No spinal cord lesion on MRI, but symptoms

[Willowwoman777]

I don't have lesions showing up in my spinal MRI (w/o contrast) but, I have the symptoms...my spine is ok, though. But, I get numbness in my feet, buzzing in my legs, my right leg has developed a new symptom of suddenly feeling cold. Could it be that there are lesions not discernible because of not being able to use contrast?

[Willowwoman777]

bump

As I'm dealing with weird sensations in my right leg, I could really use some imput please.

[luvnGod]

Hi there,

I don't feel completely qualified here to answer your question, but I do remember reading over posts and some info in the Health Pages about it being a bit more difficult to see lesions on the spine.  It seems like they would use contrast especially with the right leg being a new symptom.  As far as I'm understanding using contrast would show new activity.  

Do you know if they used 1.5 T or 3T for the MRI?  I read it is suggested, especially with the spine to use a 3T machine.

I pray you get some answers soon.  Have you been diagnosed with MS or still a limbolander like me?

Love and prayers,
Stacie

[COBOB]

Yes, it is possible.  Spinal lesions can be very difficult to detect.  3T MRI has more resolution (better signal to noise ratio)  than a 1.5T MRI and improves the detection, but it can still be difficult.  Contrast is used to detect "new"  or "active" lesions, typically those less than about 40 days old.  

The standard T2 Spin-Echo (SE) sequence has some limitations in detecting lesions on the spine.  Back in 1996, there was some talk about a different sequence, magnetization transfer–prepared gradient-echo (MT-GE,)  being superior in showing spinal lesions as compared to SE.  I think the current recommendation for maximizing the detection of Spinal MS lesions is Fast Spin Tau Inversion Recovery  (FSTIR) or (MT-GE) sequences.

I'm not sure what sequences were used in your case, but numbers
say that MT-GE provides about 90% sensitivity and SE provides about 65% sensitivity for cervical lesions. CMSC MRI guidelines call for:  Core Spinal Cord MRI Sequences

Cervical Cord coverage
Sagittal T2
Sagittal PD or STIR (Short Tau Inversion Recovery)
Sagittal T1

In theory, STIR should provide better visualization than Proton Density since STIR is a fat suppression technique and Proton Density (or Hydrogen Density) is looking for fluid.

Bob

[superscatty]

Hi, I too have no lesions on my spine, but have symptoms, bladder retention, have to self catheter, I am due to have a visual evoked response test and a lumber puncture after that.  I had a MRI that is ment to show up lesions, a weighted MRI, what ever that was.  Hope you soon get some answers.  

[COBOB]

All MRIs are "weighted."  That term has to do with the ratio of excitation to relaxation times of the magnet.  You will see study sequences labeled as T1, T2, FLAIR, STIR, PD, FSE, MT-GE, etc.  Those are the various weighted sequences.

Bob

[Udkas]

Interesting, very interesting, I might have to pull my last lot of spinal MRI out and see what technique they used, as said before it was on a T3 machine (brand spanking new) and that one was with contrast and without as neuro thought I was having a new attack, but still failed to show any lesions on my spinal cord.  If it's 90% accuracy I just think then maybe I don't have TM.

My symptoms fit spinal, bladder urgency,  numbness and some weakness, loss of sensation, burning, radicular pain (which is common with TM) pins and needles, burning sensations and lhermittes, clonus, positive babinskis, hyper reflexes, uthoff's phenomenon.

What is your thoughts Bob, my MRI has never even shown a blemish, the only comment on my spinal MRI was that I had two shwarmmi nodes in my thoracic.
Cheers,
Udkas.

[COBOB]

My opinion (not that it matters much) is that if your Neurologist didn't have access to MRI, what would he diagnose you with?  The answer should be either MS or Transverse Myelitis.  OK, so we know that there are limits on what MRI can show.  Can the radiologist improve the odds by requesting FSTIR or MT-GE of the C-spine and T-spine?  Sure.  Does it really change the diagnostic picture for the Neurologist?  Not too sure about that.  In the end, your symptoms will most likely remain even if you were put on DMDs.  Is there evidence of disease progression?  If the answer is yes, then I'd say treat it like MS, start DMDs, and prevent progression.  Follow the clinical course.  Maybe a some point you get lucky and the catch a lesion on the MRI.  

In the end, it is kind of stupid not to treat you since you have clinical involvement in more than two neurologic domains, and I;m assuming two or more attacks.  MRI evidence is supportive, but not required under the McDonald Revised criteria.  But then again, I;m not a Neurologist (or a doctor for that matter...just an old Navy Corpsman.)

