What are the next steps for a patient with multiple small hyperintense signal lesions in the upper thoracic spine spinal cord and a disc protrusion at the T5-T6 level?

Immediate Neurology Referral and Brain MRI Are Essential

This patient requires urgent neurology consultation and brain MRI to evaluate for demyelinating disease, particularly multiple sclerosis, given the multiple hyperintense thoracic spinal cord lesions. 1

Critical Next Steps

1. Neurology Consultation (Urgent)

• Refer immediately for comprehensive neurological evaluation 1
• The presence of multiple small hyperintense spinal cord lesions raises significant concern for a demyelinating process such as multiple sclerosis 1
• Spinal cord lesions identify patients at higher risk for MS confirmation, with one spinal cord lesion being sufficient to meet dissemination in space criteria when combined with brain lesions 1

2. Brain MRI with Contrast (Priority Imaging)

• Obtain brain MRI at ≥1.5T field strength to assess for dissemination in space and time per McDonald criteria 1
• Brain imaging is essential when spinal cord lesions suggest demyelinating disease, as approximately 40% of spinal cord lesions in MS patients are found in the thoracolumbar region 1
• Look for characteristic MS lesions in periventricular, juxtacortical, and infratentorial regions 1
• Contrast administration helps identify active lesions (gadolinium enhancement) for dissemination in time 1

3. Additional Spinal Cord Imaging Considerations

• Repeat thoracic spine MRI with at least two sequences (T2 and STIR or proton density) to increase confidence in lesion identification and distinguish true lesions from artifacts 1
• Consider whole cord imaging (cervical through lumbar) as approximately 40% of MS spinal cord lesions occur in the thoracolumbar region 1
• Axial imaging should be included to better characterize lesion morphology and location 1

Key Diagnostic Considerations

Demyelinating Disease Features

• Multiple small focal lesions in the thoracic cord are highly specific for MS, as spinal cord lesions are not seen with normal aging or common neurological disorders 1
• MS spinal cord lesions are typically:
  • Small (≥3 mm), covering less than two vertebral segments 1
  • Cigar-shaped on sagittal images, wedge-shaped on axial images 1
  • Located peripherally in lateral or dorsal columns 1
  • Focal with clearly demarcated borders 1

Red Flags to Exclude

The radiologist appropriately noted the T5-T6 lesion could relate to disc protrusion, but several features argue against purely mechanical compression:

• Multiple lesions at different levels suggest systemic demyelinating process rather than isolated mechanical compression 1
• Longitudinally extensive transverse myelitis (>3 vertebral segments) would suggest neuromyelitis optica spectrum disorder rather than MS 1
• Purely grey matter involvement would be atypical for MS 1

The T5-T6 Disc Protrusion

• While the disc protrusion indents the cord with signal alteration, this does not exclude concurrent demyelinating disease 1
• The presence of multiple other lesions at different levels makes isolated mechanical etiology unlikely 1
• Disc protrusions are common incidental findings in asymptomatic individuals 2
• Symptomatic lesions can still contribute to MS diagnostic criteria and may actually increase sensitivity for MS diagnosis 1

Clinical Correlation Required

The neurologist should assess for:

• Clinical symptoms suggesting demyelination (sensory changes, motor weakness, bladder dysfunction, Lhermitte's sign) 1
• Temporal pattern of symptom onset (acute vs. subacute vs. progressive) 1
• Prior neurological events that may represent clinically isolated syndrome 1
• Examination findings localizing to spinal cord levels 1

Additional Workup Through Neurology

The neurologist will likely order:

• CSF analysis if diagnostic criteria are not met by imaging alone, particularly for primary progressive MS evaluation 1
• Visual evoked potentials and ophthalmology evaluation to assess for subclinical optic nerve involvement 1
• Serum testing for NMO-IgG/aquaporin-4 antibodies to exclude neuromyelitis optica spectrum disorder 1

Common Pitfalls to Avoid

• Do not dismiss multiple cord lesions as artifacts without proper neurological evaluation 1
• Do not attribute all findings to the disc protrusion when multiple lesions are present at different levels 1
• Do not delay brain MRI as it is essential for complete MS diagnostic workup 1
• Do not assume benign etiology based on age alone; younger patients with muscle hyperintensity may have more acute pathology 3