What can MRI changes within your spinal cord tell you about your myelopathy?

[Iwan]

O.Mowforth

Note that within the spinal cord there are these two areas of 'white' termed 'high signal', highlighted here in orange

Images courtesy of Radiopaedia.org

MRI imaging is the mainstay of diagnosis of patients with CSM. Whilst the MRI can described findings associated with myelopathy, there has been a lot of debate as to whether it can tell you how bad your myelopathy is, and whether or not you would respond to surgery.

In this regard, changes within the spinal cord itself have been a major focus. MRI images are black and white. When you undergo a MRI scan there are two principal image types that are produced 'T1' and 'T2' images. The sequences highlight different features, and therefore what is white will differ from one sequence to the next.

Amongst patients with CSM, most have a 'normal' looking spinal cord, but others can have changes, including high signal (aka the 'white spot') on T2 images, with or without low signal (black) on T1 images.

​A group from North America (1), in the largest such study to date, having been looking specifically at changes within the spinal cord. Their theory was that the amount of spinal cord damage, and therefore the severity of disease and likelihood of improving after surgery, related to this sequence of changes. I.e. Normal cord was better than a white spot, but a white spot with corresponding blackness on T1 was worst of all. The white spot is thought to represent oedema, whereas the blackness loss of spinal cord tissue.

The authors analysed over 400 MRI scans of patients who went on to have surgery for CSM. Just as they thought, they found that these image changes did relate to the severity of myelopathy, and likelihood of responding to surgery.

More specifically, they found that the 'black' low signal on T1 images was the most important feature; most likely to be found in more severely affected patients, who responded less well to surgery. A 'white spot' on its own was only very slightly worse than normal looking cord, however 'white spots' at multiple levels was associated with more severe myelopathy.

This is a high-quality study, involving a large number of patients from across the globe. This is a very interesting study and moves the field forwards. The clinical relevance of a 'white spot' was uncertain, and a topic of constant debate; some studies had shown it was a sign of bad myelopathy, where as others that it was not indicative of severity (2). The finding here of the significance of one vs many white spots may explain these previously inconsistent findings. Regardless the relative, greater importance of low signal (black) on T1 images is new.

These image findings are not the be all and end all; some patients with spinal cord changes on their MRI do very well with surgery and vice versa. These findings therefore, at least for now, are only a guide.

References

1. A.Nouri et al. The Relationship Between MRI Signal Intensity Changes, Clinical Presentation, and Surgical Outcome in Degenerative Cervical Myelopathy: Analysis of a Global Cohort. Spine​. May 2017.

2. L.Tetreault et al. A Systematic Review of MRI Characteristics that Affect Treatment Decision-Making and Predict Clinical Outcome in Patients with Cervical Spondylotic Myelopathy. Spine August 2013

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Great article Iwan. I learned a lot. It made sense , now in reading and looking at our films. . Thank you. Cheers.

[MichaelBett]

Iwan, Nice article. just for clarification, signal changes refer to CSF-cerebrospinal fluid. when we have stenosis or cord compression the amount of CSF is comprimised and all of the benefits of CSF such as nutrients, protection, transmitting of nerve impulses and waste removal are lessened. Any disruption of the normal cord,especially narrowing or constricting, interferes with the natural flow of CSF. Hope this helps.

[Iwan Administrator in reply to MichaelBett]

Thank you so much for that information and explanation Michael people will really find your information really helpful and that's what the community is all about

[ALEC69]

Hi

I was interested to see your post and also to read the reply. I have a curvature of the spine in my Lumber region and Disc damage there also. Originally this was discovered some 30 years ago now. Collapsed Discs with Bulging & Debrey. For the most part, I guess, I changed my footwear (More sensible, flats as opposed to heels) Exercised regularly & so on.

For the past Two years now I have been troubled with a burning/prickly feeling in both feet especially my toes. Also a pins & needles, and or numbness feeling in my left arm, that has now progressed to the wrist.

I also have severe headaches and dizziness and my ferritin level keeps dropping to 3.

I have several Neck X rays. Last was Sept 2016 - Results after 10 weeks = "No Change"?? No change to what?

In October 2016 I began to develop headaches so bad I couldn't bare to open my eyes and would generally vomit if I did. My arm and the "sensation" (Like a stone being dropped in a puddle and the water rippling away from the splash) was becoming unbearable.

On Dec 16th I collapsed! Excessive BP, Feritan 2 and had Iron transfusions x3 and an MRI.

Total disbelief, when I was called 12 hours later to get my MRI results???... Thought was a practice error, to be honest.

The first thing the "new" Dr said, "I am so so sorry" ??

Multiple Disc degenerations and extensive central stenosis - Umm what?

C4, C5. C6, C7 at least - am possibly Thorax, though no one will confirm to date. That was Christmas week. An urgent appointment was requested with a surgeon and again x4 !! My first appointment is in 7 days time

How can it be that the Xray? Stated No change (From what as it was about the 3 or 4th) and weeks later all this was dropped on me?

Am I also correct in thinking that there now to many Discs collapsed/damaged for surgery?

A

[Iwan Administrator in reply to ALEC69]

Hi Alec sorry to hear about your experience and symptoms I'm not a medical professional but I will help you as much as I can, You symptoms are very common with myelopathy e.g. Headaches dizziness and neuropathic pain and unfortunately late diagnosis is a major problem when it comes to diagnosis, I have had the same levels done c4/c7 in 2015 my symptoms started in 2000 but I didn't have my diagnosis till 2014, how they have missed this with you is a good question All the very best with your appointment and of course you need an up to date MRI to see what level of compression you have , I hope this information somewhat helps with some of your questions but if you need more information then check out the myelopathy.org website we also have a dedicated support group too , If you need any more just ask

Iwan

[ALEC69 in reply to Iwan]

Thank you so much for the reply. I will update after my appointment next week.

Thanks for the website also, I will be sure to take a look there.

Alec

[MichaelBett]

Alec, I'm so sorry this has happened to you. Regarding your x-rays- if you didn't have a CT scan with myelogram or an MRI, the standard x-rays will not show the extent of the damage. I'm a retired occupational therapist,: I am a medical professional. You can ask me anything. but I'm not licensed anymore and can only give you my opinion. You should check with a doctor you feel comfortable in talking to for medical advise.

[smiler6]

Hi Iwan, thank you for a very interesting article especially in relation to my diagnosis, which is written in my records as follows.. There is chronic broad based disc/osteophyte formation at C3/4 resulting in moderate to severe central canal stenosis ( maximum canal diameter 6mm). This is associated with cord impression cord flattening, there is focal area of Myelopathy within the cervical cord. There is also severe bilateral foraminal stenosis at this level.

As the report you have put out suggests and I quote these findings are not the be all and end all and that some people with signal cord change do very well after surgery.

Then my question is why can I not find a surgeon who will undertake this procedure on myself, it seems that they see a white spot and automatically come up with the diagnosis that surgery what be of no benefits to me whatsoever, but the report suggests otherwise.

As you can well imagine Iwan I am totally baffled and frustrated to think that their is a possibility of hope that I am not being given the option to explore.

I would dearly appreciate your thoughts on the matter please.

[Iwan Administrator in reply to smiler6]

Hi I do apologise in advance that I can’t give any medical advice but here is a link to our website myelopathy.org we also have a support section and a Facebook support group m.facebook.com/groups/10663... hope you find the links useful best wishes Iwan

[smiler6]

Hi Iwan, thank you for your reply.