Cervical flexion-induced myelopathy (Hirayama disease): A radiology case report

Hirayama disease is a self-limiting cervical flexion myelopathy that typically affects adolescent and young adult males presenting with unilateral or asymmetric distal upper-limb weakness and atrophy. Early diagnosis is important because avoiding neck flexion with cervical collar immobilization may limit ongoing spinal cord injury and selected patients may require surgery. We report a 19-year-old male with 1 year of left-hand weakness involving the middle and ring fingers with progressive difficulty in daily activities. Neurologic examination revealed distal hand muscle wasting and weakness without sensory loss or upper motor neuron signs. Abnormalities were observed in Nerve conduction studies. Cervical MRI demonstrated subtle lower cervical cord atrophy and focal intramedullary T2 hyperintensity in the neutral position. Dynamic flexion MRI showed anterior displacement of the posterior dura with widening of the posterior epidural space, prominent epidural flow voids, and post-contrast enhancement consistent with engorged epidural venous plexus. The patient was managed conservatively with a cervical collar and activity modification; he remained clinically stable at 12-month follow-up. This case emphasizes the neutral-position MRI clues that should prompt flexion imaging and provide a reproducible dynamic MRI technique description relevant to radiology practice.