Introduction
Background
Multiple sclerosis (MS) is considered the most common demyelinating process involving the central nervous system (CNS).1 In 1988, MS was first described in the upper cervical spine using magnetic resonance imaging (MRI). Spinal MS is often associated with concomitant brain lesions; however, as many as 20% of patients with spinal lesions do not have intracranial plaques. No strong correlation has been established between the extent of the plaques and the degree of clinical disability.
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Sagittal, T2-weighted image showing areas of signal hyperintensity in the cervical spinal cord and pons. Same patient as in Images 4-5.
Corresponding axial, T2-weighted image showing a large area of signal hyperintensity in the right lateral aspect of the cord. Same patient as in Images 3 and 5.
Sagittal, T1-weighted image following gadolinium contrast showing arciform enhancement along the edge of the plaque, typical of demyelination. Same patient as in Images 3-4.
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Pathophysiology
The exact cause of MS remains unclear; however, hypotheses include viral and autoimmune etiologies.
In the acute stage, perivenular inflammation with hypercellularity (macrophages and/or lymphocytes) is encountered in typically well-demarcated areas of demyelination.
In the chronic stages of the disease, fibrillary gliosis occurs with a breakdown of myelin. The axonal structure is conserved, with a reduction or absence of oligodendroglia. Occasionally, lesions resolve incompletely, but most progress to demyelination.
Frequency
United States
There are an estimated 250,000-350,000 patients in the United States with MS.
International
Multiple sclerosis (MS) occurs worldwide.2 Its prevalence varies depending on the geographic location, rising as the northerly or southerly distance from the equator increases. Depending on the country or the specific population, the prevalence of MS ranges from 2 cases per 100,000 population to 150 cases per 100,000 population.
Mortality/Morbidity
- The morbidity and mortality rates related to multiple sclerosis (MS) are high worldwide.
- At 15 years after the onset of the disease, an estimated 50% of patients need help with ambulation.
Race
Epidemiologic series have shown that western Europeans living in temperate zones have a higher risk for MS than do other groups.
Sex
The male-to-female ratio is 2:3.
Age
MS frequently occurs in persons aged 10-50 years. However, MS has also been described in the pediatric population and in individuals older than 50 years.
Anatomy
Spinal MS has a predilection for the cervical spinal cord (67% of cases), with preferential, eccentric involvement of the dorsal and lateral areas of the spinal cord abutting the subarachnoid space around the cord. The gray matter may be involved. Approximately 55-75% of patients with MS have spinal lesions at some point during the course of the disease.
Presentation
The clinical signs vary depending on the spinal cord segment affected and the degree of involvement. MS is characterized by a typical relapsing-remitting clinical course. Spastic paraparesis/paraplegia with neurogenic bowel and bladder, as well as with sexual dysfunction, can be encountered. Dysesthetic pain syndromes may result from spinal or cranial nerve root involvement.
Heredity is suggested to be involved in the etiology of the disease because affected relatives occasionally are identified.
A concomitant presence of optic neuritis (unilateral, bilateral, or chiasm) constitutes Devic neuromyelitis optica. The brain is usually normal, but the condition is associated with a poor prognosis.
MS can be seen with Leber hereditary optic neuropathy, which is called Harding's syndrome.3
Preferred Examination
Although nonspecific, MRI is presently considered to be the most sensitive diagnostic imaging modality for revealing demyelinating plaques. MRI shows abnormalities in 95% of patients with clinically definitive MS.4,5
Limitations of Techniques
MRI is sensitive to areas of demyelination, which appear as high signal areas on long TR sequences. Lesions of other etiologies (eg, viral myelitis, acute disseminated encephalomyelitis [ADEM]) may resemble MS plaques and must be considered along with the clinical history and the patient's presenting signs and symptoms.
Differential Diagnoses
Sarcoidosis
Systemic Lupus Erythematosus
Other Problems to Be Considered
Spinal cord tumors (primary or metastasis)
Infection (particularly viral, eg, cytomegalovirus, herpes, human immunodeficiency virus [HIV])
Acute transverse myelitis (history of recent viral infection or vaccination)
Acute spinal cord infarction (acute presentation)
Radiation myelitis (generally doses >4000 cGy; 1- to 3-y latency period; chemotherapy may be synergistic)
More on Multiple Sclerosis, Spine |
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| Imaging: Multiple Sclerosis, Spine |
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References
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Further Reading
Keywords
multiple sclerosis, spinal multiple sclerosis, multiple sclerosis of the spine, demyelinating process, brain lesions, spine lesions, perivenular inflammation, plaques, fibrillary gliosis, oligodendroglia, spinal MS, spinal multiple sclerosis, Devic neuromyelitis optica, optic neuritis
