Lesions on spine MS

MRI Images of Multiple Sclerosis Lesions

MRI and MS

Multiple sclerosis (MS) is a disease in which the body’s immune system attacks the protective covering surrounding the nerves of the central nervous system (CNS). There’s no single definitive test that can diagnose MS. Diagnosis is based on symptoms, clinical evaluation, and a series of diagnostic tests to rule out other conditions.

Magnetic resonance imaging (MRI) is an important tool in diagnosing MS. It can reveal telltale scars, also called lesions, on the brain or spinal cord. MRI is also used to monitor disease activity and progression.

The role of MRI in diagnosing MS

If you have symptoms of MS, your doctor may order an MRI of your brain and spine. An MRI allows doctors to see lesions in your CNS. Lesions show up as white or dark spots, depending on the type of scan.

MRI is a noninvasive test that doesn’t involve radiation. It uses a powerful magnetic field and radio waves to transmit information to a computer, which translates the information into cross-sectional pictures.

Contrast dye, a substance that’s injected into your vein, can be used to make the MRI images show up more clearly. Although the procedure is painless, the MRI machine makes a lot of noise and you must lie very still for the images to be clear. The test takes about 45 minutes to an hour.

It’s important to note that the number of lesions shown in an MRI doesn’t always indicate severity of symptoms, or even whether you have MS. This is because not all lesions in the CNS are due to MS, and not all people with MS have lesions. According to the National MS Society, MRI shows no lesions in 5 percent of people with “clinically definite MS” at the time of diagnosis.

What MRI can show

MRI with contrast dye can highlight MS disease activity by showing the inflammation of active lesions. Active lesions are those that are new or getting bigger. The contrast images also show areas of permanent damage called “black holes.”

Following a diagnosis of MS, some doctors will use MRI to monitor MS if troubling new symptoms appear, or after the person begins a new treatment. Watching for changes in the brain may help assess current treatment and future options. Some neurologists order a new MRI scan of the brain or spinal cord every year.

MRI and different forms of MS

An MRI will show different things based on the type of MS involved. Your doctor can make diagnostic and treatment decisions based on what your MRI shows.

Clinically isolated syndrome

A single neurologic episode caused by inflammation and lasting at least 24 hours is called clinically isolated syndrome (CIS). You may be considered at high risk of MS if you’ve had CIS and an MRI shows MS-like lesions.

If this is the case, your doctor may consider treating for MS in an effort to delay or prevent a second attack. Someone who has had symptoms but no MRI-detected lesions is considered at lower risk for developing MS than those who have lesions.

Relapsing-remitting MS

People with all forms of MS can have lesions, but people with a type of MS called relapsing-remitting MS generally have periods of inflammation. Active areas of inflammation can be seen on an MRI when contrast dye is used.

In relapsing-remitting MS, distinct inflammatory attacks cause localized damage and accompanying symptoms. Each distinct attack is called a relapse. Each relapse eventually subsides, or remits, with periods of partial or complete recovery that are called remissions.

Progressive forms of MS

Rather than intense bouts of inflammation, progressive forms of MS involve a steady progression of damage. The lesions seen on MRI may be less active than those of relapsing-remitting MS.

There are two progressive forms of MS. Secondary progressive MS occurs when relapsing-remitting MS transitions to progressive MS. And with primary progressive MS, the disease is progressive from the start and does not involve distinct inflammatory attacks.

Talk with your doctor

If you have what you think may be MS symptoms, talk to your doctor. They may suggest that you get an MRI. If they do, keep in mind that this is a painless, noninvasive test that can tell your doctor a lot about whether you have MS and, if you do, what kind you have. Your doctor will explain the procedure to you in detail, but if you have questions, be sure to ask them.

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White Spot In Spinal Cord

Last Updated on Tue, 11 Jun 2019 | Spinal Tumors

Dorn Spinal Therapy

Fig. 3.17. Tl-weighted, contrast-enhanced, sagittal (a) and axial (b) MRI scans of a cavernoma at Th4 in a 57-year-old patient. The patchy contrast enhancement and irregular shape of the tumor as well as the black hemosiderin remnants on T2 (c) are typical for this tumor

Fig. 3.18. Tl-weighted sagittal (a) and axial ( i) MRI scans of an ependymal cyst of the conus in a 45-year-old woman. The cyst is located anteriorly on the left side. Please note the considerable space-occupying effect of this cyst

Fig. 3.18. Tl-weighted sagittal (a) and axial ( i) MRI scans of an ependymal cyst of the conus in a 45-year-old woman. The cyst is located anteriorly on the left side. Please note the considerable space-occupying effect of this cyst

