What is the appropriate management and treatment for a patient presenting with symptoms of myelopathy, such as numbness, weakness, or bladder and bowel dysfunction, considering potential causes like spinal cord compression, infection, or inflammation?

Management of Myelopathy

Immediately initiate high-dose dexamethasone (96 mg IV daily) upon clinical suspicion of myelopathy, even before imaging confirmation, and obtain urgent MRI of the entire spine to identify the cause and guide definitive treatment. 1

Initial Emergency Assessment and Stabilization

Immediate Corticosteroid Therapy

• Administer high-dose dexamethasone 96 mg IV daily immediately when spinal cord compression is suspected, before waiting for radiographic confirmation 1
• This intervention significantly improves ambulation rates (81% vs 63% at 3 months) compared to no corticosteroids 1
• Taper dexamethasone over 14 days, though this carries significant toxicity risk 1

Urgent Imaging

• Obtain MRI of the entire spine emergently as the preferred imaging modality (sensitivity 0.44-0.93, specificity 0.90-0.98) 1
• MRI must be performed promptly when symptoms suggest myelopathy to evaluate for spinal cord compression 2
• Myelography is an alternative if MRI is contraindicated (sensitivity 0.71-0.97, specificity 0.88-1.00) 1

Critical Clinical Assessment

• Document ambulatory status immediately, as pretreatment neurologic status is the strongest prognostic factor for recovery 1
• Assess for specific red flags: numbness, weakness, bladder/bowel dysfunction, sensory level, and duration of symptoms 2, 3
• Determine time course: acute (<21 days), subacute, or chronic, as etiologies differ dramatically 4

Definitive Treatment Selection

Surgical Indications (Absolute)

Proceed immediately to surgical decompression followed by radiotherapy if any of the following are present: 1

• Bony retropulsion or bone fragments causing cord compression 1
• Frank spinal instability 1
• Single level compression with neurologic deficits present <48 hours 1
• Age <65 years with predicted survival ≥3 months 1

Surgery plus radiotherapy is superior to radiotherapy alone in selected patients, with better maintenance of ambulatory status (P=0.006) 1

Radiotherapy Protocol

• Standard regimen: 30 Gy in 10 fractions for patients not requiring surgery 1
• Alternative regimens include 37.5 Gy in 15 fractions, 40 Gy in 20 fractions, or 28 Gy in 7 fractions—no regimen demonstrates superiority 1
• For multiple myeloma patients specifically, low-dose radiation (8 Gy in 3 fractions) or 20-30 Gy in 5-10 fractions can be used for impending cord compression 5
• Important caveat: Pain relief may be delayed up to 2 weeks following radiotherapy 1
• Post-operative radiotherapy should be administered once surgical healing has occurred 5, 1

Etiology-Specific Management

Compressive Myelopathy (Most Common in Older Adults)

• Degenerative disease of the vertebral column is the most common cause and should be screened for first 6
• Surgical decompression (posterior laminectomy) is effective, especially for vertebral collapse, though mortality rate is 6-10% 5
• Vertebroplasty or kyphoplasty may be used for severe back pain from vertebral compression fractures 1

Infectious Myelopathy

• Consider viral, bacterial (pyogenic and atypical), fungal, and parasitic causes 7
• For tuberculous myelopathy with bone/joint involvement, 6-9 month regimens containing rifampin are effective 5
• Myelopathy with or without functional impairment most often responds to chemotherapy in tuberculosis, with 74 of 85 patients achieving complete resolution 5

Inflammatory/Immune-Mediated Myelopathy

• Consider antibody-mediated myelitis and other immune causes in the differential 4
• CSF analysis may be required for diagnosis in non-compressive cases 8

Prognostic Factors and Expected Outcomes

Critical Timing Issues

• 70% of patients experience loss of neurologic function between symptom onset and treatment initiation 1
• Two-thirds of delays are attributed to patients not recognizing symptoms as urgent 1
• Patients with slower development of motor deficits (>14 days) have better functional outcomes than rapid progression (<14 days) 1

Recovery Expectations

• Ambulatory patients have 96-100% chance of remaining ambulatory after treatment 1
• Only 30% of non-ambulatory patients regain ability to walk 5, 1
• Only 2-6% of paraplegic patients regain ambulatory function 5, 1
• Recovery of neurologic function is highly dependent on pretreatment status 1

Common Pitfalls to Avoid

• Do not delay treatment waiting for complete diagnostic workup—initiate dexamethasone immediately on clinical suspicion 1
• Do not underestimate the urgency—untreated spinal cord compression leads to progressive neurological deterioration with relentless progression 2
• Do not assume radiotherapy alone is adequate for surgical candidates—surgery plus radiotherapy is superior in appropriate patients 1
• Do not delay systemic therapy for radiation—in multiple myeloma, systemic therapy can often be given concurrently with radiation 5