Cervical Myelopathy vs Cervical Radiculopathy: Upper vs Lower Motor Neuron Signs
Spine · 8 min read · 2026-04-25
Two Diagnoses, Two Trajectories
Cervical radiculopathy compresses a nerve root and produces predictable, dermatomal symptoms. Cervical myelopathy compresses the spinal cord itself and is a progressive, potentially catastrophic condition. Mistaking one for the other is one of the most consequential errors in spinal medicine.
Cervical Radiculopathy
A lower motor neuron lesion caused by compression of a single cervical nerve root, most commonly C6 or C7, by a disc herniation or foraminal stenosis.
Symptoms:
- Sharp, radiating arm pain in a dermatomal distribution
- Paraesthesia in the affected dermatome
- Weakness of myotomal muscles (e.g., biceps for C6, triceps for C7)
- Reduced or absent reflex on the affected side (biceps for C6, triceps for C7)
Key exam findings:
- Spurling's test: extension and rotation of the neck towards the painful side reproduces radicular arm pain
- Shoulder abduction relief sign: placing the hand on the head reduces pain
- Lower motor neuron signs only — no clonus, no Babinski, normal gait
Cervical Myelopathy
An upper motor neuron lesion from compression of the spinal cord, usually by progressive cervical spondylosis, ossification of the posterior longitudinal ligament, or large central disc herniation.
Symptoms:
- Progressive gait disturbance — the most common early complaint
- Loss of fine motor control in the hands ("difficulty buttoning shirts," dropping objects)
- Numbness in a non-dermatomal distribution
- Bowel or bladder dysfunction in advanced cases
- Neck pain may be minimal or absent
Key exam findings — UMN signs below the lesion:
- Hoffmann's sign: flicking the distal phalanx of the middle finger produces flexion of the thumb and index finger
- Hyperreflexia in the lower limbs
- Babinski sign: extensor plantar response
- Sustained clonus at the ankle
- Lhermitte's sign: neck flexion produces electric-shock sensation down the spine
- Wide-based, ataxic gait
- Inverted supinator reflex: tapping brachioradialis produces finger flexion instead of forearm pronation
The Differentiating Algorithm
The Three-Test Myelopathy Screen
Any patient with neck-related arm symptoms deserves a 30-second myelopathy screen:
- Hoffmann's sign — quickest UMN screen for the upper limb
- Gait observation — ask the patient to walk heel-to-toe
- Plantar response — Babinski test
A single positive finding mandates MRI of the cervical spine.
Common Pitfall
The classic miss is attributing hand clumsiness to "arthritis" or "carpal tunnel" in an older patient with progressive cervical myelopathy. The history of progressive gait change and dropping objects, combined with hyperreflexia, points to the cord — not the wrist.
Clinical Pearl
Cervical myelopathy with a positive Hoffmann's sign and an "inverted supinator reflex" usually localises the cord compression to the C5–C6 level. The combination is highly specific.
Summary
Dermatomal arm pain with reduced reflexes and a positive Spurling's = radiculopathy. Progressive gait change with positive Hoffmann's, Babinski, or clonus = myelopathy. The presence of any UMN sign mandates urgent imaging — myelopathy left untreated progresses.