As to the sensory features (which may occasionally be absent), numbness, tingling, and prickling of the hands and soles of the feet and around the ankles are the most frequent complaints. Some patients complain of numbness or paresthesias, most often in one or two digits, a part of the palm, or a longitudinal band along the forearm. Slight clumsiness or weakness of a hand is another complaint. A feeling as if “wearing gloves,” “swollen,” or the hands “coated with glue” are common descriptions. Several of our patients have complained of paresthesias in the distal limbs and trunk for years before there was any indication of motor involvement. In advanced cases, there may be a vague sensory level at or just above the clavicles. Impaired vibratory sensation and diminished position sense in the toes and feet (all indicative of a lesion of the posterior columns), as well as the Romberg sign, are the most conspicuous sensory findings. This imparts a “tabetic” unsteadiness to the gait. Sensory defects tend to be asymmetrical. (It is noteworthy that symmetric sensory symptoms and signs of identical type are seen with subacute combined degeneration as a result of vitamin B12 deficiency.) Less frequently, paresthesias and dysesthesias in the lower extremities and trunk may be the principal symptoms; even less often there are sensory complaints on the face, ostensibly corresponding to compression of the trigeminal sensory tract in the upper cervical cord. Rarely, the sensorimotor pattern takes the form of a Brown-Séquard syndrome.
The third part of the typical syndrome, spastic legs from a compressive myelopathy, most often manifests as a complaint of weakness of a leg or of getting upstairs and slight unsteadiness of gait. The entire leg or the quadriceps feels stiff and heavy and gives out quickly after exercise. Mobility of the ankle may be reduced, and the advancing toe of the shoe scrapes the floor. On examination, slight hypertonicity of the legs is usually more evident than weakness, and the tendon reflexes are increased (ankle jerks may not share in this change in the elderly). Although the patient may believe that only one leg is affected, it is commonly found that both plantar reflexes are extensor, the one on the side of the stiffer leg being more clearly so. Less often, both legs are equally affected. As the compression continues, walking becomes unsteady because of the addition of sensory ataxia.
The biceps and brachioradial reflexes on one or both sides may be depressed, sometimes in association with an increase in the triceps and finger reflexes. The hand or forearm muscles may undergo atrophy; in a few cases, the atrophy of hand muscles is severe. In such cases, the spondylotic compression, as judged by MRI or CT myelography, may be confined to the high cervical cord, well above the levels of the motor neurons that innervate these muscles. In patients with sensory loss, pain and thermal sensation often appear to be affected more than tactile sense. An unexpected Babinski sign has already been mentioned and a few fasciculations may be seen, especially in proximal arm muscles. Another unusual feature in advanced stages of cervical cord compression is the appearance of mirror movements of the hands, in which effortful attempts to make refined movements of the fingers of one hand, causes the opposite hand to move similarly.
As the myelopathy progresses, sometimes intermittently, both legs become weaker and more spastic. Sphincteric control may then be altered; slight hesitancy and precipitancy of micturition are the usual complaints; frank incontinence is infrequent. In the more advanced form of this condition, walking requires the aid of a cane or canes or a walker; in some cases, all locomotion ultimately becomes impossible, especially in the elderly patient. Abrupt worsening, even paraplegia or quadriplegia, may follow forceful traumatic flexion or extension injuries of the neck, as indicated later.