The cyst causes marked expansion of the cord and appears like a regular, symmetric cyst with sharp demarcation toward the spinal cord. There are no septations inside the cyst

Fig. 3.20. (a) T2-weighted sagittal MRI scan of a cervicothoracic syrinx with flow void signals inside the cyst (arrowhead). The cardiac gated cine MRI scans demonstrate flow signals within the syrinx in systole ( 5) and diastole (c)Fig. 3.21 (a) T2-weightedsagittalMRI scan of an ependymal cystatC4-C5 ina62-year-oldwoman. The cardiac gatedcine MRI scans display no flow signals within the cyst in systole ( 5) or diastole c)

Fig. 3.22. This T2-weighted sagittal MRI scan shows a syrinx at C4-Th3 caused by an arachnopathy at Th3. The syrinx expands in an upward direction away from the area of CSF flow obstruction. This causes an asymmetric shape of the syrinx: its diameter is largest close to the arachnopathy at Th3 (arrowhead) and gradually tapers off toward C4

Fig. 3.22. This T2-weighted sagittal MRI scan shows a syrinx at C4-Th3 caused by an arachnopathy at Th3. The syrinx expands in an upward direction away from the area of CSF flow obstruction. This causes an asymmetric shape of the syrinx: its diameter is largest close to the arachnopathy at Th3 (arrowhead) and gradually tapers off toward C4

Fig. 3.23. T1-weighted sagittal MRI scan (without contrast) of a predominantly intramedullary dermoid cyst at L1-L2 in a 42-year-old woman. The hyperdense signal of the cyst wall and part of the cyst contents represent fatty components Fig. 3.24. Sagittal (a) and axial (3) T1-weighted images (without contrast) of an intramedullary lipoma at L1 in a 32-year-old patient with an additional tethered cord related to a low conus position. The typical hyperdense signal of the lesion is apparent

Fig. 3.25. MRI scans of a 50-year-old woman with multiple sclerosis. a This contrast-enhanced, T1-weighted image shows an enhancing intramedullary spot at C4, which could be mistaken for an angioblastoma. b Sagittal T2-weighted image showing some perifocal edema and another hyperdense lesion at C2. c Axial T2-weighted image demonstrating a lesion in the posterior midline and a normally shaped cord. d Cranial T2-weighted scan displaying further lesions in the white matter, particularly on the left side.

Fig. 3.25. MRI scans of a 50-year-old woman with multiple sclerosis. a This contrast-enhanced, T1-weighted image shows an enhancing intramedullary spot at C4, which could be mistaken for an angioblastoma. b Sagittal T2-weighted image showing some perifocal edema and another hyperdense lesion at C2. c Axial T2-weighted image demonstrating a lesion in the posterior midline and a normally shaped cord. d Cranial T2-weighted scan displaying further lesions in the white matter, particularly on the left side.

Fig. 3.26. Signal characteristics of inflammatory lesions may change with time. These T1-weighted sagittal MRI scans without (a) and with contrast (b), show an inflammatory lesion at C2-C3. The lesion does not cause a space-occupying effect. Without contrast, the cord looks absolutely normal. After contrast application, there is some enhancement surrounding the lesion. The sagittal (c) and axial (d) T2-weighted images present an ill-defined, hyperdense lesion in the left side of the cord. On follow up after 12 weeks, the lesion appears larger and better demarcated on the sagittal (e) and axial (f) T2-weighted image, but there is still no space-occupying effect

The differential diagnosis to inflammatory and demyelinating diseases may be difficult, especially with lesions that take up no or little contrast. If an intramedullary lesion is suspected to be a tumor, the following questions should be asked:

1. Is the lesion space occupying?

2. Does the lesion display different signal characteristics with time?

3. Does the pathology affect different parts of the spinal cord with time?

As a general rule, inflammatory and demyelinating lesions almost never displace cord tissue at all, or to an extent that would explain the clinical symptoms (Figs. 3.25-3.29) . Multiple spinal cord lesions maybe detected in demyelinating (Fig. 3.25) and

