Hoffman Sign for Upper Motor Neuron

Hoffman Sign is a neurological examination used to assess the presence of an upper motor neuron lesion from spinal cord compression. It’s also referred to as the digital reflex, the snapping reflex, Tromner sign and jakobson sign. This sign was first introduced by the German neurologist Johann Hoffman, It was described by his assistant Hans Curschmann in 1911 and has become a standard part of the common neurologic exam.

Hoffman Sign is the upper limb equivalent of the Babinski sign of the lower limb.

How do you perform the Hoffman Sign?

To elicit the Hoffmann sign, the patient’s relaxed hand is held with the wrist dorsiflexed and fingers partially flexed. With one hand, the examiner holds the partially extended middle finger between his index finger and thumb or between his index and middle fingers. With a sharp, forcible flick of the other thumb, the examiner nips or snaps the nail of the patient’s middle finger, forcing the distal finger into sharp, sudden flexion followed by sudden release.

Denno and Meadows advocated a dynamic Hoffmann sign to assist in the diagnosis of early spondylotic cervical myelopathy. The patient is asked to repeatedly flex and extend the head, and then the test is performed as described previously. Denno and Meadows believed that the dynamic test showed positive results earlier than the static or normal Hoffmann sign.

See Also: Spurling Test

What is the Hoffman Sign Positive Meaning?

A positive test is adduction and opposition of the thumb and slight flexion of the fingers.

If only the thumb or only the index finger responds, the sign is incomplete.

The Hoffman sign is not necessarily pathologic and is often present to some degree in normal individuals, where up to 3% of the population has been found to have a positive Hoffman without cord compression or upper motor neuron disease.

It’s only of clinical significance when markedly active or very asymmetric. A very active, complete Hoffmann sign, especially if unilateral or associated with other reflex abnormalities or a consistent history, is certainly suggestive if not diagnostic of corticospinal tract involvement.

Accuracy

There are no known studies assessing the interexaminer reliability of this test, and its significance remains disputed in the literature.

References

1. Gilman S: The physical and neurologic examination. In: Gilman S, ed. Clinical Examination of the Nervous System. New York, NY: McGrawHill, 2000:15–34.
2. 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 Neurosurg. 2019 Aug;128:e782-e786. [PubMed]
3. Denno JJ, Meadows GR. Early diagnosis of cervical spondylotic myelopathy. A useful clinical sign. Spine (Phila Pa 1976). 1991 Dec;16(12):1353-5. doi: 10.1097/00007632-199112000-00001. PMID: 1771463.
4. Sung RD, Wang JC. Correlation between a positive Hoffmann’s reflex and cervical pathology in asymptomatic individuals. Spine (Phila Pa 1976). 2001 Jan 1;26(1):67-70. doi: 10.1097/00007632-200101010-00013. PMID: 11148648.
5. Wong TM, Leung HB, Wong WC: Correlation between magnetic resonance imaging and radiographic measurement of cervical spine in cervical myelopathic patients. J Orthop Surg 12:239–242, 2004.
6. Glaser JA, Curé JK, Bailey KL, Morrow DL. Cervical spinal cord compression and the Hoffmann sign. Iowa Orthop J. 2001;21:49-52. PMID: 11813951; PMCID: PMC1888193.
7. Dutton’s Orthopaedic Examination, Evaluation, And Intervention 3rd Edition.
8. Sarvdeep S. Dhatt, Sharad Prabhakar – Handbook of Clinical Examination in Orthopedics. An Illustrated Guide-Springer Singapore.