Cervical myelitis: a practical approach to its differential diagnosis on MR imaging

Abstract

Background Differential diagnosis of non-compressive cervical myelopathy encompasses a broad spectrum of inflammatory, infectious, vascular, neoplastic, neurodegenerative, and metabolic etiologies. Although the speed of symptom onset and clinical course seem to be specific for certain neurological diseases, lesion pattern on MR imaging is a key player to confirm diagnostic considerations.

Methods The differentiation between acute complete transverse myelitis and acute partial transverse myelitis makes it possible to distinguish between certain entities, with the latter often being the onset of multiple sclerosis. Typical medullary MRI lesion patterns include a) longitudinal extensive transverse myelitis, b) short-range ovoid and peripheral lesions, c) polio-like appearance with involvement of the anterior horns, and d) granulomatous nodular enhancement prototypes.

Results and Conclusion Cerebrospinal fluid analysis, blood culture tests, and autoimmune antibody testing are crucial for the correct interpretation of imaging findings. The combination of neuroradiological features and neurological and laboratory findings including cerebrospinal fluid analysis improves diagnostic accuracy.

Key Points: 

• The differentiation of medullary lesion patterns, i. e., longitudinal extensive transverse, short ovoid and peripheral, polio-like, and granulomatous nodular, facilitates the diagnosis of myelitis.

• Discrimination of acute complete and acute partial transverse myelitis makes it possible to categorize different entities, with the latter frequently being the overture of multiple sclerosis (MS).

• Neuromyelitis optica spectrum disorders (NMOSD) may start as short transverse myelitis and should not be mistaken for MS.

• The combination of imaging features and neurological and laboratory findings including cerebrospinal fluid analysis improves diagnostic accuracy.

• Additional brain imaging is mandatory in suspected demyelinating, systemic autoimmune, infectious, paraneoplastic, and metabolic diseases.

Zusammenfassung

Hintergrund Die Differentialdiagnose der nicht durch eine Kompression bedingten zervikalen Myelopathie umfasst ein breites Spektrum von inflammatorischen, infektiösen, vaskulären, neoplastischen, neurodegenerativen und metabolischen Ätiologien. Obschon Symptombeginn und klinischer Verlauf für einzelne neurologische Erkrankungen spezifisch erscheinen, nimmt die MRT eine Schlüsselrolle in der Bestätigung diagnostischer Überlegungen ein.

Methode Durch die Unterscheidung von akut kompletter und akut partieller transversaler Myelitis können verschiedene Entitäten differenziert werden, letztere öfter als Ouvertüre einer Multiplen Sklerose. Charakteristische medulläre Läsionsmuster sind a) die longitudinal extensive transversale Myelitis, b) kurzstreckige ovale und peripher im Rückenmarksquerschnitt gelegene Läsionen, c) polio-ähnliche Signalalterationen in den Vorderhörnern und d) granulomatös-nodulär anmutende Kontrastmittelanreicherungen.

Ergebnisse und Schlussfolgerung Die Fusion von charakteristischen medullären Läsionsmustern sowie klinischen und laborchemischen Befunden einschließlich der Liquoranalyse verbessert die differentialdiagnostische Abklärung und Zuordnung zervikaler Myelitiden.

Kernaussagen: 

• Die Unterscheidung verschiedener Läsionsmuster wie longitudinal extensiv transversal, kurzstreckig ovoid und peripher gelegen, polio-ähnlich und granulomatös-nodulär erleichtert die Differenzierung von Myelitiden.

• Die Differenzierung zwischen akut kompletter und akut partieller transversaler Myelitis trennt verschiedene Ätiologien, letztere oft als Ouvertüre einer multiplen Sklerose (MS).

• Die Neuromyelitis-optica-Spektrum-Erkrankung (NMOSD) kann als kurzstreckige Myelitis beginnen und darf nicht mit einer MS verwechselt werden.

• Die Fusion von neuroradiologischen, neurologischen und laborchemischen Befunden einschließlich Liquoranalyse erhöht die diagnostische Sicherheit.

• Bei Verdacht einer demyelinisierenden, systemisch autoimmunen, infektiösen, paraneoplastischen oder metabolischen Ätiologie ist eine zusätzliche zerebrale Bildgebung essentiell.

Zitierweise

• Weidauer S, Hattingen E, Arendt CT. Cervical myelitis: a practical approach to its differential diagnosis on MR imaging. Fortschr Röntgenstr 2023; 195: 1081 – 1096

Key words

spinal cord - myelitis - myelopathy - magnetic resonance imaging - differential diagnosis

Publication History

Received: 23 January 2023

Accepted: 25 May 2023

Article published online:
06 July 2023

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