Bob

[Udkas]

You seem to be pretty in the know, I will have to have a look at my spinal MRIs to see what format they used.
As for diagnosis my neurologist has diagnosed me with Transverse Myelitis based on his findings and what I have told him, he seems to be certain that is what I have, down side was he said just recently he can't treat me anyway as there is nothing he can do for TM but treat the symptoms but why I have ongoing symptoms or flares I just don't know, but he said TM can be like that but I feel I am getting worse, but he did say TM can reoccur and you are right I do have two areas of damage if you go by my clinical signs, so two attacks, my previous neuro told me he was 99% sure I had MS but then when MRI failed to confirm and LP he said we will just have to wait and see, but as time went by he said no I didn't have MS but I still had symptoms hence why I decided to seek a second opinion.

But my heart thinks it is getting worse, my neuro is undecided I think, last exam he said my reflexes etc. had remained the same and he thought I was stable, this flare I talked to the nurse not him directly and he said my TM was rumbling, whatever that meant... and basically if it was getting worse there was not that much he could do unless it was a real biggy, but he has offered me  a course of IV steriods last time when he thought I was having an attack.

Hmmm sorry I am so confused with my symptoms and my lack of evidence, frustrating to say the least.
I want validation but then I don't really want to be getting worse.
Cheers,
Udkas.
Thanks Bob, sorry I have written a book, just venting out loud.

[Udkas]

Sorry I highjacked your thread, but have a similar problem, I think as Bob and others have said, including my neurologist MRI is still not perfect at detecting spinal lesions.  If they suspect spinal cord lesions they will prob do a repeat MRI again down the track, and a T3 machine is better than a lower strength one as said. Good luck.

Have you had a full MS workup, including LP, brain and full spinal MRI cervical and thoracic, things to eliminate other causes like nerve conduction studies etc., full bloodwork done for vitB def., lupus etc. etc.  

My neuro did the nerve conduction tests and told me he knew they wouldn't show anything but just did them as another process of elimination so to speak..
best of luck
Udkas

[COBOB]

Well, TM lesions tend to be larger than MS lesions on the spine.  At least your Neuro is on his game enough to think TM, even though it can;t be seen on MRI.  Your Neuro could try and call a neuroradiologist at the 3T facility and see if they would consider FSTIR and/or MT-GE  (or some other fat suppressed) sequences of your C-spine/T-spine.  This is like hunting for a needle in a hay stack.  Clinically, the odds say it is there.  If you have a clear brain on T2, there is no sense looking there.  If they find 2 or more lesions in the spine, it would then most likely be MS, not TM.  

Keep venting

Bob

[Nancy T]

You can certainly have lesions on the spinal cord without them being seen on MRI. I had a neck MRI (without contrast) which showed absolutely nothing abnormal--yet I have Lhermitte's. (Not diagnosed with anything.)

[COBOB]

Lhermitte's can be caused by any involvement of the cord's posterior columns (the main sensory tracts in the cord.)  This includes the THORACIC SPINE.  Look it up.   Are you telling me that  with that symptom, your neuro didn't image your T-spine?  If that is the case, I'd be looking for a new Neuro.

Bob

[Willowwoman777]

I definitely do have MS...numerous large lesions in brain - neuro said classic ms lesions. The spine he did for low back pain, showed a minor problem but no lesions showed up. They can not use contrast on me because I have kidney disease and the contrast is an absolute no no with kidney involvement..so thanks all...I guess you answered that just because no lesions showed up doesn't mean there aren't any...

[Nancy T]

That is correct, I have never had a thoracic MRI, only cervical and once a lumbar (ordered by the orthopedic scoliosis specialist, who said my symptoms were not caused by the scoliosis, which however is thoraco-lumbar in my case).

What you say is interesting, because the very first Lhermitte's-type experience I ever had was a period when I'd get an odd momentary "numb" sensation in my tailbone when bending my body (not nec. head) slightly forward, such as when standing and reaching across a bed to pull up the covers. So it makes sense to me that Lhermitte's can come from elsewhere in the spine, not just the neck.

That said, the neuro that I'm about to see (after an MRI this week) told me 2 years ago that my Lhermitte's is not Lhermitte's because the sensations don't run down my spine when I bend my neck, they're only in my lower body. He also states on an ask-the-doctor forum that by definition, no lesions on MRI = no MS. So I don't have much confidence in him. I have to start with him because of my insurance. Will move on later if necessary.

