Spinal Cord MRIs and Lesions

Hi, Everyone.  The "topic du jour" appears to be spinal cord MRIs.  I have responded to two questions already and been asked another via PM.  I think it is time for a overall discussion, to the extent that I understand the topic.

Then, when we had the 3T images he showed me the clear, small lesions, in exactly the same areas.  These were brighter, these interiors were homogeneous, and their edges very clear and well-demarcated.  In my case the difference was night and day.
First I want to say to the forum that this understanding of MS and its diagnosis is an evolving topic for me.  When I look back a year ago, I was somewhat off-base in many of my answers on many topics and have tried to clear that up as I learned more.  I also realize that a lot of my stances and opinions seem to be "out there" when compared with those of neurologists as a whole.  I want to tell you that it is soooo incredibly important to me that I give you all good and solid information.  Much of what I tell you is stuff that I have gleaned from the studies and from the articles by people who clearly understand what is happening in MS.  Some of what I tell you is intuitive, but that I believe HAS to be true, given the known facts.

I never, ever, want to be that "radical wacko" who is on a mission to denigrate neurologist and promote my agenda.  This forum is the most important thing in my life after my family.  I think about the issues literally all the time.  And when one of you comes back with support for what I have been saying, I literally do the Snoopy Dance (well, what would be the Snoopy Dance if he had cement boots on and had the equivalent weight of a rhino).  I run and tell my sister triumphantly that again I have been vindicated.  I fear she is getting tired of this constant self-stoking of my ego.  But, this week has seen a leap in those vindications.  I hope you all don't see it only as the gloating it is, but also as my being thrilled that I have not led you all astray.

SPINAL CORD LESIONS

How do spinal cord lesions show up?  There are several symptoms that state unequivocally that there is damage in the spinal cord.

In the spinal cord the nerves that deal with the whole body run very close together down the cord.  A single lesion can cut across an area that affects a large section of the body.  In fact, one good sized lesion can essentially "cut off " the body below it as if the spine had been severed.  This is the worst case scenario of the lesions of Transverse Myelitis.  But, most lesions are not that large.  The areas that deal with the motor functions (driving the muscles) on one side, all run together and the part of the cord that handles the sensory input is all on a different section from the motor.

As the cord runs down the back, the nerves branch off and leave the cord - becoming peripheral nerves.  The nerves to the arms leave the cord in the cervical spine.  The nerves that drive the muscles of the torso leave in the lower cervical spine and the from the thoracic.  The nerves to the legs travel on through the cervical and upper thoracic to leave the spinal cord lower down.  Many of them stay in the spinal canal below where the spinal cord ends as a loose-floating bundle of nerves called the "cauda equina" - the horse's tail.  These nerves exit through the vertebrae in the lumbar spine.  

One of the ditties I remeber from medical school about the location of the nerves that allow us to stand goes, "Lumbar One Two Three Four! - Keeps the Feet On the Floor!"

So some combination of problems on the neuro exam point to a specific "level" of damage in the spinal cord where there must be a lesion.  Neurologist know that there is no lesion in the more spread out brain that could cause that combination of problems.  An example is any kind of "Hug" sensation, especially around the chest or abdomen.  Because the sensation usually goes pretty much all around it has to involve a problem with a large section of the spine.

The strongest sign is the presence of hyperreflexia.  Because the reflex contraction is due to a spinal loop of nerve signals, this finding on neuro exam points to a symptomatic lesion in the spinal cord.  If the arms are hyperreflexic, then the lesion must be in the cervical spine.  The legs can point to a lesion anywhere in the spinal cord - but often in the thoracic spine.

Numbness from one level on down is indicative of a cord lesion, like the people that describe being "numb from the waist down."  It doesn't have to be at the waist.  Numbness to about the same height in both legs shows this, too.

These are just a couple of examples.  In all honestly, I do not know many more.  I am still looking for a good description of other problems that firmly indicate more problems that show there is a lesion in the spine.  If any of you find such a description we will include it.

What do lesions look like in the spine?  They look the same as lesions in the brain.  They are brighter on the T2 and FLAIR sequences of the MRI.  They may be wide and extend across a large portion of the cord, but more commonly they are smaller and extend more up and down, sometimes as long as a couple of vertebral segments.  The can be seen both from the sideways cuts (where you see the full length of the cord) called the "sagittal view."  And they will also be visible from the crossways cuts (where you see the cord in cross-section as a semirounded object) called "transverse view" or axial view" or (in the brain) "coronal view."

