Hoffmann Sign

Eric Whitney; Sunil Munakomi

Hoffmann Sign

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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 (see Diagram. Hoffmann Sign). The reflexive pathway causes the thumb to flex and adduct quickly. A positive Hoffman sign indicates 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.[2]

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.[3] During a standard neurological exam, the 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 insufficient data to support the use of the exam alone to confirm or refute a diagnosis of degenerative cervical myelopathy.[4] 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 on MRI correlate with 67% of those with a positive Hoffman sign.[5] The Hoffman sign is not always indicative of pathological cord compression.[2] 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]

Nursing, Allied Health, and Interprofessional Team Interventions

As a standard part of neurological examination, all interprofessional healthcare team members should be familiar with the Hoffman sign and its clinical ramifications. This includes clinicians (including NPs and PAs) and nurses, plus physical therapists and chiropractors. It is an easy test to perform, and understanding the significance can help direct the patient to the clinical care they need (e.g., via appropriate referrals and further testing) and improve outcomes. This requires open communication between all members of the healthcare team across professional disciplines. [Level 5]

(Click Image to Enlarge)

Hoffmann Sign. Diagram depicting a positive Hoffmann sign.

Contributed by R Kabir, MD

Details

References

[1]

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 Aug:128():e782-e786. doi: 10.1016/j.wneu.2019.04.254. Epub 2019 May 9 [PubMed PMID: 31078802]

[2]

Annaswamy TM, Sakai T, Goetz LL, Pacheco FM, Ozarkar T. Reliability and repeatability of the Hoffmann sign. PM & R : the journal of injury, function, and rehabilitation. 2012 Jul:4(7):498-503. doi: 10.1016/j.pmrj.2012.02.019. Epub 2012 Apr 28 [PubMed PMID: 22543037]

[3]

Davies BM, Mowforth OD, Smith EK, Kotter MR. Degenerative cervical myelopathy. BMJ (Clinical research ed.). 2018 Feb 22:360():k186. doi: 10.1136/bmj.k186. Epub 2018 Feb 22 [PubMed PMID: 29472200]

[4]

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 PMID: 29668564]

Level 1 (high-level) evidence

[5]

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 1:40(1):6-10. doi: 10.1097/BRS.0000000000000659. Epub [PubMed PMID: 25341986]