What is the expected presentation of MS with lesions in the cervical spinal cord?

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Expected Clinical Presentation of MS with Cervical Spinal Cord Lesions

Multiple sclerosis with cervical spinal cord lesions typically presents with decreased hand dexterity, gait instability, sensory disturbances, and motor dysfunction in the upper and lower extremities, with symptoms corresponding to the specific locations of the lesions in the spinal cord. 1, 2

Specific Symptoms Based on Lesion Location

Right Lateral and Central Cord at C3 and C4

  • Motor symptoms:
    • Right-sided weakness in upper and lower extremities
    • Decreased fine motor control of the right hand
    • Possible diaphragmatic weakness (if phrenic nerve involvement)
  • Sensory symptoms:
    • Numbness, tingling, or altered sensation on the right side of the body
    • Proprioceptive deficits affecting balance and coordination

Left Lateral Cord at C4/C5

  • Motor symptoms:
    • Left-sided weakness, particularly in the shoulder and upper arm
    • Possible weakness in left deltoid and biceps muscles
  • Sensory symptoms:
    • Numbness or paresthesias in the left upper extremity
    • Altered temperature and pain sensation on the left side

Right Lateral Cord at C6-C7

  • Motor symptoms:
    • Weakness in right wrist extensors, finger extensors, and triceps
    • Decreased grip strength in the right hand
  • Sensory symptoms:
    • Numbness or paresthesias in the right hand, particularly affecting thumb, index, and middle fingers
    • Altered sensation in the C6-C7 dermatomes on the right

General Clinical Manifestations

The pattern described shows multiple focal lesions in the cervical spinal cord, which is highly characteristic of MS. According to guidelines, spinal cord involvement is seen in 80-90% of MS patients, with the cervical portion most frequently affected 1.

The clinical presentation may include:

  1. Upper Motor Neuron Signs:

    • Hyperreflexia in affected limbs
    • Spasticity
    • Positive Babinski sign
    • Clonus

  2. Sensory Disturbances:

    • Lhermitte's sign (electric shock-like sensation down the spine with neck flexion)
    • Paresthesias
    • Sensory level deficits
    • Impaired vibration and position sense

  3. Autonomic Dysfunction:

    • Bladder urgency or retention
    • Bowel dysfunction
    • Sexual dysfunction

  4. Other Manifestations:

    • Fatigue
    • Weakness that worsens with heat or exertion (Uhthoff's phenomenon)
    • Possible respiratory involvement with higher cervical lesions

Diagnostic Considerations

The MRI findings described are consistent with MS, showing multiple short-segment lesions in the cervical spinal cord. These are typical "green flag" findings for MS as they are:

  • Focal with clearly demarcated borders
  • Less than two vertebral segments in length
  • Asymmetrically distributed
  • Affecting both lateral columns and central gray matter 1

It's important to note that these lesions differ from "red flag" findings such as:

  • Longitudinally extensive transverse myelitis (>3 vertebral segments) seen in neuromyelitis optica spectrum disorders
  • Diffuse spinal cord lesions with ill-defined borders
  • Selective involvement of lateral and posterior columns seen in subacute combined degeneration 1

Management Implications

Given the presence of established MS lesions in the cervical spinal cord, management should focus on:

  1. Disease-Modifying Therapy:

    • Nine classes of DMTs are available for relapsing-remitting MS and secondary progressive MS with activity
    • These reduce clinical relapses by 29-68% compared to placebo or active comparators 2, 3

  2. Symptomatic Treatment:

    • Physical therapy for spasticity and gait problems
    • Occupational therapy for hand dexterity issues
    • Energy conservation strategies for fatigue
    • Medications for specific symptoms (pain, spasticity, bladder dysfunction) 2

  3. Monitoring:

    • Regular MRI follow-up to assess for new lesions
    • Clinical assessments to monitor disability progression
    • Prompt treatment of relapses with high-dose corticosteroids when indicated 2, 4

Prognosis

The presence of multiple cervical cord lesions may indicate a more aggressive disease course, as spinal cord involvement is associated with greater disability. Patients with primary progressive MS tend to have more spinal cord involvement than those with relapsing-remitting MS 1. Early treatment with appropriate disease-modifying therapy is crucial to prevent further lesion accumulation and disability progression 4.

References

1
Guideline

Guideline Directed Topic Overview

Dr.Oracle Medical Advisory Board & Editors, 2025

2
Guideline

Imaging and Management of Multiple Sclerosis

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2025

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Professional Medical Disclaimer

This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.

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