Multiple Sclerosis — Spinal Cord¶
Definition¶
Multiple sclerosis (MS) is a chronic demyelinating disease of the central nervous system that frequently involves the spinal cord. Spinal cord lesions are present in 80–90% of MS patients on MRI and may be the presenting manifestation. The cervical cord is most commonly affected.
Imaging Findings¶
MRI¶
- T2-weighted — Focal, well-defined hyperintense lesions within the cord, typically spanning fewer than 2 vertebral segments ("short-segment" lesions)
- Location — Peripheral (dorsal or lateral columns), involving less than 50% of the cord cross-sectional area on axial images. This peripheral location corresponds to the white matter tracts.
- Cervical cord — Most common location (60%), followed by thoracic cord
- Enhancement — Active (acute) lesions enhance with gadolinium; chronic lesions do not enhance. Incomplete ring or open-ring enhancement is relatively specific for demyelination.
- Cord atrophy — Progressive cord atrophy develops over time in established MS and correlates with disability
Key Features Distinguishing MS from NMOSD¶
| Feature | MS | NMOSD |
|---|---|---|
| Lesion length | Short (<2 segments) | Long (≥3 segments) |
| Cross-section | Peripheral, <50% area | Central, >2/3 area |
| Cord swelling | Minimal | Moderate to marked |
| Enhancement | Incomplete ring | Ring or patchy |
| Cervical predilection | Yes | Yes |
| Brain lesions | Periventricular, Dawson fingers | Absent or area postrema |
| AQP4 antibody | Negative | Positive (~70%) |
Brain MRI¶
Brain MRI is essential in any patient with suspected MS cord lesion — periventricular white matter lesions (Dawson fingers), juxtacortical lesions, and infratentorial lesions support the diagnosis per the McDonald criteria.
Clinical Pearl
A short-segment, peripheral, dorsal or lateral cord lesion in the cervical spine with an incomplete ring enhancement pattern on post-contrast MRI is highly suggestive of MS. Always obtain a brain MRI — the presence of characteristic periventricular, juxtacortical, and infratentorial lesions allows diagnosis of MS per the McDonald criteria even from a single clinical episode (clinically isolated syndrome).
Key Points¶
- Spinal cord lesions are present in 80–90% of MS patients
- Short-segment (<2 vertebral bodies), peripheral lesions are characteristic
- Cervical cord is most commonly affected
- Incomplete ring enhancement suggests active demyelination
- Cord atrophy develops with disease progression and correlates with disability
- Brain MRI is essential for diagnosis per McDonald criteria
- Distinguish from NMOSD (long-segment, central) — different treatments required
References¶
- Thompson AJ, Banwell BL, Barkhof F, et al. Diagnosis of multiple sclerosis: 2017 revisions of the McDonald criteria. Lancet Neurol. 2018;17(2):162-173. https://pubmed.ncbi.nlm.nih.gov/29275977/
- Wattjes MP, Ciccarelli O, Reich DS, et al. 2021 MAGNIMS-CMSC-NAIMS consensus recommendations on the use of MRI in patients with multiple sclerosis. Lancet Neurol. 2021;20(8):653-670. https://pubmed.ncbi.nlm.nih.gov/34139157/
- Agarwal V, Shah LM, Parsons MS, et al. ACR Appropriateness Criteria® Myelopathy: 2021 Update. J Am Coll Radiol. 2021;18(5S):S73-S82. https://pubmed.ncbi.nlm.nih.gov/33958120/
- Tafti D, Ehsan M, Xixis KL. Multiple Sclerosis. In: StatPearls. Treasure Island (FL): StatPearls Publishing; updated 2024 Mar 20. https://www.ncbi.nlm.nih.gov/books/NBK499849/
- Marrodan M, Gaitán MI, Correale J. Spinal Cord Involvement in MS and Other Demyelinating Diseases. Biomedicines. 2020;8(5):130. https://pmc.ncbi.nlm.nih.gov/articles/PMC7277673/
- Chen Y, Haacke EM, Bernitsas E. Imaging of the Spinal Cord in Multiple Sclerosis: Past, Present, Future. Brain Sciences. 2020;10(11):857. https://pmc.ncbi.nlm.nih.gov/articles/PMC7696997/
- Multiple sclerosis. Radiopaedia.org. https://radiopaedia.org/articles/multiple-sclerosis