Multiple Sclerosis (MS) of the Spine

Diagnosis Definition

• Multiple sclerosis (MS) is the most common demyelinating process involving the central nervous system; the diagnosis is made from a combination of clinical, imaging, and laboratory findings
• Patients with MS can present with motor, sensory, visual, and/or autonomic pathway symptoms
• Spinal MS is often associated with brain lesions; however, 20% of patients with spinal lesions do not have intracranial plaques
• Spinal cord atrophy is related to progressive MS and physical disability

Imaging Findings

• The 2017 revised McDonald criteria confirmed that MRI is the most useful paraclinical test to aid the diagnosis of MS, and can be used to establish dissemination of lesions in space and time
• Spinal MS lesions often occur in the cervical region and less frequently in the lower thoracic spinal cord (T7–12)
• Depending on their age, MS plaques appear normal or slightly hypointense on T1-weighted images and hyperintense on T2; the spinal cord may be enlarged when the disease is active and is atrophied when chronic
• Spinal plaques may appear as nodules, rings, or arcs on enhanced MRI and are generally less than 2 vertebral bodies in length, although involvement can be diffuse
• Enhancement, seen as high signal on T1, indicates active disease

KEY IMAGES

Pearls

• Spinal cord lesions are more likely than brain lesions to be symptomatic and leave residual neurological impairment, due to poor compensatory capacity of the spinal cord; despite this, 58% of new spinal cord lesions are asymptomatic
• The differential diagnosis includes primary or metastatic spinal cord neoplasm (cysts and hemorrhage common), acute disseminated encephalomyelitis (non-relapsing and history of viral infection), sarcoidosis (pial involvement common), transverse myelitis (usually involving a longer segment), infarct (usually a single lesion in an older patient with vascular disease), vasculitis, radiation myelitis (l-3 years latency period), and arteriovenous fistula (associated with serpiginous flow void)

References

1. Valsasina P, Aboulwafa M, Preziosa P, et al. Cervical cord T1-weighted hypointense lesions at MR imaging in multiple sclerosis: relationship to cord atrophy and disability. Radiology 2018; 288: 234–244
2. Tartaglino LM, Friedman DP, Flanders AE, Lublin FD, Knobler RL, Liem.  Multiple sclerosis in the spinal cord: MR appearance and correlation with clinical parameters.  Radiology 1995; 195(3):725-732
3. Traboulsee A, Simon JH, Stone L, Fisher E, Jones DE, et al.  Revised Recommendations of the Consortium of MS Centers Task Force for a Standardized MRI Protocol and Clinical Guidelines for the Diagnosis and Follow-Up of Multiple Sclerosis.  AJNR Am J Neuroradiol 2016; 37(3):394-401