1500 patients who underwent magnetic resonance imaging of the spine from 2012-2018 were included in the analysis.
The following pathologies which presented as atypical myelopathy were encountered on MRI analysis:
•Glial neoplasms - Ependymoma,
Astrocytoma.
•Mixed neuronal/ glial neoplasm - Ganglioglioma.
•Non-glial neoplasm: Vascular neoplasms – Haemangioblastoma,
Paraganglioma.
•Rare non-glial neoplasm- Lymphoma,
Metastasis.
•Benign neoplasms – Epidermoid,
Lipoma.
•Infective masses – Tuberculous granuloma,
Hydatid disease.
•Vascular masses – Arteriovenous malformation and cavernoma.
•Others – Transverse myelitis,
Multiple Sclerosis,
Hirayama disease.
Need for MRI pattern approach?
- Almost all cord pathologies appear T2 hyperintense.
- Clinical information helps in narrowing down the differentials to some extent.
- Specific imaging patterns can be applied to further narrow the differential diagnosis.
5 Steps in MRI Pattern Recognition of Cord Lesions [1-4]:
1.
Number of lesions:
- Single lesion - Transverse myelitis,
NMO,
Cord neoplasm
- Multiple lesions – Multiple sclerosis,
ADEM,
Vasculitis,
Infective/ Inflammatory,
Metabolic
2.
Vertebral level involvement:
Cervical:
The common lesions involving the cervical cord are:
- Multiple sclerosis
- NMO
- Ependymoma
- Radiation myelopathy- Head and neck cancers
Cervicodorsal:
The common lesions involving the cervicodorsal cord are:
- Multiple sclerosis
- Anterior spinal artery infarct
- Vasculitis
- SACD
Dorsal:
The common lesions involving the dorsal cord are:
- ADEM
- Acute transverse myelopathy
- Astrocytoma
- HIV myelitis
- Varicella Zoster myelitis
Lumbar:
The common cord lesions involving the lumbar level:
- Conus- myxopapillary ependymoma
- Cauda equina-GBS
- Venous congestion from spinal vascular malformation
3.
Longitudinal extent:
SHORT SEGMENT INVOLVEMENT: Multiple sclerosis,
Acute Transverse Myelitis – RARELY ( MAY PROGRESS TO MANIFEST AS MS IN FUTURE).
LONG SEGMENT INVOLVEMENT (3/>): Neuromyelitis optica (NMO),Transverse myelitis (TM),
Ischemia,
Neoplastic - astrocytoma & ganglioglioma more common,Metabolic.
4.
Cross-sectional pattern:
Central gray matter involvement
- NMO
- ATM
- HIV myelitis
- Venous congestion from spinal AVM
Lateral cord involvement
Anterior cord involvement
- Infarct
- Poliomyelitis
- Hirayama disease
Posterior cord involvement
- MS
- SACD
- Vacuolar myelopathy- AIDS
- Varicella Zoster myelitis
- Copper deficiency
- Radiation myelopathy
5. Enhancement pattern:
Homogenous enhancement
o MS
Patchy enhancement
o MS,
NMO,
TM,
Tumour,
Vascular
Rim enhancement
o MS,
Abscess
Cauda equina nerve root enhancement
o BOTH ANTERIOR AND POSTERIOR NERVE ROOT ENHANCEMENT- GBS,
arachnoiditis,
Vasculitis,
CIDP,
hereditary neuropathy,
carcinomatosis,
Lymphoma
ANTERIOR NERVE ROOT ENHANCEMENT- GBS
A case-based approach of each pathology - refer to figures from 1 - 20.