Cervical Stenosis, Hoover’s Sign, and Clinical Blind Spots
Christoff Truter
Spousal caregiver
In Functional Neurological Disorder (FND), standard brain imaging (e.g. MRI, CT) usually appears normal, showing no structural damage, lesions, tumours, or other typical neurological signs, except when FND is comorbid with an organically confirmed neurological condition, such as multiple sclerosis, stroke, or epilepsy (but consider weakness was never claimed).
In my wife's case, the scans were not entirely clean. I've included one of the sagittal views of her spine along with the radiology report. You will notice what is described as "moderate stenosis," or more generally, cervical stenosis.
This imaging was reviewed by four neurosurgeons and two neurologists, who all deemed it benign. They don’t believe that any of her symptoms can be attributed to what is seen in these scans.
However, I am unconvinced, as my wife experiences explainable intermittent symptoms such as numbness or tingling in her left arm and reduced finger dexterity that occur due to mechanical factors, for example, flexing or turning her neck. These symptoms correspond precisely to the areas affected by her cervical stenosis. This pattern suggests subtle cord irritation or a transient mechanical disturbance not visible on static imaging, further supported by her experiencing Lhermitte’s sign when she flexes her neck.
To evaluate dynamic compression or irritation
of this nature, it may be prudent to perform a flexion-extension MRI or dynamic
imaging, which could reveal a completely different picture, especially given that something as simple as
turning her neck triggers symptoms, a finding that contrasts sharply with the typical FND narrative.
Nonetheless, at this point, they resorted to functional explanations, and Hoover’s sign
became the tool used to support that shift.
Possibly one of the most common clinical tests for FND used by neurologists to distinguish true neurological leg
weakness from functional (non-organic) weakness, Hoover’s sign was first described by Charles Franklin Hoover in
1908.
I'm not sure if this was applied with proper clinical consideration, but as we explained to the various
neurologists, her symptoms gradually worsen throughout the day as she becomes more fatigued. So in the case of
Hoover's sign, presentation might be variable depending on her level of fatigue.
To emphasize how ill designed this is, you can review actual physical data [here], no need for magic tricks. This is not a case of pseudo-paralysis. The data clearly show effort in both legs, though the dominant leg exhibits motor control disturbances, not suppression.
Furthermore, Hoover's sign has been reported only to have a ~63% sensitivity and is prone to examiner bias, especially when unblinded. In mechanically-provoked cervical stenosis, variable strength due to fatigue or cord compression can mimic 'give‑way' effort. Clinical guidelines warn against using such signs in isolation, especially when structural disease hasn't been fully ruled out.
So if we were to visualise what is happening here.
Think of the spinal cord like a circuit board. Compression is like a warped board — it mostly works, but bending it (flexion) causes intermittent signal glitches.
During a test like Hoover's, these glitches might look like inconsistent effort, but it’s really position-triggered malfunction, not functional but rather mechanically induced.
Mechanical issues can logically mimic "functional" signs if they’re dynamic.
If a specialist ignores dynamic compression and relies only on static tests, ongoing spinal cord compression can
cause nerve damage, including demyelination, leading to worsening symptoms, irreversible harm, delayed treatment,
ultimately harming my wife's health and quality of life.
