Suspected inflammatory spinal cord lesion (transverse myelitis)

ACR AC Myelopathy (2021); MAGNIMS-CMSC-NAIMS consensus

An acute cord syndrome is a compressive question until proven otherwise. The first study must therefore be capable of excluding compression as well as demonstrating intrinsic cord signal change, which means contrast-enhanced MRI of the whole cord rather than of the segment the sensory level suggests.

Subacute or acute weakness, sensory level and sphincter disturbance developing over hours to days, without trauma, in a patient in whom an inflammatory, demyelinating or infective cord lesion is suspected.

Referenced decision support — confirm against your local protocol.

Decision support, not a directive. Protocols and timings shown are typical published ones — your local protocol takes precedence, and the vetting radiologist decides.

The request in front of you

Everything is optional. Leave a field alone and the answer assumes nothing — the verdict updates as you go.

Study requested

What the referrer actually asked for. It is evidence of intent, not a constraint on the right answer.

Contrast as written

What the request form says, not what it should say.

Age

Pick a band, or type an exact age if it matters.

years

Pregnancy status

Renal risk factors

The question a vetter can actually answer from the request. An explicit “none known” is a real answer, and it removes checks rather than deferring them.

Previous contrast reaction

The pathway — tap anything already done

Marking a study complete moves the answer on. A patient arrives partway through a pathway far more often than at the start of one.

Accept as requested

MRI Spine — myelitis / inflammatory cord disease

MRI Whole Spine

What we'd amend, and why

One acquisition has to do two jobs. It must exclude a compressive cause — disc, tumour, abscess, haematoma — because that is the diagnosis with an operation attached to it, and it must characterise intrinsic cord signal change, which needs the tissue contrast only MRI provides. Gadolinium is part of that characterisation rather than an optional extra: the pattern and presence of enhancement separates active inflammation from an old lesion, and distinguishes inflammatory disease from neoplastic and vascular causes. Whole-cord coverage is used because sensory levels are unreliable and lesion length is itself diagnostic.

Nothing needs resolving before this goes ahead. Routine checks below are owned downstream.

How was this decided?

pathwayadult — Adults
rulerule-mr-device-screening — MR safety screening for implants and foreign bodies; checked by Radiographer at the scanner
rulerule-contrast-reaction-premed — Prior contrast reaction and elective premedication; checked by Nurse before the scan
rulerule-gadolinium-renal — Kidney function and gadolinium-based contrast; checked by Radiographer at the scanner
rulerule-pregnancy-gadolinium — Gadolinium in known or possible pregnancy; checked by Radiographer at the scanner
rulerule-iv-access — Intravenous access adequate for the planned injection; checked by Radiographer at the scanner

Decision support only. Local protocol takes precedence.

Handled at the scanner(2)nothing for you to do

Settled and owned downstream. Each returns to a radiologist only on the stated trigger.

MR safety screening for implants and foreign bodies
Complete the MR safety questionnaire, verify implant labelling and its stated conditions of use against this scanner and this protocol, and ensure no ferromagnetic object enters Zone IV.
Radiographer at the scannerBefore the scan
Flags back if: An implant or retained foreign body that is MR Unsafe, unlabelled, or cannot be identified; or an MR Conditional device whose stated conditions this scanner or the requested protocol cannot satisfy; or a credible unexcluded intraocular metallic foreign body history.
An acute cord syndrome is time-critical because the compressive causes are surgical. Screening runs in parallel with preparation, and where MRI genuinely cannot be delivered quickly, CT myelography is the recognised substitute for the compression question — it cannot characterise inflammation and does not close the pathway.
Intravenous access adequate for the planned injection
Site and test a cannula that supports the protocol flow rate, preferring an antecubital or large forearm vein, and observe the injection for extravasation. A 20-gauge or larger cannula is preferred for flow rates of 3 mL/s or more.
Radiographer at the scannerAt the scanner
Flags back if: No cannula can be sited that supports the protocol flow rate — for example only a 22-gauge hand or foot cannula for a CT angiogram needing 4–5 mL/s; or the only available access is a central line or port that is not labelled power-injectable; or an extravasation occurs.

Pathways

Big forks are separate pathways; the first whose conditions match is the one used.

Adults

Matches your inputsDefault

Role	Study & protocol	Why this answers the question
First line	MRI Whole Spine MRI Spine — myelitis / inflammatory cord disease usually appropriate	One acquisition has to do two jobs. It must exclude a compressive cause — disc, tumour, abscess, haematoma — because that is the diagnosis with an operation attached to it, and it must characterise intrinsic cord signal change, which needs the tissue contrast only MRI provides. Gadolinium is part of that characterisation rather than an optional extra: the pattern and presence of enhancement separates active inflammation from an old lesion, and distinguishes inflammatory disease from neoplastic and vascular causes. Whole-cord coverage is used because sensory levels are unreliable and lesion length is itself diagnostic.
Second line	MRI Brain MRI Brain — demyelination / multiple sclerosis	Performed in the same episode rather than as a later step. The brain establishes dissemination in space when demyelination is suspected, and area postrema, hypothalamic and periependymal lesions point specifically towards neuromyelitis optica spectrum disorder. A normal brain study alongside a longitudinally extensive cord lesion is itself informative.

Pitfalls

Imaging only the segment the sensory level suggests, which frequently misses a lesion several levels higher.
Reporting cord signal change without excluding compression, which is the finding with an immediate surgical consequence.
Missing a spinal dural arteriovenous fistula, which produces progressive myelopathy with cord oedema and dilated perimedullary vessels and is treatable.
Calling a longitudinally extensive lesion multiple sclerosis. That pattern points elsewhere and drives a different treatment.
Under-calling a subtle cord lesion on sagittal images alone; axial sections through the abnormal segment are what confirm it and localise it within the cord.

Priors — what to pull first

A previous cord or brain MRI establishes whether a lesion is new, which distinguishes a first demyelinating event from a relapse.
Where the patient is already on disease-modifying therapy, the treatment start date frames whether a new lesion represents breakthrough disease or a therapy complication.

What makes a good request

Compression comes first in the differential regardless of how inflammatory the history sounds, because it is the one cause with a same-day surgical treatment. The imaging has to answer both questions in one visit.
Sensory levels localise poorly. A lesion is frequently found several segments above the clinical level, which is the argument for whole-cord sagittal coverage rather than a targeted study.
Lesion length is the discriminator that changes treatment: a short segmental lesion suggests multiple sclerosis, while a longitudinally extensive lesion spanning three or more vertebral segments points towards neuromyelitis optica spectrum disorder or MOG-associated disease.
Brain imaging is done alongside rather than afterwards, because dissemination in space and the pattern of brain involvement contribute directly to the diagnosis.

Scoring this once it is done

The classification and risk tools this question ends in.

ASIA Impairment Scale (AIS) with Frankel Mapping Fazekas Scale (White Matter Lesions)ARWMC Scale (Wahlund White Matter Changes)

How these studies are acquired

Contrast, phases and timing for every study on the pathways above.

MRI Spine — myelitis / inflammatory cord disease MRI Brain — demyelination / multiple sclerosis

Confirm locally

MRI Spine — myelitis / inflammatory cord disease: timings are typical — confirm against local protocol.
Timings, contrast volumes and rates above are typical published values. Your department's protocol, scanner and patient population decide the actual numbers.
Safety thresholds and premedication policy follow local policy where it differs from the cited guidance.

References

Implemented from the cited published sources. Educational and workflow support only; confirm against current guidelines and local policy before clinical use.