• Seidenwurm DJ, Brunberg JA, Davis PC, De La Paz RL, Dormont PD, Hackney DB, Jordan JE, Karis JP, Mukherji SK, Turski PA, Wippold FJ II, Zimmerman RD, McDermott MW, Sloan MA, Expert Panel on Neurologic Imaging. Myelopathy. [online publication]. Reston (VA): American College of Radiology (ACR); 2006. 11 p. [58 references]

This is the current release of the guideline.

This guideline updates a previous version: Seidenwurm D, Drayer BP, Anderson RE, Braffman B, Davis PC, Deck MD, Hasso AN, Johnson BA, Masaryk T, Pomeranz SJ, Tanenbaum L, Masdeu JC. Myelopathy. American College of Radiology. ACR Appropriateness Criteria. Radiology 2000 Jun;215(Suppl):495-505.

The appropriateness criteria are reviewed annually and updated by the panels as needed, depending on introduction of new and highly significant scientific evidence.

Myelopathy

Diagnosis
Evaluation

Emergency Medicine
Infectious Diseases
Neurological Surgery
Neurology
Oncology
Radiology

Health Plans
Hospitals
Managed Care Organizations
Physicians
Utilization Management

To evaluate the appropriateness of initial radiologic examinations for patients with myelopathy

Patients with myelopathy

1. Computed tomography (CT), spine
   • Without contrast
   • With contrast
   • Postdiscogram
2. Computed tomography angiography (CTA), spine
3. Magnetic resonance imaging (MRI), spine
   • Without contrast
   • Without and with contrast
   • Flow
4. Magnetic resonance angiography (MRA), spine
5. CT myelography
6. Myelography
7. X-ray, spine
8. Nuclear medicine (NUC)
   • Bone scan (include single-photon emission computed tomography [SPECT])
   • White blood cell (WBC) scan
   • Cerebral spinal fluid (CSF) flow scan
9. Invasive (INV), spinal arteriography
10. Discogram
11. Epidural venography
12. Thermography
13. Ultrasound (US)

Utility of radiologic examinations in differential diagnosis

Searches of Electronic Databases

The guideline developer performed literature searches of recent peer-reviewed medical journals, and the major applicable articles were identified and collected.

The total number of source documents identified as the result of the literature search is not known.

Weighting According to a Rating Scheme (Scheme Not Given)

Not stated

Systematic Review with Evidence Tables

One or two topic leaders within a panel assume the responsibility of developing an evidence table for each clinical condition, based on analysis of the current literature. These tables serve as a basis for developing a narrative specific to each clinical condition.

Expert Consensus (Delphi)

Since data available from existing scientific studies are usually insufficient for meta-analysis, broad-based consensus techniques are needed to reach agreement in the formulation of the appropriateness criteria. The American College of Radiology (ACR) Appropriateness Criteria panels use a modified Delphi technique to arrive at consensus. Serial surveys are conducted by distributing questionnaires to consolidate expert opinions within each panel. These questionnaires are distributed to the participants along with the evidence table and narrative as developed by the topic leader(s). Questionnaires are completed by the participants in their own professional setting without influence of the other members. Voting is conducted using a scoring system from 1-9, indicating the least to the most appropriate imaging examination or therapeutic procedure. The survey results are collected, tabulated in anonymous fashion, and redistributed after each round. A maximum of three rounds is conducted and opinions are unified to the highest degree possible. Eighty percent agreement is considered a consensus.

If consensus cannot be reached by the Delphi technique, the panel is convened and group consensus techniques are utilized. The strengths and weaknesses of each test or procedure are discussed and consensus reached whenever possible. If "No consensus" appears in the rating column, reasons for this decision are added to the comment sections.

Not applicable

A formal cost analysis was not performed and published cost analyses were not reviewed.

Internal Peer Review

Criteria developed by the Expert Panels are reviewed by the American College of Radiology (ACR) Committee on Appropriateness Criteria.

ACR Appropriateness Criteria®

Clinical Condition: Myelopathy

Variant 1: Traumatic.

Note: Abbreviations used in the tables are listed at the end of the "Major Recommendations" field.

Variant 2: Painful.

Note: Abbreviations used in the tables are listed at the end of the "Major Recommendations" field.

Variant 3: Sudden onset.

Note: Abbreviations used in the tables are listed at the end of the "Major Recommendations" field.

Variant 4: Stepwise progressive.

Note: Abbreviations used in the tables are listed at the end of the "Major Recommendations" field.

Variant 5: Slowly progressive.

Note: Abbreviations used in the tables are listed at the end of the "Major Recommendations" field.

Variant 6: Infectious disease patient.

