Hoffmann Sign


Article Author:
Eric Whitney


Article Editor:
Sunil Munakomi


Editors In Chief:
Dustin Constant
Donald Kushner


Managing Editors:
Avais Raja
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Khalid Alsayouri
Trevor Nezwek
Radia Jamil
Patrick Le
Anoosh Zafar Gondal
Saad Nazir
William Gossman
Hassam Zulfiqar
Hussain Sajjad
Steve Bhimji
Muhammad Hashmi
John Shell
Matthew Varacallo
Heba Mahdy
Ahmad Malik
Sarosh Vaqar
Mark Pellegrini
James Hughes
Beata Beatty
Beenish Sohail
Nazia Sadiq
Hajira Basit
Phillip Hynes


Updated:
8/6/2019 10:02:40 AM

Definition/Introduction

The German neurologist Johann Hoffman first postulated this sign.  It was described by his assistant Hans Curschmann in 1911 and has become a standard part of the common neurologic exam.[1] The Hoffman sign is an involuntary flexion movement of the thumb and or index finger when the examiner flicks the fingernail of the middle finger down. The reflexive pathway causes the thumb to flex and adduct quickly.  A positive Hoffman sign can be indicative of an upper motor neuron lesion and corticospinal pathway dysfunction likely due to cervical cord compression. However, up to 3% of the population has been found to have a positive Hoffman without cord compression or upper motor neuron disease. 

Issues of Concern

While the Hoffman sign can help as a screening tool, it is not reliable as a stand-alone predictor of spinal cord compression. Degenerative cervical myelopathy is a spinal cord dysfunction that can lead to numbness, pain, imbalance, sensory loss, hyperreflexia, and urinary incontinence. Estimates are that nearly 1.6 per 100000 have had surgical treatment for cervical myelopathy.[2] During a standard neurological exam, Hoffman sign is common, and a positive sign can aid in the diagnosis.  However, a 2018 systematic review, with level 1 evidence, on the utility of the Hoffman sign for the diagnosis of degenerative cervical myelopathy found that there was insufficient data to support the use of the exam alone to confirm or refute a diagnosis of degenerative cervical myelopathy.[3] While the Hoffman sign can help as a screening tool, clinicians cannot rely on it as a stand-alone predictor of spinal cord compression.

Clinical Significance

The gold standard for diagnosing cervical myelopathy is an MRI. A 2015 study found that positive cord signal changes seen on MRI correlate with 67% of those with Hoffman sign.[4] The Hoffman sign is not always indicative of pathological cord compression.  But when it is present with corresponding MRI images, it was shown that if the compression of the cervical cord was higher in the canal, it correlated with a higher incidence of a positive Hoffman sign.[1]


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Hoffmann Sign - Questions

Take a quiz of the questions on this article.

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A 56-year-old caucasian male with a past medical history of hypertension and type 2 diabetes presents with the complaints of chronic midline neck pain, right arms paresthesias, and increasing right arm weakness for the past 6 months. During your neurological exam, you perform the test shown in the image. If the test is positive, this indicates that the patient could have?

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    Image courtesy S Bhimji MD
Attributed To: Image courtesy S Bhimji MD



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A 17-year-old male with no significant past medical history comes in for a routine annual physical. He has no complaints. During the neurological exam, the clinician notices that on flicking the middle finger of the right hand, there is movement of the thumb. The remainder of the exam is unremarkable. What is the next course of action?



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A 30-year male presents to the office on a followup from a recent emergency room visit where two weeks ago he went in for back and leg pain. An MRI of the lumbar spine was done while he was there, and he has brought the disk in for his appointment. It reveals an L5 S1 left-sided disc herniation. He says that for the past three weeks, he has had bilateral lower leg numbness from the hips down, back pain, hyperalgesia, but no radiating leg pain. On physical exam, he has a positive Hoffmans and left hip flexor weakness. What is the next best step in the management of this patient?



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Hoffmann Sign - References

References

Cao J,Liu Y,Wang Y,Zhao L,Wang W,Zhang M,Wang L, A Clinical Correlation Research of the Hoffmann Sign and Neurological Imaging Findings in Cervical Spinal Cord Compression. World neurosurgery. 2019 May 9;     [PubMed]
Davies BM,Mowforth OD,Smith EK,Kotter MR, Degenerative cervical myelopathy. BMJ (Clinical research ed.). 2018 Feb 22;     [PubMed]
Fogarty A,Lenza E,Gupta G,Jarzem P,Dasgupta K,Radhakrishna M, A Systematic Review of the Utility of the Hoffmann Sign for the Diagnosis of Degenerative Cervical Myelopathy. Spine. 2018 Dec 1;     [PubMed]
Nemani VM,Kim HJ,Piyaskulkaew C,Nguyen JT,Riew KD, Correlation of cord signal change with physical examination findings in patients with cervical myelopathy. Spine. 2015 Jan 1;     [PubMed]

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