There are built-in problems in viewing lesions with the spinal cord.  The area that is being looked at is small and it is completely surrounded by CSF.  Areas of the body that are right next to fluid are more difficult to image in the MRI.  The water seems to cause reflection of the signal and tends to "blur" out the image.  That is why they developed different techniques, like the FLAIR, to make the lesions more visible.  Some neurologists feel that even the 1.5T does not show the smaller lesions adequately.  My neuro was one of them and I always harp on this.  He won't even look at a spinal cord MRI on a 1.5T unless there is NO WAY the patient can get the 3T which he prefers.

This week two people have reported on this problem.  One is the study posted by Doublevision that Brigham and Womens Hospital in Boston is conducting a study comparing the 1.5T and the 3T for visualizing spinal cord lesions in MS.  This indicates that there is enough of a concern about the difference to do a study to confirm or disprove it.   Slightlybroken reports that her neurologist felt that her previous spinal cord 1.5T MRI was terrible and insists on repeating it on a 3T adds more information that the difference between 1.5T and 3T may be really significant.  Yes, both of these posts elicited the Snoopy Dance.  :))

I also have been asked to describe what my lesions looked like on the 1.5T and the 3T.  On the 1.5T my neuro had to zoom way in and enlarge the areas.  As you know, often when you super-enlarge an image it becomes coarse and grainy.  Well, he pointed to about 4 little areas that looked more coarse.  The pixels were oviously more gray-light-gray-light in those little areas.  And the areas that he was concerned about had no clear borders.  They were just a little ratty.  I'm not even sure that many other neurologists bother to do this "zoom in."  But, my neuro said that, based on my exam, he knew he had to look for some spinal cord lesions.  I am diffusely hyperreflexic, moreso on the right.

Quix

[Quixotic1]

Does the spine HAVE to be done in the very beginning of the workup?  In my reading of the "Protocol" it does not.  But, most of the reading I have done about this says yes.  One way of thinking is that the doc already knows if there are signs on the neuro exam that indicate spinal cord lesions (eg. hyperreflexia) so you don't have to look.  Another is that you should look, to verify,  if there are signs on the exam (I think this is ridiculous!).  And more recently, I have been reading about "assymptomatic" spinal cord lesions that we should search for, that really help make the diagnosis (this makes a lot of sense to me).  Having sorted it all out, I have come down on the side of recommending that the spinal cord SHOULD be imaged if MS is suspected.  Yes, you can make the diagnosis on just the brain, but the whole CNS needs to be looked at as a baseline for anyone whose symptoms highly suggest MS.

Something to take away from the information above is 1) Lesions in the spinal cord can be assymptomatic, and 2) there can be indications that a spinal lesion definitely exists, but it may not be seen on MRI (invisible) lesions.  I would say that this includes images on a 3T.  The reason for this is that the 3T is the lowest strength that some are seen on.  It only stands to reason that some lesions are still "invisible" at the 3T resolution.

This was all I could think of in discussion spinal lesions and imaging them.  The floor is open

Quix

[Quixotic1]

Here is a good descritpion of symptoms arising from spinal cord lesions:

http://www.*************.com/multiple-sclerosis/c/6639/25072/cord-ms

Q

[Quixotic1]

Again.  With Feeling!

http://www.************* [dit] /multiple-sclerosis/c/6639/25072/cord-ms

[Quixotic1]

Okay the program does not like this competing site.   h e a l t h c e n t r a l   I'll look for an academic reference.

[monotreme]

I know my brain is fuzzy, but what do the asterisks stand for?
Elaine

[Quixotic1]

I got bleeped by the MedHelp censor that forbids us to send people to commercial and competing sites.  See my last post.  If need be I will paraphrase that article.

[sunshine8]

You certainly never led me astray! In fact, it was you who helped guide me with your knowledge. That was a great explanation and it was easy to read!  Thanks Quix!

[jensequitur]

Hey, Fuzzy... ;-)

replace the asterisks with h e a l t h c e n t r a l - (without the spaces, of course.)  This site is deleting the competing site's url.

Spinal cord symptoms?  Since I don't know if I have a lesion (and might not, even after this 0.7 Tesla MRI!)  take what I say with a grain of salt.  However, I am numb on the right side of my torso, from around the shoulder area to mid-waist.  I also have numb patches on my legs, and around the knees.  My weird spasms seem to center around two spots on my back - somewhere around the braline, and somewhere above the lumbar region (probably the cauda equina or a little above.)  But what really convinced me was the leg weakness.  Walking in the last three weeks seems to set it off - my legs start feeling tingly and numb, and then they get weak.

