Clinical biomarkers differentiate myelitis from vascular and other causes of myelopathy

Barerras et al. recently published a study in which they analyzed the clinical presentation, spinal cord MRI findings, and cerebrospinal fluid (CSF) features of patients who were initially diagnosed with transverse myelitis (TM). Their goal was to see how these characteristics may help differentiate inflammatory myelopathy (TM) from other causes of myelopathy.

Myelopathy is a general term used to describe a disease of the spinal cord. Myelopathy can be caused by inflammation, as is the case with transverse myelitis, but myelopathy can be caused by cancer (neoplastic), vascular issues (related to blood vessels), compression (spondylotic), or metabolic issues (for example, B12 deficiency). In a podcast about the study, Dr. Carlos Pardo expresses the importance of making the distinction between myelopathy versus TM to avoid an incorrect diagnosis of TM and, most importantly, immunosuppressive treatments that are not truly indicated.

In order to investigate effective approaches to making a definite TM diagnosis, 457 patients with a newly established diagnosis of TM who were referred to the myelopathy center between 2010 and 2015 were included in the study. 58% were female (n=265), with a median age of 46 years.

First, they looked at how specific characteristics were associated with different myelopathies. These myelopathies were

  1. inflammatory myelopathy (IM)
  2. vascular myelopathy (VM)
  3. spondylotic myelopathy (SM)
  4. other causes of myelopathy (OM)

The characteristics they looked at were demographic/medical histories, clinical presentations, neurologic examinations, MRI findings, and CSF findings.

After looking at the clinical, MRI, and CSF characteristics of the participants, 55% of 457 patients (n=247) were classified as true inflammatory myelopathy, 20% (n=92) were reclassified as vascular myelopathy, 8% (n=35) as spondylotic myelopathy, and 18% (n=83) as other myelopathy.

Their analysis showed that a shorter time between symptom onset and when an individual’s symptoms were at their worst was associated with different types of myelopathies. IM’s temporal profile most often was subacute (between 49 hours and 21 days between onset and symptoms being at their worst), while VM’s temporal profile was most often hyperacute (less than 6 hours).

The researchers emphasize the importance of biomarkers and minute aspects of a patient’s medical history, family medical history, and the temporal progression of symptom onset for accurate diagnosis of inflammatory myelopathy. As stated by Dr. Pardo in the podcast, the literal “clinical dissection” of a patient’s clinical presentation, combined with past medical history and diagnostic MRI imaging is paramount for successful diagnosis of true myelitis of inflammatory origin.

The study analyzed the inflammatory group as one category, which as the authors state “…may not reflect important differences among specific etiologies within the inflammatory group such as MS vs NMOSD or NMOSD vs sarcoidosis myelopathy as has been shown previously.” Also, because the study took place at a referral center for myelopathies, and because the center often receives patients who may be difficult to diagnose, it is possible that these cases may be overrepresented in the study, and that these findings may not be entirely reflective of the larger population of individuals with inflammatory myelopathy.

You can learn more about the study from Dr. Carlos Pardo’s presentation at the 2017 Rare Neuro-Immune Disorders Symposium:

Article: Barreras P, Fitzgerald KC, Mealy MA et al. Clinical biomarkers differentiate myelitis from vascular and other causes of myelopathy. Neurology. 2018 Jan 2;90(1):e12-e21. doi: 10.1212/WNL.0000000000004765. Epub 2017 Dec 1.

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Podcast featuring an interview with Dr. Pardo about this publication:

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