Bilateral hand dysfunction
Loss of fine motor control affecting both hands together: buttons, coins, keys, handwriting. Often described as clumsiness rather than weakness, and frequently attributed to age before it is attributed to the neck.
Urgent referrals and myelopathy red flags
Most cervical referrals are routine and most cervical nerve pain settles. Degenerative cervical myelopathy is the exception: it progresses, function lost to it does not reliably return, and the signs that identify it are found on examination rather than on imaging. This page sets out what to look for, what the severity bands mean, and what belongs in an emergency department.
The short version
Bilateral hand clumsiness and gait disturbance are the classic early signs, often before significant pain.
Hyperreflexia, Hoffmann's sign, clonus and an extensor plantar response are the findings that reclassify the referral.
Untreated, around 21 per cent deteriorate by two years and around 56 per cent by ten.
International guidelines recommend surgical decompression for moderate and severe myelopathy.
Progressive motor deficit, sphincter disturbance or acute cord compression is an emergency department presentation.
Urgent concerns are better phoned through on (07) 3870 3708 than sent by fax or through the website form.
The examination
Cord signs are found on examination. A scan alone will not sort a myelopathy from an incidental finding.
21% by 2 years
Deterioration in untreated cervical myelopathy, rising to around 56 per cent by ten years.
mJOA 12 to 14
Moderate myelopathy. Guidelines recommend surgical decompression at this level and below.
Phone, do not fax
Rooms direct on (07) 3870 3708 for anything urgent, Monday to Friday, 8:30am to 4:30pm.
CORD SIGNS
What separates a myelopathy from a radiculopathy
The distinction is clinical. A patient with severe arm pain and intact power is usually on a favourable trajectory; a patient with mild neck ache and bilateral hand clumsiness may not be.
Gait disturbance
Broad-based or unsteady gait, difficulty on uneven ground, or a patient who has started holding the handrail. Ask about falls specifically, because people rarely volunteer them.
Upper motor neurone signs
Hyperreflexia, Hoffmann's sign, clonus, an extensor plantar response, and inverted supinator reflex. Their presence in a patient with cervical imaging changes reframes the whole referral.
Lhermitte's phenomenon
An electric shock sensation running down the spine or into the limbs on neck flexion. Not specific to degenerative disease, and worth eliciting and recording when it is present.
A patient-facing explanation of the same signs, useful to hand on, is at cervical myelopathy.
SEVERITY
The mJOA bands and what guidelines recommend
The modified Japanese Orthopaedic Association score is the standard severity measure in degenerative cervical myelopathy, and international guideline recommendations are framed around it.
Mild
mJOA 15 to 17
What it means
Function only slightly affected. Surgery or a closely supervised trial of non-surgical care are both defensible.
Referral implication
Specialist opinion, with a clear plan for review and an explicit list of what would prompt earlier reassessment.
Moderate
mJOA 12 to 14
What it means
Everyday function is clearly affected. Surgical decompression is recommended in international guidelines.
Referral implication
Prompt specialist referral rather than a further trial of conservative management.
Severe
mJOA 11 or less
What it means
Function substantially affected. Surgery is recommended, and generally without much delay.
Referral implication
Urgent. Phone the rooms rather than relying on a faxed referral reaching a routine list.
Any band
If it is progressing
What it means
Documented deterioration between reviews matters more than the absolute score on any single day.
Referral implication
Treat progression as the trigger. Function already lost does not reliably return once decompressed.
PUBLISHED RESEARCH
Why the timing matters
56% by 10 years
Deterioration in untreated cervical myelopathy
Roughly 6 per cent had worsened in daily activities by one year, around 21 per cent by two years, close to 28 per cent by three years, and around 56 per cent by ten. The decline is stepwise rather than linear, which is what makes it easy to miss in routine review.
AO Spine RECODE-DCM, natural history
Decompression halts it
Surgical outcomes in guideline review
Surgery to decompress the cord halts progression for most people, and international guidelines report clear improvements in function and quality of life after it, with low complication rates. Earlier treatment, before significant loss, gives the better odds of recovering function rather than simply arresting the decline.
