Myelopathy Imaging Correlation¶
Definition¶
Myelopathy is dysfunction of the spinal cord itself, as opposed to radiculopathy (nerve root dysfunction). Myelopathy produces upper motor neuron signs — spasticity, hyperreflexia, gait disturbance, and sometimes bowel/bladder dysfunction.
Imaging Findings Suggesting Myelopathy¶
MRI¶
- T2 hyperintensity within the cord — The most important finding. Represents edema, gliosis, or myelomalacia depending on the clinical stage.
- Cord compression — Effacement of the CSF space around the cord, flattening or deformity of the cord
- Cord atrophy — Reduced cord diameter, indicating chronic damage
- T1 hypointensity within the cord — Suggests irreversible damage (myelomalacia/cavitation); worse prognosis than T2 hyperintensity alone
- Enhancement — Active inflammation, ischemia, or tumor
Prognostic Significance¶
| MRI Finding | Clinical Significance |
|---|---|
| T2 hyperintensity alone | Edema/gliosis — potentially reversible |
| T2 hyperintensity + T1 hypointensity | Myelomalacia — likely irreversible |
| T2 hyperintensity + enhancement | Active process (inflammation, ischemia) |
| Cord atrophy | Chronic damage — poor recovery potential |
Common Causes¶
- Compressive — Cervical spondylotic myelopathy (most common overall), disc herniation, ossification of the PLL, tumor
- Inflammatory — MS, transverse myelitis, NMOSD, sarcoidosis
- Vascular — Spinal cord infarction, dural AVF with venous congestion
- Metabolic — B12 deficiency (dorsal column T2 hyperintensity)
- Infectious — HIV vacuolar myelopathy, HTLV-1
Clinical Pearl
When you see T2 hyperintensity within the cord, the distribution pattern on axial MRI helps determine the etiology: anterior two-thirds = arterial infarction; dorsal columns = B12 deficiency; central = syrinx or tumor; peripheral (dorsal/lateral) = MS; diffuse central = NMOSD. The pattern narrows the differential significantly.
Key Points¶
- T2 hyperintensity within the cord is the hallmark MRI finding of myelopathy
- T1 hypointensity indicates irreversible damage (worse prognosis)
- Axial distribution pattern helps determine the etiology
- Cervical spondylotic myelopathy is the most common cause
- Urgent decompression is indicated for compressive myelopathy to prevent irreversible damage
References¶
- Agarwal V, Shah LM, Parsons MS, et al; Expert Panel on Neurological Imaging. ACR Appropriateness Criteria® Myelopathy: 2021 Update. J Am Coll Radiol. 2021;18(5S):S73-S82. doi:10.1016/j.jacr.2021.01.020. https://pubmed.ncbi.nlm.nih.gov/33958120/
- Lee MJ, Aronberg R, Manganaro MS, Ibrahim M, Parmar HA. Diagnostic Approach to Intrinsic Abnormality of Spinal Cord Signal Intensity. RadioGraphics. 2019;39(6):1824-1839. doi:10.1148/rg.2019190021. https://pubmed.ncbi.nlm.nih.gov/31589577/
- Laur O, Nandu H, Titelbaum DS, Nunez DB, Khurana B. Nontraumatic Spinal Cord Compression: MRI Primer for Emergency Department Radiologists. RadioGraphics. 2019;39(6):1862-1880. doi:10.1148/rg.2019190024. https://pubmed.ncbi.nlm.nih.gov/31589584/
- Sarbu N, Lolli V, Smirniotopoulos JG. Magnetic resonance imaging in myelopathy: a pictorial review. Clin Imaging. 2019;57:56-68. doi:10.1016/j.clinimag.2019.05.002. https://pubmed.ncbi.nlm.nih.gov/31129392/
- Margetis K, Donnally CJ III. Cervical Myelopathy. In: StatPearls. Treasure Island (FL): StatPearls Publishing; 2024. https://www.ncbi.nlm.nih.gov/books/NBK482312/
- Gaillard F, et al. Cervical spondylotic myelopathy. Radiopaedia.org. https://radiopaedia.org/articles/cervical-spondylotic-myelopathy