Myelopathy Diagnosis and Management

Definition and Classification

Myelopathy is characterized by localization of neurological findings to the spinal cord, rather than the brain or peripheral nervous system, according to the American College of Radiology 1
Myelopathies are commonly classified based on time to reach maximum deficit, with the American College of Radiology citing chronic myelopathy as a slow, progressive development 2

Degenerative disease, particularly in the cervical spine, is the most common cause of myelopathy, with contributing factors including spinal degenerative changes and disc herniations, as noted by the American College of Radiology 3, 4
Extrinsic compression causes, such as epidural lipomatosis, post-surgical complications, primary or metastatic tumors, and rare conditions like Hirayama disease, can also lead to myelopathy, according to the American College of Radiology 4, 5
Non-compressive causes, including vascular conditions like spinal cord ischemia and spinal arteriovenous malformations, can also result in myelopathy, as reported by the American College of Radiology 2, 3
Inflammatory/demyelinating conditions, such as multiple sclerosis and neuromyelitis optica, can also cause myelopathy, according to the American College of Radiology 4, 6
Metabolic conditions, including vitamin B12 deficiency and copper deficiency, can also lead to myelopathy, as noted by the American College of Radiology 4
Infectious conditions, such as human T-cell lymphotropic virus myelitis and tuberculosis, can also cause myelopathy, according to the American College of Radiology 4

Thoracic myelopathy may present with thoracic midback pain, motor/sensory deficit, spasticity/hyperreflexia, and bladder dysfunction, with a reported incidence of 76%, 61%, 58%, and 24%, respectively, as noted by the American College of Radiology 7

MRI is the preferred initial imaging modality for myelopathy evaluation, with superior soft-tissue resolution and multiplanar capability, as recommended by the American College of Radiology 3, 6, 7
MRI protocols, including MRI without IV contrast and MRI with and without IV contrast, can be used to evaluate compressive myelopathy and suspected malignancy, infection, or inflammation, according to the American College of Radiology 3, 5, 6, 7
CT myelography can be useful when MRI is contraindicated and can help assess patency of spinal canal/thecal sac, as noted by the American College of Radiology 6, 7

Myelomalacia, or softening of the spinal cord, is a consequence of myelopathy, with pathological progression including acute compression or trauma, breakdown of blood-cord barrier, progressive necrosis, edema, and development of post-traumatic infarction and cavitation, as reported by the American College of Radiology 2

The degree of radiographic abnormality may not match symptom severity, and myelomalacia on imaging should not be confused with other causes of T2 hyperintensity, such as demyelination, inflammation, or neoplasm, as noted by the American College of Radiology 2