Avoiding Diagnostic Overshadowing: A Case Series on Cervical Myelopathy in Patients with Fibromyalgia

Cervical myelopathy is a condition that presents with variable clinical symptoms including neck, arm, low back, and leg pain, numbness, weakness, difficulty with ambulation, and changes in fine motor skills. Fibromyalgia may also present with similar symptomatology including widespread pain and mild subjective symptoms of paresthesias, numbness, and weakness. Although fibromyalgia may be associated with some neurologic symptoms, it is important to note that fibromyalgia itself is not associated with severe, progressive neurologic symptoms or indications of upper motor neuron involvement (ex. Hoffman's sign). We present three patients who were referred to our multidisciplinary chronic pain clinic specifically for fibromyalgia evaluation and treatment. After thorough clinical and radiographic evaluations, they were discovered to have severe physical and neurological impairments caused by unrecognized cervical myelopathy. Fibromyalgia is no longer considered a diagnosis of exclusion and may coexist with other conditions with overlapping symptomatology. Therefore, atypical clinical features should prompt further evaluation rather than be attributed solely to fibromyalgia. Patients with fibromyalgia who describe significant neurological dysfunction accompanied by severe physical limitations should raise clinical concerns. A thorough musculoskeletal and neurological physical examination should always be performed in any patient presenting for fibromyalgia consultation, particularly if these symptoms are present. Imaging studies should be obtained if there are concerning signs, symptoms, and physical examination findings as prompt recognition of cervical myelopathy can lead to treatment that may improve a patient's quality of life. These cases seek to highlight important clinical implications of diagnostic overshadowing in patients with fibromyalgia.