Gadolinium Enhancement In Spondylotic Myelopathy Mimicking Tumors And Inflammation; A Case Series Of 56 Patients (S31.001)

OBJECTIVE: To highlight an underrecognized radiological feature of some spondylotic myelopathies that may lead to diagnostic confusion BACKGROUND: Spondylotic myelopathy may be associated with extensive intramedullary T2-signal changes and gadolinium enhancement that may persist following decompressive surgery and lead to concern of an alternative neoplastic/inflammatory etiology. DESIGN/METHODS: Patients were identified retrospectively from 1/1/1996-12/31/2012. Inclusion criteria were: 1) suspected spondylotic myelopathy; 2) gadolinium enhancement on MRI; 3) spinal surgery performed. Telephone follow-up evaluated clinical symptomatology, subsequent alternative diagnoses and follow-up MRI findings. RESULTS: Fifty six patients were included of whom 70% were men and whose median age was 53.5 years (range, 24-80). Spinal cord MRI (cervical, 52; thoracic, 4) revealed longitudinal-spindle-shaped-T2-signal hyperintensity (100%) and cord enlargement (79%). A characteristic transverse band, or ‘pancake-like’ enhancement typically just caudal to the site of maximal spinal canal narrowing was noted in 41(73%). Forty (70%) patients were initially diagnosed with neoplastic or inflammatory myelopathies and median delay to surgery (laminectomy, 21; fusion, 21; or other, 14) was 11 months (range, 1-64). Six patients underwent spinal cord biopsy which did not reveal any alternative diagnosis. Fifty three (95%) patients were improved or stable after surgery, but gadolinium enhancement regressed slowly. Seventy five percent had residual enhancement 12 months post-operatively often resulting in concerns about accuracy of initial diagnosis. Thirty six (64%) were ambulatory without aids, 6 (11%) required a cane, 9 (16%) a walker and 5 (7%) a wheelchair at last follow up (median 60 months, range 10-172). The need for a gait aid pre-operatively (p=0.005), but not delay to surgery, predicted need for gait aid at final follow-up. CONCLUSIONS: Spindle-shaped longitudinal intramedullary T2 hyperintensity with transverse ‘pancake-like’ gadolinium enhancement just caudal to the site of maximal stenosis is highly suggestive of spondylotic myelopathy. Persistent gadolinium enhancement months to years following decompressive surgery is typical. Recognition of this radiological feature is important to prevent delay in definitive decompressive surgery or subsequent inappropriate interventions. Disclosure: Dr. Flanagan has nothing to disclose. Dr. Krecke has nothing to disclose. Dr. Marsh has nothing to disclose. Dr. Giannini has nothing to disclose. Dr. Keegan has received personal compensation for activities with BIONEST Partners and GlaxoSmithKline, Inc. Dr. Keegan has received personal compensation in an editorial capacity for eMedicine. Dr. Keegan has received research support from Terumo BCT. Dr. Weinshenker has received personal compensation for activities with Novartis, Biogen Idec, and Mitsubishi Pharmaceuticals as consultant on data safety monitoring boards; and with Elan Corporation, Ono Pharmaceutical, GlaxoSmithKline Inc., Alexion and Chugai Pharmaceuticals, and Asahi Kasei Medical Company as a consultant. Dr. Weinshenker has received royalty payments from Mayo Foundation.