What is the treatment approach for an adult patient with myomalacia and spinal cord atrophy?

Myomalacia with Spinal Cord Atrophy: Definition and Treatment

Myomalacia (also termed myelomalacia) is irreversible spinal cord tissue necrosis resulting from compression, ischemia, or trauma, and when accompanied by spinal cord atrophy, requires urgent surgical decompression if symptomatic compression is present, as this represents the only treatment that can prevent further neurological deterioration. 1, 2

What is Myomalacia?

Myomalacia represents irreversible necrotic death of spinal cord tissue characterized by:

• Necrosis with cytoplasmic swelling, mechanical rupture of plasma membranes, and irreversible cell death 1
• T2 hyperintensity on MRI within the spinal cord, often with cord atrophy in chronic cases 1, 2
• Progressive pathological cascade: initial compression → blood-cord barrier breakdown → edema → progressive necrosis → cavitation → gliosis 1

The condition differs fundamentally from reversible cord edema or inflammation—it represents permanent tissue loss 1.

Primary Causes

Compressive Mechanisms

• Degenerative disease is the most common cause, particularly cervical spondylosis with disc herniations, osteophyte formation, and spinal malalignment 1, 2
• Post-surgical complications including seromas, pseudomeningoceles, hematomas, and epidural abscesses 1, 2
• Tumors in extradural and intradural extramedullary spaces 1

Vascular Mechanisms

• Spinal cord ischemia from compromised blood supply due to compression 2
• Vascular malformations causing venous hypertension and progressive myelopathy 1, 2
• Atheromatous disease, aortic surgery complications, systemic hypotension, and thoracoabdominal aneurysms 1

Traumatic Mechanisms

• Direct spinal cord injury with fractures leading to central hemorrhage and spreading ischemia 1

Diagnostic Approach

MRI is the gold standard for detecting myomalacia and should include: 1, 2

• T2-weighted sequences showing hyperintensity within the cord
• T1-weighted sequences to assess cord atrophy
• Diffusion-weighted imaging which can detect acute ischemic changes earlier than T2-weighted images 1
• Contrast-enhanced sequences to differentiate ischemic from inflammatory or neoplastic causes 1

Critical imaging findings include: 1, 2

• T2 hyperintensity at and below the level of stenosis
• Cord atrophy in chronic cases
• Possible enhancement patterns depending on acuity

Treatment Algorithm

For Symptomatic Compression with Myomalacia

Surgical decompression is the definitive treatment and should be performed urgently to prevent further neurological deterioration: 2

1. Decompression with fusion is recommended to prevent instability and kyphotic deformity 2
2. Laminectomy alone carries higher risk of reoperation due to restenosis, adjacent-level stenosis, and postoperative kyphotic deformity 2
3. Timing is critical: patients with preoperative myomalacia can still show significant neurological improvement if decompressed before complete cord destruction 2

For Malignant Spinal Cord Compression

If myomalacia occurs in the context of malignancy: 3

• High-dose dexamethasone before radiotherapy improves ambulatory outcomes (81% vs 63% ambulation at 3 months, P=0.046) 3
• MRI is the preferred imaging technique with sensitivity 0.44-0.93 and specificity 0.90-0.98 3
• Treatment decisions must consider pretreatment ambulatory status, presence of bony compression, spinal instability, and surgical risk 3

Symptomatic Management

For neuropathic pain associated with spinal cord injury and myomalacia: 4

• Pregabalin 150-600 mg/day is FDA-approved for neuropathic pain associated with spinal cord injury
• Dosing involves 3-week adjustment phase followed by maintenance
• Common adverse effects include dizziness (20.9%), somnolence (35.7%), and peripheral edema (10.4%) 4

Monitoring and Prognosis

Intramedullary cord signal changes on MRI represent important prognostic factors for neurosurgical outcomes: 1, 2

• The presence of myomalacia does not necessarily correlate with poor outcomes if decompression is performed before complete cord destruction 1
• Imaging must be interpreted with clinical findings, as radiographic severity may not match symptom severity 1

Critical Pitfalls to Avoid

Do not confuse myomalacia with reversible conditions: 1

• Demyelination, inflammation, or neoplasm can also cause T2 hyperintensity
• Contrast enhancement patterns help differentiate these entities

Do not delay surgical intervention in symptomatic patients with progressive neurological deficits, as myomalacia represents ongoing irreversible tissue destruction 2

Do not rely on laminectomy alone for decompression, as fusion is typically required to prevent postoperative instability 2

Recognize that cord atrophy indicates chronicity but does not preclude potential benefit from decompression if active compression persists 1, 2