Compressive myelopathy: magnetic resonance imaging findings simulating idiopathic acute transverse myelopathy

Increased signal intensity on postoperative T2-weighted axial images in cervical spondylotic myelopathy: Patterns of changes and associated impact on outcomes

Although T2-weighted axial magnetic resonance imaging (MRI) has strength in demonstrating morphologic characteristics of the spinal cord in cervical spondylotic myelopathy (CSM), no study has investigated postoperative changes. We aimed to assess postoperative changes on T2-weighted axial MRI using the classification system based on axial imaging in cervical compressive myelopathy (Ax-CCM) and associated impact on outcome in CSM. In total, 250 patients with CSM who underwent decompressive surgery with preoperative and postoperative MRI were included. At first, we investigated the presence of increased signal intensity (SI) in cervical spinal cord on T2-weighted sagittal images. Next, the increased SI was assessed using Ax-CCM on T2weighted axial images. The classifications were type 0, no-signal abnormality; single-level type 1, diffuse; single-level type 2, fuzzy focal; single-level type 3, discrete focal; and two-level. The recovery rates (RRs) of modified Japanese Orthopaedic Association (mJOA) score were evaluated from 5 to 10 months postoperatively. Eighty-seven patients (34.8%) exhibited postoperative changes. Most of postoperative changes were in single-level type 1 and 2. Patterns of changes were resolution, reduced extent, or transition to discrete margin. The most common pattern was resolution in type 1 (23.9%) and transition to discrete margin in type 2 (46.5%). In each group, resolution showed the best RR, but insignificantly (p > 0.05).

Imaging Considerations in Spinal Cord Evaluation

Multiple diverse pathologies result in the clinical presentation of myelopathy. The preferred way to image the spinal cord depends on clinical history, anatomic site of interest, and patient issues limiting certain imaging modalities. This radiology-focused article discusses pertinent physiological considerations, reviews basic and newer imaging techniques, and examines several distinct disease entities in order to highlight the key role of imaging in the work-up of myelopathy.

Diagnostic Approach to Intrinsic Abnormality of Spinal Cord Signal Intensity

Intramedullary cord hyperintensity at T2-weighted MRI is a common imaging feature of disease in the spinal cord, but it is nonspecific. Radiologists play a valuable role in helping narrow the differential diagnosis by integrating patient history and laboratory test results with key imaging characteristics. The authors present an algorithmic approach to evaluating intrinsic abnormality of spinal cord signal intensity (SI), which incorporates clinical evaluation results, time of onset (acute vs nonacute), cord expansion, and pattern of T2 SI abnormality. This diagnostic approach provides a practical framework to aid both trainees and practicing radiologists in workup of myelopathy.^©RSNA, 2019.

Clinical biomarkers differentiate myelitis from vascular and other causes of myelopathy

Objective

To assess the predictive value of the initial clinical and paraclinical features in the differentiation of inflammatory myelopathies from other causes of myelopathy in patients with initial diagnosis of transverse myelitis (TM).

Methods

We analyzed the clinical presentation, spinal cord MRI, and CSF features in a cohort of 457 patients referred to a specialized myelopathy center with the presumptive diagnosis of TM. After evaluation, the myelopathies were classified as inflammatory, ischemic/stroke, arteriovenous malformations/fistulas, spondylotic, or other. A multivariable logistic regression model was used to determine characteristics associated with the final diagnosis and predictors that would improve classification accuracy.

Results

Out of 457 patients referred as TM, only 247 (54%) were confirmed as inflammatory; the remaining 46% were diagnosed as vascular (20%), spondylotic (8%), or other myelopathy (18%). Our predictive model identified the temporal profile of symptom presentation (hyperacute <6 hours, acute 6–48 hours, subacute 48 hours–21 days, chronic >21 days), initial motor examination, and MRI lesion distribution as characteristics that improve the correct classification rate of myelopathies from 67% to 87% (multinomial area under the curve increased from 0.32 to 0.67), compared to only considering CSF pleocytosis and MRI gadolinium enhancement. Of all predictors, the temporal profile of symptoms contributed the most to the increased discriminatory power.

Conclusions

The temporal profile of symptoms serves as a clinical biomarker in the differential diagnosis of TM. The establishment of a definite diagnosis in TM requires a critical analysis of the MRI and CSF characteristics to rule out non-inflammatory causes of myelopathy.

Classification of evidence

This study provides Class IV evidence that for patients presenting with myelopathy, temporal profile of symptoms, initial motor examination, and MRI lesion distribution distinguish those with inflammatory myelopathies from those with other causes of myelopathy.

A simplified algorithm for diagnosis of spinal cord lesions

Neuroimaging is indispensable for evaluation of Myelopathy not only for localization but also for etiologic determination. MRI is the preferred examination for further characterization of the majority of these conditions. These include traumatic, inflammatory, infections, compressive and neoplastic conditions. This article provides an overview of a variety of pathologies that afflict the spinal cord in an easy to understand format. Their respective imaging manifestations on MRI and differential diagnoses are focused in this review. Early diagnosis and treatment of Myelopathy is critical in preventing or arresting neurological morbidity.

Clinical features and surgical results of cervical myelopathy caused by soft disc herniation

Objective

There are many causes of cervical myelopathy including trauma, degenerative conditions, tumors and demyelinating disorders. However, myelopathy caused by soft disc herniation might be seen rarely than the spondylosis caused by hard disc. Here, authors retrospectively analyzed the clinical features and results of cervical myelopathy caused by soft disc herniation.

Methods

From March 2010 to December 2010, 134 patients with degenerative cervical spinal disease were treated with anterior cervical discectomy and interbody fusion. Among them, 21 patients with cervical myelopathy secondary to cervical soft disc herniation were analyzed. Their clinical features, preoperative and, postoperative clinical results were evaluated by Nurick Grade and Japanese Orthopaedic Association scale (JOA) retrospectively. Preoperative clinical features including duration of myelopathy, pain intensity and postoperative clinical results including improvement rate of myelopathy and radiculopathy were retrospectively analyzed by Nurick Grade and JOA scale. We also evaluated correlation between the duration of symptom, type of the disc herniation, pain intensity and clinical outcome.

Results

Mean age was 49.7 and male was predominant. Gait disturbance with mild to moderate pain was most common symptom in clinical features. Severe pain was shown in only 9 cases, and the other 12 cases experienced mild to moderate pain. Mean duration of myelopathy was 1.18 month. The mean JOA scores were 11.22 before surgery and 14.2 after surgery. The mean Nurick grades were 2.78 before treatment and 1.67 after treatment. Neurologic status of mild or moderate pain group on preoperative state is worse than that of severe pain group. The patients with duration of myelopathy symptom (<1 month) showed lower clinical improvement rate than the patients with myelopathy over 1 month. Patients with median type of disc herniation showed poorer neurological status than those with paramedian type of herniation in preoperative state.

Conclusion

Authors reviewed the clinical features and surgical outcome of the cervical myelopathy secondary to cervical soft disc herniation. We presumed that patients of more than one month of symptom duration, mild to moderate initial symptom would be related with better postoperative improvement rate.