Note: Abbreviations used in the tables are listed at the end of the "Major Recommendations" field.

Variant 7: Oncology patient.

Note: Abbreviations used in the tables are listed at the end of the "Major Recommendations" field.

The term myelopathy is used to describe any neurological deficit related to the spinal cord itself. Most frequently, myelopathy is due to compression of the spinal cord by osteophyte or extruded disc material in the cervical spine. Osteophytic spurring and disc herniation may also produce myelopathy localized to the thoracic spine, though this is less common. The next most common sources of myelopathy are spinal cord compression due to extradural mass caused by carcinoma metastatic to bone, and blunt or penetrating trauma. Many primary neoplastic, infectious, inflammatory, neurodegenerative, vascular, nutritional, and idiopathic disorders may also result in myelopathy, though these are very much less common than discogenic disease, metastases, and trauma. A variety of cysts and benign neoplasms may also compress the cord; these tend to arise intradurally. The most common of these are meningiomas, nerve sheath tumors, epidermoid cysts, and arachnoid cysts.

In general, disorders of the spinal cord itself are uncommon and difficult to treat effectively. Therefore, most attention in the radiological evaluation of myelopathy is focused on extrinsic compression of the spinal cord. Classically, radiological evaluation of myelopathic patients consisted of positive contrast myelography. Later, this evaluation was supplemented by CT and CT myelography. MRI has become the mainstay in the evaluation of myelopathy. More recently, imaging of the spinal cord has improved to the point that reliable diagnosis of nonexpansile spinal cord lesions is routinely possible.

Despite the wide variety of causes of myelopathy, diagnosis and treatment rest on demonstration of mechanical stability of the spine, particularly in the cervical region and when tumor or trauma history is present. Depiction of direct neural involvement by a pathologic process is then required for more refined diagnosis and specific treatment decisions. Anatomical diagnosis of myelopathy rests principally in the distinction between extradural, intradural, and intramedullary lesions.

Clinically, the diagnosis of myelopathy depends on the neurological localization of the finding to the spinal cord, rather than the brain or peripheral nervous system, and then to a particular segment of the spinal cord. The antecedent clinical syndrome and other details of the patient's course help to refine diagnosis, but imaging plays a crucial role. In general, myelopathy is clinically divided into categories based on the presence or absence of significant trauma, presence or absence of pain, and the mode of onset (slowly progressive or insidious onset vs. a stepwise progression vs. a sudden onset). Patients with known tumor history and those in whom infectious disease is likely may also be considered separately.

In the patient with traumatic myelopathy, the first priority for the spine is mechanical stability. Plain radiographs are useful for this purpose, but CT may be more useful when a high probability of bony injury or ligamentous injury is present. At some centers, routine multidetector CT with sagittal and coronal reconstructions is supplanting the role of plain radiographs, especially in the setting of multiple trauma. MRI is widely considered the study of choice when paralysis is incomplete or under other circumstances where direct visualization of neural or ligamentous structures is clinically necessary. If surgery for herniated disc, hematoma, or other cause of incomplete paralysis is planned, MRI best depicts the relation of pathology to the cord, and can help predict which patients may benefit from surgery.

When local or radicular pain accompanies myelopathy, the most likely diagnoses are spondylosis, tumor, and infection. Plain radiographs may depict osteophytic narrowing of the spinal canal or bone destruction. CT improves the depiction of both bony encroachment on the spinal canal and compression of neural structures by herniated disc material that is occult to plain radiographic evaluation. Bone destruction and soft tissue masses are also better seen. MRI has largely replaced CT scanning in the noninvasive evaluation of patients with painful myelopathy because of its superior soft tissue resolution and multiplanar capability. Invasive evaluation by means of myelography and CT myelography may be supplemental when visualization of neural structures is required for surgical planning or other specific problem solving, though this is less frequent.

Although most commonly due to spondylosis and disc herniation, a significant proportion of painful myelopathy is caused by tumor or infection. Demyelinating disease may present with pain symptoms as well. Occasionally, syringomyelia may present with the anesthesia dolorosa syndrome. The ability of MRI to depict the spinal cord directly and to assess its contour and internal signal characteristics reliably and noninvasively has resulted in general acceptance of MRI as the study of choice in evaluating cervical myelopathy when spondylosis or disc herniation is the most likely cause. When MRI is not available, or to answer specific questions before surgical intervention, myelography and CT myelography may be useful.

