Continuum: Lifelong Learning in Neurology®

Inflammatory and infectious myelopathies are common and often treatable. Infectious causes include viral, bacterial, mycobacterial, fungal, and parasitic agents. Noninfectious inflammatory myelopathies were previously often categorized as idiopathic transverse myelitis, but advances in neuroimaging and the discovery of a serum autoantibody marker, neuromyelitis optica immunoglobulin G (NMO-IgG), have allowed more specific diagnoses, such as multiple sclerosis and neuromyelitis optica, to be made more confidently and at an earlier stage than previously possible. This chapter summarizes an approach to evaluation and management of infectious and inflammatory causes of acute and subacute myelitis and chronic progressive myelopathy.(C) 2008 American Academy of Neurology

Spinal cord vascular disease is rare but can be devastating to patients. Hypotension, especially in association with vascular procedures, and embolism are common causes of cord ischemia. Ischemia generally presents with acute painful myelopathy. The enclosed space of the spinal canal also renders the cord vulnerable to compressive effects of space-occupying vascular lesions, such as the dilated veins associated with vascular malformations. These are more likely to present with progressive myelopathy. MRI is the imaging modality of choice in identifying the cause and extent of vascular myelopathy. Interventional endovascular approaches to spinal vascular malformations are becoming more common.(C) 2008 American Academy of Neurology

There is a broad spectrum of causes of compressive myelopathies. Resulting neurologic deficits may not improve after decompression. Early diagnosis and treatment are paramount to ensuring long-term functional outcome, and errors in diagnosis with resultant delays in treatment can have drastic consequences. The history, including patient demographics and the onset and progression of the disease, and physical examination are critical tools in arriving at a correct diagnosis. Very often, the diagnosis is obvious.After the history and physical examination have concluded that a myelopathy is present, imaging is necessary to evaluate for a compressive etiology. Spinal MRI, including gadolinium-enhanced images, is the diagnostic study of choice and should be obtained expediently. Major advantages of MRI include its multiplanar capabilities and the ability to visualize nonosseous lesions.Dependent on MRI findings, other radiologic evaluations may be necessary, including noncontrast CT and plain x-rays. If an MRI is not obtainable because of the presence of a pacemaker, claustrophobia, lack of availability, clinical situation, or a multitude of other possible reasons, CT myelography is an excellent alternative tool. Plain myelography can help in defining a compressive lesion. The goal of imaging studies is to define the lesion and guide surgical decision making if cord compression is found.(C) 2008 American Academy of Neurology

Disorders of the brachial and lumbosacral plexuses are rare mimickers of spinal cord and root diseases. The clinical manifestations consist of pain, weakness, and sensory loss in the affected limb. The plexuses may be injured by several mechanisms, including trauma, inflammation, structural compression, or infiltration. The use of careful electrodiagnostic testing and neuroimaging studies, in addition to the identification of clinical clues, is important in diagnosing plexopathies and determining etiology. Despite identification of the etiology of plexopathies, treatment is often limited. Treatment of the underlying cause, as well as supportive and symptomatic treatment, may lead to improvement of neurologic function.(C) 2008 American Academy of Neurology