^ 1 / J

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Typically when people think about multiple sclerosis (MS), the brain is usually the focus. It’s not uncommon with MS, however, to discover multiple silent brain lesions on magnetic resonance imaging (MRI) and find a person afflicted with only spinal cord problems due to the disease. Sometimes the symptomatic spinal cord lesions are more difficult to identify on scans than some clinically quiet but MRI evident brain lesions. About 90% of those with MS find that their spine is involved at some point.
As a central relay station for sensation, movement, balance and coordination for so much of the body, the spinal cord is crucial for limb function and the muscles involved in respiration.
Many with spinal cord problems and MS have numbness on one side of the body and weakness on the opposite side. They may lose standing balance or have a gait problem characterized by ataxia, such as the inability to walk a straight line. Paralysis and loss of sensation of part of the body are common. This can include total paralysis or numbness and varying degrees of movement or sensation loss.
Spinal cord lesions due to MS in the upper spine or neck (cervical region) can cause cape like sensation loss in both shoulders and in the upper arms. Quadriplegia is the great danger in cervical region MS. Anesthesia in a band like distribution around the trunk can be experienced in those with mid spinal cord inflammation and carry a chance that they could become paraplegic. All of those with MS in the spinal cord can potentially have bladder or bowel control problems. However, those with spinal cord MS of the lumbar region (the spinal cord ends at the beginning of the lumbar spine) can have symptoms dominated by retention of urine.
For those with MS, pain below the level of spinal cord involvement and sexual problems were the greatest complaints, even when there were motor difficulties in the limbs. Spinal cord induced pain is typically excruciating and often shoots down the spine (Lhermitte’s Sign) or to the limb that is involved due to spinal cord damage.
Erectile dysfunction is common in men with spinal cord MS. Orgasmic and fertility problems can strike both sexes with cord lesions. Spasticity is another major problem for those with spinal cord problems of all types. The increase in muscle tone from spasticity can also be painful and movement limiting.
Medication and certain devices such as spinal cord stimulators can be valuable for many of these issues. Dyssnergia (movement incoordination) involves bladder muscle difficulties due to cord MS. The incontinence and bladder emptying problems that results can be treated with medication as well.
Therapeutic research in spinal cord disorders including MS involves consideration for the transplantation of stem cells, the injection of nerve and brain derived growth factors, and medicines that can provide the energy source for spinal cord regrowth.
In addition, rehabilitation of the patient with spinal cord problems is critical by way of special conditioning and strengthening programs.
In MS, an acute spinal cord attack is called Myelitis. Immunomodulator and steroid therapy is often utilized with success with a dramatic reversal possible. If the MS patient has persistent neurological signs and symptoms from the spinal cord inflammatory attack, they are said to have a myelopathy.
Often the severity of MS is very much related to how bad the myelopathy is. Progressive MS can be characterized by spinal cord shrinkage (atrophy) over time. Reversal of this aspect of advancing MS remains a great challenge for ongoing research. Defeating the immunological process that triggers both the brain and spinal cord damage in MS is the best defense against the terrible effects of spinal cord involvement in demyelinating disease.
Spinal Cord Lesions
There are several symptoms that show signs that there is damage in the spinal cord. In the spinal cord the nerves that deal with the whole body run very close together down the cord. A single lesion can cut across an area that affects a large section of the body. One good sized lesion can essentially “cut off ” the body below it as if the spine had been severed. This is the worst case scenario of the lesions of transverse myelitis, however, most lesions are not that large. The areas that deal with the motor functions on one side, all run together and the part of the cord that handles the sensory input is all on a different section from the motor.
As the cord runs down the back, the nerves branch off and leave the cord, thus becoming peripheral nerves. The nerves to the arms leave the cord in the cervical spine. The nerves that control the muscles of the torso leave in the lower cervical spine and the from the thoracic. The nerves to the legs travel on through the cervical and upper thoracic to leave the spinal cord lower down. Many of them stay in the spinal canal below where the spinal cord ends as a loose-floating bundle of nerves called the “cauda equina” or horse’s tail. These nerves exit through the vertebra in the lumbar spine.
The greatest concern is the fact that the spinal cord is basically a bundle of wires that are very small and compact. A single lesion in this area will affect many nerves and the systems that they control. Unlike the brain where the damage is more specific or precise, in the spine it essentially is more widespread. So one good sized lesion can essentially “cut off ” the body below it as if the spine had been severed.
Typical Signs of a Spinal Cord Lesion
A specific or some combination of problems on the neurological exam can point to a specific “level” of damage in the spinal cord where there must be a lesion. Neurologists know that a lesion in the brain could not cause the same combination of problems as a lesion in the spine. Numbness, paresthesias, and/or weakness from one level on down is indicative of a cord lesion.
One of the difficulties with spinal lesions is that there can be indications that a lesion definitely exists, but it may not be seen easily or at all on MRI.

Maybe you have heard the term “Spinal MS.” What is that? I thought MS could be relapsing, primary progressive, secondary progressive, or “benign.”

