiness, worst in the dark, with two falls in the last 3 months. She denies bowel or bladder change and denies neck pain apart from morning stiffness. Examination: wide-based, mildly ataxic gait; Romberg positive with eyes closed; biceps and brachioradialis reflexes 3+ and symmetric; Hoffmann sign present bilaterally; ankle clonus of 2 beats bilaterally; pinprick intact throughout; vibration reduced at the great toes; no intrinsic hand wasting. Cervical range of motion is full and painless.
1. Which findings localize this to the spinal cord rather than to bilateral carpal tunnel syndrome or a peripheral neuropathy, and how do you weigh them?
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The localizing signature is upper motor neuron signs plus a posterior column sign, in the absence of a lower motor neuron lesion explaining them.
| Finding | Meaning |
|---|---|
| Hoffmann bilaterally, 3+ biceps/brachioradialis, 2-beat clonus | UMN corticospinal involvement - cord or above, not a peripheral nerve |
| Ataxic, wide-based gait + positive Romberg + vibration loss at the toes | Dorsal column / posterior cord involvement |
| Numb, clumsy hands with preserved pinprick and no thenar wasting | Cervical myelopathy's classic “numb clumsy hands”; myelopathy, not median nerve entrapment |
Why not bilateral carpal tunnel: CTS is a median-distribution, nocturnal, activity-related sensory syndrome. It does not produce Hoffmann signs, clonus, hyperreflexia, Romberg positivity, or toe vibration loss. Bilateral CTS can coexist - but it cannot explain this exam. Why not a peripheral neuropathy: neuropathy is length-dependent, gives hyporeflexia, and does not produce Hoffmann or clonus. The combination of hyperreflexia and posterior column loss is central.
Caveats to state: Hoffmann is sensitive but not specific (a normal variant in some, absent in some with stenosis); clonus of 2 beats is a soft finding and needs corroboration. The pattern - UMN signs, hand dysfunction out of proportion to pain, gait disorder - is what carries the diagnosis.
Also on the differential and needing exclusion: vitamin B12 deficiency/subacute combined degeneration, copper deficiency, multiple sclerosis, syringomyelia, and intraspinal tumor. Cervical spondylotic myelopathy is the most likely given her age, but “most likely” is not “confirmed.”
2. What will you add to the examination, what will you order, and how urgent is this?
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Add to the exam:
- Grip-and-release test (10 seconds) and 9-hole peg test - quantifies hand dysfunction and gives you a baseline to re-measure.
- Gait speed / timed 10-metre walk - objective, repeatable.
- Babinski, lower-limb reflexes, and superficial abdominal reflexes - establishes the level and confirms UMN signs below the lesion.
- Lhermitte sign and a careful sensory level.
- Cranial nerve screen and upper-limb coordination to keep a central/above-foramen magnum cause in view.
Order:
- MRI of the cervical spine without contrast (with contrast if tumor or infection is suspected) - this is the definitive study. Plain films cannot assess the cord.
- B12, folate, methylmalonic acid, copper, CBC - cheap, and a treatable mimic.
- Consider brain imaging if cranial findings or optic neuritis symptoms emerge.
Urgency: this is urgent but not emergent. No bowel/bladder change and no rapidly progressive weakness means it is not a same-hour emergency, but progressive myelopathy with two falls and 8 months of decline warrants MRI and neurological/surgical referral within days, not weeks. Document the falls and the walking tolerance - they are the functional markers that drive surgical decision-making. Do not manage this as a “wait and see” case.
3. She asks whether an adjustment will “fix the pinched nerve.” How do you decide on technique, and what do you tell her?
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Decision: high-velocity, low-amplitude cervical manipulation is contraindicated, and cervical extension/rotation positioning should be avoided. Rationale: the cord is the structure at risk, the deficits are progressive, and the mechanism of harm (further cord compromise at a stenotic segment) is not correctable by technique modification. Force is not the issue - the stenotic canal is.
What is offered instead:
- An honest statement that manipulation does not decompress a stenotic spinal canal and will not restore cord function.
- Gentle, pain-free-range mobilization and soft tissue work for comfort and neck stiffness, if she tolerates it - but explicitly as symptom management, not as treatment of the myelopathy.
- Activity guidance: avoid prolonged end-range extension, reduce fall risk at home (lighting, rugs, handrails), and safety-proof the kitchen given the burns.
- Co-management with neurology and, if MRI confirms compression with signal change, neurosurgery - referrals sent today.
Script: “The numbness and clumsiness in your hands and the trouble walking are coming from pressure on the spinal cord itself, in your neck. An adjustment moves joints; it cannot open that canal, and pushing on it can make it worse. What I can do is help you stay comfortable and safe while we get the MRI and a specialist opinion, and I want you seen soon.”
Document: the cord signs, that manipulation was declined and why, the referrals made, and the safety counselling.