[Quixotic1]

It appears to me that all of these are likely spinal cord symptoms.  Numb patches could be either.

[Udkas]

Hi Quix,

Thank you again for such an interesting article. I look forward to peeking at that site.

I still have a few questions in regards to my last post on spinal cord lesions.

1. Can spinal cord lesions be worsened my movement?

Mind you I think my back is better now and I am still getting burning sensations in both arms and legs but not all day but on and off throughout the day?

2. Does nerve compression show up on MRI

I have my spinal MRI on Wednesday without contrast on a 6 week old machine that is a T3 machine.

My last MRI was completed on a T3 machine (also less than 12mths old) my neurologist who is from Boston (well last place he worked) before he came to Aus. said that the 3T machines still don't show all the lesions.. that spinal cord lesions can be difficult to see even on good machines but he does reckons there is not a lot of difference between the 3T and the 2T.

He believes that I have lesions that are not visable on MRI that are prob too close to the cord in the thoracic region i think?  Will ask more questions when I go back..

[jensequitur]

That's right, numb patches aren't necessarily from the spine...  the ones on my legs might just be the brain.

More spinal cord (maybe!) symptoms:

• Bladder urgency
• Severe constipation (core muscle weakness in the torso)
• Shortness of breath (diaphragm weakness)

[Quixotic1]

1) Spinal lesions "could" worsen with movement depending on whether that movement actually changed the position of the spinal cord.   Also, if you are having neuropathic pain caused by a spinal or brain lesion, then, yes, the pain or paresthesia can be worsened by movement.  It's not the location of the lesions for neuropathic pain, it is the faulty signal traveling through the lesion.

2) Yes, compression of the peripheral nerves as they leave the spinal column and exit through the holes in the sides of the veterbrea CAN be seen quite well with even the lower power MRIs.

3) I agree with your neuro.  I also do not think that even the 3T still show all of the lesions ion the CNS as shown by the studies (on cadaver brains) with the higher power 7T machines.  He may be quite right about the 2T and the 3T.  I have not seen any back to back comparisons.

4) ALL lesions are actually IN the spinal cord not close to it, but he may have meant "too close to the edge of the cord" where they would be right up against the CSF and be harder to see.  Also, everyone needs to remember that the spinal cord gets narrower and narrower as the nerves leave it to go out to the body until it finally just tapers off.

Quix

[doublevision1]

Yet another informative and thorough post.  We should be paying you for all your hard work.  If not in cash, then in baked goods.  My specialty is brownies.  Do you prefer yours with pecans, or without?  ;)


FYI to those who are interested but may have missed it, yesterday I posted some info about a spinal cord MRI study currently underway in Boston.  They are currently recruiting research participants.  The post may have been bumped to page 2 or 3 by now.

DeeBee!!

[Udkas]

Thank you!!! all questions answered for now!!!  It is so nice to be able to have people that understand who you are feeling and to help with questions (if i asked every question I had at the neuro) it would take 2 hours. Thanks again!

I think I should just accept that it is prob TM. I have since read a lot more on it and MS and it certainly fits the TM tag...

I might have misunderstood what my neuro said but he was just trying to tell me that MRI machines are not totally accurate even the new machines and he agreed that it does depend on who is reading the results as well and that things can be missed.

The machine I have on Wed is T2 not 3 as I stated but my last MRI was on T3.  I can only be guided by my neuro and he said there wasn't much in it but I also asked my daughters boyfriend who is a radiologist and works with the fellas that do the MRI and they told him the same thing.

[slightlybroken]

Thanks for the info! I appreciate it. I was always wondering about spinal lesions and what they look like since I've never really had MRIs properly done on the right machine.

My MS specialist did confirm everything you have said about the difference between MRI strengths and seeing lesions in the spine. He said that the 3T can shows so much more compared to the 1.5T and the quality is much clearer.

[sllowe]

Oh, I'm doing the Snoopy Support dance - in clogs, like a dutch girl!

This is excellent.

Ok, you are looking for addt. descriptions of symptoms ref. spinal cord lesions, and I'm at your disposal.  I'll describe what I presented with (though I don't know if these are common w/brain lesions). It's important to note that once I describe to my neuro, he "pointed" to his neck in the C spine area said, "I suspect you have a lesion in this area."

Feel free to pick my brain as I've not include everything.

