From the Guidelines
Acute myelopathy requires immediate medical attention and evaluation with MRI imaging to determine the cause, which may include trauma, inflammation, infection, vascular issues, or compression, and treatment should be guided by the underlying cause, with high-dose corticosteroids, surgical decompression, or antibiotics as necessary. The condition can be subdivided into noninflammatory and inflammatory causes, with noninflammatory conditions including extrinsic compression of the spinal cord, vascular pathologies, and trauma, and inflammatory conditions including demyelinating diseases, systemic inflammatory diseases, and infection 1.
Causes and Evaluation
The evaluation of acute myelopathy should include MRI imaging of the spinal cord, which is useful for evaluating the spinal cord and surrounding osseous and soft-tissue structures, and can help identify the underlying cause of the condition, such as extrinsic compression, inflammation, or infection 1. Diffusion-weighted imaging can show signal alteration in the spinal cord earlier after patient symptom onset compared with T2-weighted images, and should be included in the evaluation when spinal cord ischemia is suspected 1.
Treatment and Management
Treatment of acute myelopathy depends on the underlying cause, but may include high-dose corticosteroids, such as methylprednisolone, if inflammation is suspected, particularly within 8 hours of symptom onset, as well as surgical decompression for cases involving trauma, herniated discs, or tumors causing cord compression, and antibiotics if infection is the cause 1. Physical and occupational therapy should begin as soon as medically stable to prevent complications and maximize recovery, and patients should be closely monitored for respiratory compromise, especially with high cervical lesions, and management of bladder and bowel dysfunction 1.
Prognosis and Recovery
The prognosis of acute myelopathy varies based on the cause, severity, and timing of treatment, with better outcomes generally associated with earlier intervention, and recovery can continue for up to two years after the initial injury, making ongoing rehabilitation crucial 1. The presence of certain "red flags" on MRI imaging, such as longitudinally extensive transverse myelitis or spinal cord swelling, can indicate a poorer prognosis and require more aggressive treatment 1.
Key Considerations
In evaluating and treating acute myelopathy, it is essential to consider the potential causes and to use MRI imaging to guide diagnosis and treatment, and to initiate treatment promptly to minimize morbidity and mortality, and to improve quality of life 1.
From the Research
Definition and Characteristics of Acute Myelopathy
- Acute myelopathies are spinal cord disorders characterized by a rapidly progressive course, reaching a nadir within hours to a few weeks, and may result in severe disability 2.
- These disorders are heterogeneous, with distinct etiologies, clinical and radiologic features, and prognoses 3.
- Myelopathy is an inclusive term referring to pathology leading to a neurologic deficit related to the spinal cord, requiring a detailed history, physical examination, and neuroimaging for diagnosis 4.
Diagnosis and Management
- Awareness of clinical and magnetic resonance imaging characteristics of different myelopathies is fundamental for a correct diagnosis 2.
- Neuroimaging helps distinguish compressive etiologies that may require urgent surgery from intrinsic etiologies that generally require medical treatment 2, 4.
- Differentiation between various myelopathies is essential to establish timely and appropriate treatment and avoid harm from unnecessary procedures 2, 3.
- The clinical approach to myelopathy diagnosis involves an integrative strategy, including diagnostic neuroimaging techniques and understanding of immune pathogenic mechanisms associated with spinal cord disorders 5.
Treatment and Outcomes
- The role of methylprednisolone in acute transverse myelitis is not well established, with some studies suggesting no beneficial effect on outcome 6.
- Advances in diagnostic techniques and understanding of myelopathies have expanded knowledge of inflammatory and noninflammatory myelopathies, allowing for more precise diagnosis and treatment 3, 5.
- Knowledge of clinical variety and strategies for precise diagnosis, identification of etiologic factors, and implementation of therapies can help improve outcomes in patients with myelopathies 5.