On Cave Paintings and Shallow Waters—The Case for Advancing Spinal Cord Imaging in Multiple Sclerosis

Spinal cord imaging in multiple sclerosis (MS) plays a significant role in diagnosing and tracking disease progression. The spinal cord is one of four key areas of the central nervous system where documenting the dissemination in space in the McDonald criteria for diagnosing MS. Spinal cord lesion load and the severity of cord atrophy are believed to be more relevant to disability than white matter lesions in the brain in different phenotypes of MS. Axonal loss contributes to spinal cord atrophy in MS and its degree correlates with disease severity and prognosis. Therefore, measures of axonal loss are often reliable biomarkers for monitoring disease progression. With recent technical advances, more and more qualitative and quantitative MRI techniques have been investigated in an attempt to provide objective and reliable diagnostic and monitoring biomarkers in MS. In this article, we discuss the role of spinal cord imaging in the diagnosis and prognosis of MS and, additionally, we review various techniques that may improve our understanding of the disease.

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Advances in spinal cord imaging in multiple sclerosis

Therapeutic Advances in Neurological Disorders ◽

10.1177/1756286419840593 ◽

2019 ◽

Vol 12 ◽

pp. 175628641984059 ◽

Cited By ~ 16

Author(s):

Marcello Moccia ◽

Serena Ruggieri ◽

Antonio Ianniello ◽

Ahmed Toosy ◽

Carlo Pozzilli ◽

...

Keyword(s):

Multiple Sclerosis ◽

Spinal Cord ◽

Imaging Techniques ◽

Quantitative Imaging ◽

Automated Analysis ◽

Spinal Cord Atrophy ◽

Recent Developments ◽

Magnetic Resonance Imaging Mri ◽

Spinal Cord Imaging

The spinal cord is frequently affected in multiple sclerosis (MS), causing motor, sensory and autonomic dysfunction. A number of pathological abnormalities, including demyelination and neuroaxonal loss, occur in the MS spinal cord and are studied in vivo with magnetic resonance imaging (MRI). The aim of this review is to summarise and discuss recent advances in spinal cord MRI. Advances in conventional spinal cord MRI include improved identification of MS lesions, recommended spinal cord MRI protocols, enhanced recognition of MRI lesion characteristics that allow MS to be distinguished from other myelopathies, evidence for the role of spinal cord lesions in predicting prognosis and monitoring disease course, and novel post-processing methods to obtain lesion probability maps. The rate of spinal cord atrophy is greater than that of brain atrophy (−1.78% versus −0.5% per year), and reflects neuroaxonal loss in an eloquent site of the central nervous system, suggesting that it can become an important outcome measure in clinical trials, especially in progressive MS. Recent developments allow the calculation of spinal cord atrophy from brain volumetric scans and evaluation of its progression over time with registration-based techniques. Fully automated analysis methods, including segmentation of grey matter and intramedullary lesions, will facilitate the use of spinal cord atrophy in trial designs and observational studies. Advances in quantitative imaging techniques to evaluate neuroaxonal integrity, myelin content, metabolic changes, and functional connectivity, have provided new insights into the mechanisms of damage in MS. Future directions of research and the possible impact of 7T scanners on spinal cord imaging will be discussed.

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Clinical monitoring of multiple sclerosis should routinely include spinal cord imaging – Yes

Multiple Sclerosis Journal ◽

10.1177/1352458518778010 ◽

2018 ◽

Vol 24 (12) ◽

pp. 1536-1537 ◽

Cited By ~ 3

Author(s):

Rosa Cortese ◽

Olga Ciccarelli

Keyword(s):

Multiple Sclerosis ◽

Spinal Cord ◽

Clinical Monitoring ◽

Spinal Cord Imaging

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Evaluation of the 2010 McDonald multiple sclerosis criteria in children with a clinically isolated syndrome

Multiple Sclerosis Journal ◽

10.1177/1352458512444661 ◽

2012 ◽

Vol 18 (12) ◽

pp. 1768-1774 ◽

Cited By ~ 25

Author(s):

Barbara Kornek ◽

Beate Schmitl ◽

Karl Vass ◽

Sonja Zehetmayer ◽

Martin Pritsch ◽

...

