This chapter, contrary to others in this text, commences with an established neuroanatomic diagnosis. Within the rubric of spinal cord pathology a more precise anatomic diagnosis can be made. Is the lesion extradural (epidural), extramedullary intradural, or intramedullary? For example, a typical epidural mass might be a metastasis, abscess or herniated disk. The most common extramedullary intradural lesion is a benign neoplasm such as a meningioma or schwannoma and it is also the location of leptomeningeal disease. The differential diagnosis of an intramedullary lesion is manifold and especially challenging. Multiple sclerosis, astrocytoma, ependymoma, vascular disease, subacute combined degeneration and syringomyelia are a few examples.
Fortunately, magnetic resonance imaging (MRI) solves many but certainly not all of these questions. In numerous instances cerebrospinal fluid studies and occasionally somatosensory-evoked potentials can be more useful. Moreover, MRI may be contraindicated in patients who have a pacemaker or metallic implant.
There are a wide variety of unusual or rare etiologies that must be recognized to enable efficacious treatment, removal of a toxic substance or to initiate further investigations to unmask the underlying etiology. This will require familiarity with specific deficits involving sensory, motor, and autonomic systems, vascular anatomy and associated or causative medical illnesses.
Through case discussions I hope to convey some of this critical information plus expose the reader to the diagnostic challenges presented by many patients. An extensive review is clearly not intended but a fastidious analysis of symptoms and signs is essential. Answers to the questions raised on each case will be provided at the end of this chapter.
KeywordsMyelopathy Subacute combined degeneration Cauda equina syndrome Multiple sclerosis Anterior spinal artery syndrome
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