[COBOB]

All I can say is that if Neurologists knew how MRI worked they would never say that.  The small difference in the signal gradients between a "higher water lesion" and "lower water intact myelin" is so small that it can be lost in the fast fourier transforms used to get rid of the noise in the data.

One of the problems of using technology without understanding technology is the "belief in false gods."  To give you an example, MRI is so inaccurate, it CAN NOT be used for radiation therapy planning.  Spiral CAT is the "gold standard" for therapy planning.  You can do some magic and match fiduciary landmarks to make an MRI match the spiral CAT, then you can use the combined image for therapy planning.

So why do Neuros trust MRI so much?  Because most Neuros don't know any better.

Bob
    

[Nancy T]

And, I might add, some doctors also have no interest in learning something new or figuring out that what they learned in the past is faulty, incomplete, or outdated. You can really tell the difference between doctors who are curious, attentive, and most of all interested in GETTING THINGS RIGHT, and those who aren't.

[Udkas]

Hi Nancy, I never realised that you didn't have your thoracic region MRI, so I hope they do that too?? Can you get it scheduled if they are only doing your cervical, as high up in the thoracic can cause lhermittes too.

My neuro pretty much explained to me about MRI how you did Bob, he lost me a bit because it went over my pretty head (lol) and sometimes I think he thinks I understand it all, but basically he said equipment is not perfect and something about if the lesion was now I can't remember but basically in a certain spot it might not show up on MRI, I think he does have balls being able to give me a diagnosis without relying on equipment, but some people can have reoccuring TM, they get lesions only in their spinal cord and the lesions are always bigger and span across the segement (transverse) in nature, although rare it is not unheard of and then there is NMO or Devics where there is eye involvement.

I would have thought that having TM it would be clearer to see but it is all about positioning of the lesion and the thoracic is the hardest bit to MRI, as he says just because we can't see it doesn't mean it's not there, I know it's there, I can tell from your reflexes etc... as I have said at least he doesn't think I am insane, many neuros it seems fob their patients off as mad when nothing shows up.
Cheers,
Udkas.

[BOK2Bjan]

I was interested in this thread, because I'm going to have another Spinal MRI due to severe new right leg symptoms.   BUT - I've had so many lower extremity symptoms since the beginning of this disease, a each time, my neuro said they could be explained by the lesions in my brain.  My question to her was "Are there symptoms that indicate to you that I would probably have a lesion on my spine, or can most all of the symptoms can be explained by lesions in the  brain."  She said that the lesions in the brain can cause symptoms everywhere in your  body - therefore there was no need to think I had gotten any in my spine.  

Well, I haven't gone back to her.  I haven't gone to anyone, due to having so many diagnosis and being on Medicaid - no one wants to see me who is a specialist.  I have a great internist who orders all my tests, and if he needs help he talks to the specialists for me.  It's a mess.  This past two weeks, I suddenly had pain in my right leg - my calf, and it is so swollen and tight too.  I have foot drop on that side as well.  My right arm is constantly feeling like it's either asleep or just waking up from sleep.  Pins and needles like crazy.  

I also lost muscle mass in my right hip and gluts - noticeable by anyone who looks.  SO, my point is - I'm going to have an MRI on my spine again, but am not expecting anything.  I'd like to see how many new lesions are in my brain tho.  They keep multiplying!

And Bob, thanks for your MRI information - always appreciated.

Best to you all.  Jan

[ShesinPain]

I am running into the same problem with my 9 year old who has been sick for 4 months now, starting with Mycoplasma which after meds ended up with severe lower back pain, to tingly legs and arms and loss of strength in legs for about a week - prednisone and cipro at the hospital for 2 weeks.  3 MRIs - 1 lower w/o contrast, 1 full with, and 1 lower with all came back negative.  LP is also negative.  However, her spinal pain is still severe and the latest diagnosis is fibromyalga  They also have given her 2 weeks of doxycycline recently because her IGG was back up to 4900  it brought it down to 3700 which is the lowest it's been since 1/1/14  They've ruled out TM several times but are still thinking about it as a possibility.  Going to a larger childrens hospital on Wednesday to start all over again.  She has a tutor, cannot attend school due to pain (especially from sitting in the chairs) and has fatigue, back pain, etc.  Very difficult with the nice weather upon us.  We like to play outside and parks, bikes, etc are out of the question.  I don't want to be the diagnosis of TM, but I would like to have a plan of action to relieve the pain and get her back to being a kid.  I too wonder if you can have TM without lesions visible.  Good luck to you.....