Keyword(s):

Magnetic Resonance Imaging ◽

Multiple Sclerosis ◽

Spinal Cord ◽

Magnetic Resonance ◽

Demyelinating Disease ◽

Clinically Isolated Syndrome ◽

Resonance Imaging ◽

Mcdonald Criteria ◽

Paediatric Multiple Sclerosis ◽

Spinal Cord Imaging

Background: Magnetic resonance imaging diagnostic criteria for paediatric multiple sclerosis have been established on the basis of brain imaging findings alone. The 2010 McDonald criteria for the diagnosis of multiple sclerosis, however, include spinal cord imaging for detection of lesion dissemination in space. The new criteria have been recommended in paediatric multiple sclerosis. Objective: (1) To evaluate the 2010 McDonald multiple sclerosis criteria in children with a clinically isolated syndrome and to compare them with recently proposed magnetic resonance criteria for children; (2) to assess whether the inclusion of spinal cord imaging provided additional value to the 2010 McDonald criteria. Methods: We performed a retrospective analysis of brain and spinal cord magnetic resonance imaging scans from 52 children with a clinically isolated syndrome. Sensitivity, specificity and accuracy of the magnetic resonance criteria were assessed. Results and conclusion: The 2010 McDonald dissemination in space criteria were more sensitive (85% versus 74%) but less specific (80% versus 100%) compared to the 2005 McDonald criteria. The Callen criteria were more accurate (89%) compared to the 2010 McDonald (85%), the 2005 McDonald criteria for dissemination in space (81%), the KIDMUS criteria (46%) and the Canadian Pediatric Demyelinating Disease Network criteria (76%). The 2010 McDonald criteria for dissemination in time were more accurate (93%) than the dissemination in space criteria (85%). Inclusion of the spinal cord did not increase the accuracy of the McDonald criteria.

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Clinical monitoring of multiple sclerosis should routinely include spinal cord imaging – Commentary

Multiple Sclerosis Journal ◽

10.1177/1352458518783362 ◽

2018 ◽

Vol 24 (12) ◽

pp. 1539-1540

Author(s):

Jaume Sastre-Garriga

Keyword(s):

Multiple Sclerosis ◽

Spinal Cord ◽

Clinical Monitoring ◽

Spinal Cord Imaging

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Spinal cord imaging in multiple sclerosis: Filling the gap with the brain

Neurology ◽

10.1212/wnl.0000000000000873 ◽

2014 ◽

Vol 83 (15) ◽

pp. 1306-1307

Author(s):

N. De Stefano ◽

S. A. Smith

Keyword(s):

Multiple Sclerosis ◽

Spinal Cord ◽

The Brain ◽

Spinal Cord Imaging

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Failure to develop multiple sclerosis in patients with neurologic symptoms without objective evidence

Multiple Sclerosis Journal ◽

10.1177/1352458507088156 ◽

2008 ◽

Vol 14 (6) ◽

pp. 804-808 ◽

Cited By ~ 4

Author(s):

A Boster ◽

C Caon ◽

J Perumal ◽

S Hreha ◽

R Zabad ◽

...

Keyword(s):

Multiple Sclerosis ◽

Spinal Cord ◽

Evoked Potentials ◽

Cervical Cord ◽

Neurologic Symptoms ◽

Objective Evidence ◽

Mri Scans ◽

Thoracic Cord ◽

Spinal Cord Imaging

Background Many patients referred to multiple sclerosis (MS) centers with symptoms suggestive of MS are found to have normal neurologic examinations, normal or non-specific brain magnetic resonance imaging (MRI) scan findings, and normal cerebrospinal fluid (CSF). Persistent symptoms often lead to multiple consultations and repeated diagnostic investigations. We performed a study to evaluate the diagnostic utility of repeated evaluations in patients with normal initial assessments and persistent neurologic symptoms. Methods 143 patients were evaluated initially and 109 returned for a second evaluation after a mean interval of 4.4 years. Results All 143 patients had normal initial examinations, brain MRI scans, screening blood tests, and CSF studies. Spinal cord imaging was normal in all patients tested (cervical cord, n = 126; 88.1%; thoracic cord, n = 58; 40.6%). Evoked potential studies were abnormal in a small percentage of patients: visual evoked potentials, VEP (8.1%), somatosensory evoked potentials, SSEP (4.9%), and brainstem auditory evoked potentials, BAEP (2.8%). All follow-up patients ( n = 109) had normal examinations and MRI scans. Repeat CSF studies ( n = 35; 32.1%) and spinal cord imaging (cervical cord n = 57; 52.3%; thoracic cord n = 32; 29.4%) were normal in all follow-up patients tested. No patients at initial presentation or at follow-up fulfilled diagnostic criteria for MS. Conclusions Patients and clinicians may be reassured that persistent neurologic symptoms in the absence of objective clinical evidence do not lead to the development of MS. Costly serial investigations should be carefully considered, particularly in the presence of normal neurologic examination at follow-up.

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