Spinal cord compression and myelopathies

Patients with signs and symptoms of acute myelopathy require urgent neurologic evaluation focused upon the identification and management of treatable disorders. MRI of the spine is the imaging modality of choice to evaluate for a compressive lesion. When cord compression is present, surgical treatment is usually indicated. When compression is not detected, an analysis of precise lesion localization, nonneurological clinical features, MRI findings, and serologic studies narrow the differential diagnosis. The key diagnostic considerations include demyelinating, vascular, inflammatory, infectious, and paraneoplastic disorders. Empiric high-dose corticosteroid treatment is often indicated in noncompressive myelopathy; additional investigations are important to identify patients with relapsing or progressive disorders who may benefit from preventive therapies. Patients whose symptoms continue to progress after initial immunosuppressive treatment may benefit from plasmapheresis and occasionally from biopsy for definitive diagnosis.