The lesions caused by multiple sclerosis can occur anywhere within the central nervous system, which includes the brain, the spinal cord, and the optic nerves. Approximately 55-75 percent of patients with MS will have spinal cord lesions at some time during the course of their disease. If a patient does have lesions in the spinal cord, he/she may be said to have Spinal MS.

A smaller number of MS patients, approximately 20 percent, may have only spinal lesions and not brain lesions. I am an example of one of those 20 percent of MS patients who only have spinal lesions.

Symptoms of Spinal MS

Spinal MS occurs more commonly with lesions in the cervical spine (the neck area) in approximately 67 percent of cases. Lesions in this area often affect the corticospinal tract. Neurological signs which indicate lesions in the corticospinal tract include the Babinski Sign and the Hoffmann Sign. Additional indicators of lesions in the upper spine include the l’Hermittes phenomenon and the Romberg Sign. At one time or another, I have shown each of these signs of neurological involvement/interference due to MS lesions.

Although the location of lesions do not always closely correlate to areas of clinical disability, there are cause/effect patterns which do emerge. Patients with spinal cord lesions are more likely to develop bladder dysfunction (e.g., urinary urgency or hesitancy, partial retention of urine, mild urinary incontinence), bowel dysfunction (e.g., constipation or urgency), and sexual dysfunction (e.g., erectile dysfunction or impotence in men, genital anesthesia or numbness in women, pain with intercourse for either sex). Complete loss of bladder and bowel control may be lost in more advanced cases of MS.

Spinal cord lesions can also lead to sensory and motor deficits, including dysesthesias, spasticity, limb weakness, ataxia or other gait disturbances.

Conditions similar to Spinal MS

An acute attack of myelitis is caused by inflammation in the spinal cord. Some patients may be diagnosed with Transverse Myelitis if they are experiencing their first attack of demyelination and inflammation. One of my earlier diagnoses (on the road to getting a firm diagnosis of MS) was acute transverse myelitis. It was treated with five days of IV Solumedrol (steroid) infusions. Significant improvement occurred very quickly.

Similarly, patients who are later diagnosed with Neuromyelitis Optica Spectrum Disorder (NMOSD) may initially receive a diagnosis of transverse myelitis. NMO is a demyelinating disease of the central nervous system which primarily affects the optic nerves and spinal cord.

Spinal MS and disease progression

In conclusion, if you read the phrase “spinal MS,” know that it simply refers to the presence of lesions in the spinal cord in a patient diagnosed with MS. These lesions may cause various types of sensory and motor dysfunction below the level of the spinal cord involvement. The prognosis of spinal MS does not appear to be more dire than that of MS only affecting the brain. However, the higher incidence of spinal cord lesions often found in primary progressive multiple sclerosis (PPMS) does contribute to a more rapid development of disability.

See more helpful articles:

What is Primary Progressive Multiple Sclerosis?

MS Signs & Symptoms: What is the Romberg Sign?

Managing Bowel Dysfunction in MS

What are the motor symptoms of a spinal cord attack of MS?

Motor symptoms consist of disturbances in moving one or more limbs. These movement disturbances may include weakness or spasticity (the tendency of a limb to become stiff and relax only with difficulty) or both.

Weakness: Weakness may be so mild that the complaint will be that the limb just tires easily or feels heavy. Or the weakness may be such that the limb is difficult to lift. Often the weakness disappears after resting or occurs later in the day when the leg, for example, has been fatigued by a lot of standing and walking. Often the individual notices that the toes of shoes wear out prematurely and walking over rough surfaces such as carpets and unpaved walkways is more difficult than over smooth surfaces. Weakness can also appear in the arms or hands, affecting dexterity and causing handwriting to become less legible. Often, in early or mild cases, it is difficult to detect weakness in the limbs in an ordinary exam. But abnormalities can be found in tests of motor reflexes.

Spasticity: Spasticity (rigidity or stiffness) usually involves only the leg, rarely the arm. Individuals may start to notice they can’t walk as quickly, or running to catch a ball seems more difficult. Walking up or down stairs is no longer effortless. The limb may stiffen out or draw up involuntarily at times, causing “charley horses” to occur, especially with changes in position such as getting into bed at night. These spasms are more inconvenient than disabling, although some may result in falling without warning.

Weakness by itself is a symptom that brings up many possible diagnoses, with MS far down on the list. Other conditions to consider include pinched nerves, slipped discs, diabetic neuritis, thyroid disease, or even lead poisoning. Weakness with spasticity is more suggestive of something wrong in the spinal cord, with MS high on the list.

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