AO Spine and Cervical Spine Research Society guideline
How to read this
These are group figures from natural history series and guideline reviews, not predictions for an individual patient, and a proportion of people with mild myelopathy remain stable for years. What the data supports is narrower and still practical: progression is common enough, and recovery of lost function unreliable enough, that a suspected myelopathy is worth acting on rather than watching.
Set that against the base rate in imaging: 5.3 per cent of 1,211 asymptomatic volunteers had spinal cord compression on MRI. Cord compression on a scan is not myelopathy. The examination is what distinguishes them.
The examination is what separates a scan finding from a diagnosis
In 1,211 asymptomatic volunteers, 5.3 per cent had spinal cord compression on MRI. What identifies a patient who needs prompt decompression is bilateral hand dysfunction, gait disturbance and upper motor neurone signs, not the appearance of the canal. Documented progression between reviews matters more than the score on any single day.
OTHER URGENT PRESENTATIONS
Four more that do not belong on a routine list
01
Progressive motor deficit
Documented weakness worsening between reviews, as distinct from pain that is not settling. Objective grading in the referral is what makes this actionable.
02
Sphincter disturbance
New bladder or bowel change in a patient with cervical pathology, or spreading lower limb numbness. Emergency department rather than outpatient referral.
03
Significant trauma
New neck pain or neurological change after a fall or impact, particularly in a patient known to have significant canal stenosis. Assess acutely rather than in clinic.
04
Systemic red flags
Fever, night pain, unexplained weight loss, immunosuppression, or a history of malignancy. Infection and metastatic disease are a different differential and a different pathway.
HOW TO ESCALATE
Which channel for which situation
Urgent, but the patient is stable
Phone the rooms on (07) 3870 3708 during business hours rather than relying on a faxed referral. The practice states that it cannot guarantee a timely response to urgent matters sent through the website enquiry form.
Contact details ›Acute or rapidly progressing
Acute cord compression, rapidly progressive weakness or new sphincter disturbance needs emergency assessment with imaging, not an outpatient appointment. Direct the patient to an emergency department.
About cervical myelopathy ›Emergency presentations
Rapidly worsening weakness, an acute decline in walking or hand function, or new loss of bladder or bowel control needs emergency assessment. Advise the patient to call 000 or attend their nearest emergency department. GPs with an urgent concern about a stable patient can phone the rooms directly on (07) 3870 3708.
NEXT
Related referrer pages
Refer a patient
Where to send it, referral validity, a checklist of what to include, and what to tell the patient to bring.
How to refer ›For referring doctors
What makes a cervical referral useful, which investigation answers which question, and the natural history that sets the timing.
Referrer information ›Cervical myelopathy
A patient-facing explanation of cord compression, the early signs, the progression data and what decompression achieves.
Read about myelopathy ›About this information
The contact details and the statement about urgent matters sent through the enquiry form are as published by the practice. The clinical content is general information for referring practitioners, drawn from the sources below, and is not a protocol or a substitute for your own clinical judgement. More about Dr Tollesson.
References
A Clinical Practice Guideline for the Management of Degenerative Cervical Myelopathy, AO Spine and the Cervical Spine Research Society, for the mJOA severity bands, the treatment recommendations and the reported surgical outcomes.
Degenerative Cervical Myelopathy: Development and Natural History, AO Spine RECODE-DCM, for the progression figures in untreated myelopathy.
Abnormal Findings on Magnetic Resonance Images of the Cervical Spines in 1211 Asymptomatic Subjects. Spine, 2015, for the prevalence of cord compression in people without symptoms.
Cervical Radiculopathy, StatPearls, National Library of Medicine, for the natural history of acute cervical radiculopathy referred to above.
Radiculopathy usually settles. Myelopathy usually does not.
If the examination shows cord signs, phone the rooms rather than sending it to a routine list. (07) 3870 3708, Monday to Friday, 8:30am to 4:30pm.