*Had to correct my walk - would drift to the side
*Slurred speech
*Worsening with stimulation
*Could not react (i.e., if I went to write, my hand wouldn't do it - would go to grab a spatula while cooking, and had to think of how to grab it).  Apply this example to all reactions, like going to speak, and so on, etc.  Apply all stroke like symptoms.

Imaging afterward showed:
        Within the spinal cord at the level C5 ovoid focus of high signal measuring 10mm in craniocaudal dimension x 6 mm in transvers diameter x 4mm in AP diameter.  In the midline anteriorly within the spinal cord and consistent w/a focal demyelinating plaque.
        The technique was multiplanar multisequence on Siemens 1.5T superconducting magnet.

Since then, imaging included other sequences but I dont' have reports with me) and my C-spine MRI describe the same lesion  - mentioned I believe to traverse the cord and 7mm in that traverse diameter. I'll verify that though.

I have now always, but in varying degrees burning on my back, across the mid and lower section. Have had bowel problems, standing and sitting leg difficulty (walking was fine)and assoc. problems that worsen with particular movement and positions.  i.e., while sitting (always now) if I slouch at all, there is pressure in my spine - feels like it's pressing out and I'm not sure how to describe that.  Have had feelings of water moving in there, etc.

Hope this helps describe spinal lesion symptoms...

Thanks for this Quix.  I'm sure Sister gets just as excited as you and all of us do when all of your hard work on behalf of this disease is vindicated.
Thank-you,
Shell

[doni54]

Thank you again for a wonderful, easy to understand explanation.  You know, since my clear brain MRI, that I have been struggling to understand where my symptoms are originating.

My neuro appt is Nov 20 and I was told that he will be doing nerve conduction tests.  Will this test indicate or point to maybe there being spinal lesions?  Sorry if that is a dumb question. I have been at such a loss since the MRI, trying to understand all this.

I thought I had a good perception of all things MS, as I have learned so much over the last 15 months, from you and from the experiences of others here.  

But, now I'm just flat out scared that I may never have a dx, and my symptoms are getting so scary I'm afraid to get up in the mornings, not knowing what else might have gone wrong while I slept.

How many tests do you think the neuro with do before he requests a spinal MRI?  I know that is probably an impossible question to answer as all neuros are different.  But could you give me some examples?

I just pray every day that I am lucky enough to find the right neuro the first time, as with no health ins and limited funds I can't take this search on for long.

Thanks again, Quix, you are, and always have been my hero!!!!!  Think I'll send you a bright red cape for Christmas with a huge Q on the back!!!!!!  Don't think you would go for the spandex.....heeheeheehee

Love & Hugs
doni

[doublevision1]

Another sensory symptom caused by cervical spine lesions is Lhermitte's Sign.

[Quixotic1]

Any symptoms that are stroke-like would fall into the category of brain symptoms.  I have been doing more reading and will have a list later today.

Thank you for all your input.  I think this needs to be a Health Page.  Keep the comments coming.

Q

[vickie_07]

Does a LP have to be positive When you have MS?

thanks,
vickie

[Fluffysmom]

Don't mean to answer for Quix, but I was happy to see a question that I know the answer for!  

1 in 25 people with MS have a negative LP.  I read it in the Health Pages.  You can check it out; it really helped clarify things for me when I had a negative LP.

Kathy

[Quixotic1]

No, you do not have to have a positive LP.  I actually believe that more than 1 in 25 have a negative LP.  And this is the reason why.  When you put all the studies together the percentage that have a negative LP with MS comes out to be between 5% and 10%.  But, those are all studies where the CSF testing is totally controlled and optimal.  The lab tech is highly trained and using the newest preferred test.

In real life, the labs may not be using the newest test and the lab tech may be unkilled in interpreting the result.  I believe that we have a larger group of false negatives in the uncontrolled real world.

Some neurologists will cancel a diagnosis of MS if the LP is negative.  There is NOTHING in the MS literature or studies that support doing this.  In fact, the emphasis on even doing an LP is lessening.  In Europe, they rarely use an LP at all.  The current diagnostic guidelines, called the McDonald Criteria, make no use of the results of the LP except as supportive evidence.  This meanings that a positive result is helpful in determining that a person does have MS, but a negative result doesn't tell you much.

There is an exception, that the McDonald Criteria does mention using the results of the LP in helping to make the diagnosis of Primary Progressive MS.

Quix

[Lulu54]

I just followed the link under *related discussions* on another question and found this brilliant discussion from last fall about spinal lesions.  I don't know how I missed this one but figure it is well worth bumping up so others can read it too.

- Lulu