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So now let's talk about the approach to myelopathy in a patient who presents with
signs and symptoms concerning for a spinal cord disorder. What's our approach,
how do we break that down, how do we approach those patients? Well first of all,
let's start with a definition. Myelopathy just means any disorder affecting the spinal
cord. We can refine that word and say myelitis and there we mean any infectious
or sometimes inflammatory problem affecting the spinal cord, but myelopathy is that big
overarching umbrella term that we use to mean a problem of the spinal cord. Typically,
these patients present with very characteristic symptoms, and let's walk through
those. First, we want to look for upper motor neuron signs. This may include weakness
and spasticity, increase in tone below the area or below the level of the deficit,
patients may have discoordination or problems with coordination from descending
cerebellar tracts and present with clumsiness. We can see altered tone, hyperreflexia
as a very characteristic symptom in patients with spinal cord disorders and should
be one of the first things we look at on the exam. We may see pathologic reflexes,
crossed adduction or other signs of upper motor neuron pathology. Hoffman sign or
Tromner's or upper extremity signs that suggest upper motor neuron pathology
and extensor plantar responses or the Babinski sign also points to a problem affecting
the spinal cord or somewhere in the central nervous system. We can also see lower
motor neuron signs from spinal cord disorders and this is where it gets a little bit
complicated. We can see the combination of upper and lower motor neuron signs.
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The key is the lower motor neuron signs are at the level of the disorder and the
upper motor neuron signs are below or distal to the level of the lesion. Lower motor
neuron signs may include weakness, clumsiness in the muscle group that's innervated
at that level, the myotome. Muscle atrophy, hyporeflexia at the level of the lesion,
muscle hypotonicity or flaccidity of the muscles and fasciculations. Fasciculations are
automatic movements of the muscle, it's a lower motor neuron sign that results from
denervation at the level of that lesion. We can see sensory deficits and importantly
we want to look for a sensory level. A sensory level is essentially diagnostic of a
spinal cord process. Sometimes it can be very difficult to differentiate a sensory
level from other sensory findings and it takes meticulous focus to the neurologic exam
in these patients to discern that level, which is critically important when evaluating
these patients. And then lastly, bowel and bladder symptoms are not uncommon,
and sexual dysfunction which requires a careful history and detailed examination.