In slowly progressive myelopathy, the ability of MRI to depict the spinal cord noninvasively is most valuable. Some specifically treatable disorders may be localized and depicted quite well by means of myelography followed by CT myelography. However, the occasional complication of myelography in cases of spinal block, difficulty in visualizing the upper extent of lesions, and relative "blind spots" at the cervical thoracic and craniocervical junctions limit the utility of myelography. CT myelographic techniques may help avoid these pitfalls and may be useful to answer specific preoperative questions about bony anatomy.

Enlargement of the spinal cord by intramedullary mass is well depicted by myelography only when large masses are present. CT myelography can be extremely useful in supplementing the plain radiographic examination. These techniques, however, are less useful than MRI because the distinction between solid and cystic masses is usually not possible, even when delayed examination is performed. The distinction of syrinx from tumor, location of tumor nodule, extent of cyst, and distinction of nodule and cyst from edema are crucial in treatment planning for intramedullary disease and virtually necessitate MRI.

When myelopathy progresses stepwise or is of sudden onset, vascular processes become significant diagnostic possibilities. Vascular malformations, spinal cord infarct, and epidural hematoma account for most of vascular lesions of the cord. In practice, they are difficult to distinguish clinically from other nontraumatic causes of myelopathy because the classic history is frequently absent or difficult to elicit from a seriously ill patient. If AVM is considered clinically likely, gadolinium-enhanced MRI, MRA, and myelography to demonstrate abnormal vasculature may be useful adjuncts to guide spinal arteriography. More recently, progress in CT angiography has led to the use of this technique in preangiographic evaluation of patients with suspected spinal vascular abnormalities.

If myelopathy is painless and slowly progressive, the differential diagnosis is quite broad. Neoplastic disease of the spinal cord and extrinsic compression by epidural or intradural tumor may present in this manner. Demyelinating disease, degenerative diseases, and metabolic or deficiency diseases also present in this fashion. Spondylosis may present painlessly as well, particularly in elderly. In these cases, visualization of the spine as well as the spinal cord is useful and this is best accomplished noninvasively by MRI.

In oncology and infectious disease patients, multiple sites of involvement are possible. In these patients it is often necessary to study the entire spine or even the entire skeleton despite a specifically localized myelopathic level. MRI is considered more sensitive at an individual site, but the convenience of radionuclide bone scanning makes it useful in this setting as well. Acquired immune deficiency syndrome (AIDS) patients may present with myelopathy due to primary cord disease caused by human immunodeficiency virus (HIV) infection. No high quality evidence supports the use of discography, thermography, epidural venography, ultrasound, CSF flow studies in the evaluation of myelopathy. Radionuclide bone scan may play an adjunctive role, for example, to locate a safer biopsy site in patients with suspected metastatic cord compression.

An important limitation of MRI in the diagnosis of myelopathy is its high sensitivity. The ease with which the study depicts expansion and compression of the spinal cord in the myelopathic patient may lead to false positive examinations and inappropriately aggressive therapy if findings are interpreted incorrectly. For example, transverse myelitis due to demyelinating disease may demonstrate cord enlargement and be mistaken for tumor. Spondylosis, which occurs with normal aging, may be mistaken for clinically significant osteophytic compression of the spinal cord in a patient who is myelopathic for other reasons. These problems are minimized by experienced observers and meticulous clinical correlation with radiologic findings. Similar problems are present in the interpretation of any anatomical study of the spinal cord and are not unique to MRI. Careful patient selection and clinical correlation are essential in interpretation of imaging findings everywhere.

Abbreviations

• AVM, arteriovenous malformation
• CT, computed tomography
• CTA, computed tomography angiography
• CSF, cerebrospinal fluid
• INV, invasive
• MRA, magnetic resonance angiography
• MRI, magnetic resonance imaging
• NUC, nuclear medicine
• SPECT, single photon emission computed tomography
• US, ultrasound
• WBC, white blood cell

Algorithms were not developed from criteria guidelines.

The recommendations are based on analysis of the current literature and expert panel consensus.

Selection of appropriate radiologic imaging procedures for evaluation of patients with myelopathy

• An important limitation of magnetic resonance imaging in the diagnosis of myelopathy is its high sensitivity. The ease with which the study depicts expansion and compression of the spinal cord in the myelopathic patient may lead to false positive examinations and inappropriately aggressive therapy if findings are interpreted incorrectly.
• Similar problems are present in the interpretation of any anatomical study of the spinal cord and are not unique to magnetic resonance imaging. Careful patient selection and clinical correlation are essential in interpretation of imaging findings everywhere.

An American College of Radiology (ACR) Committee on Appropriateness Criteria and its expert panels have developed criteria for determining appropriate imaging examinations for diagnosis and treatment of specified medical condition(s). These criteria are intended to guide radiologists, radiation oncologists and referring physicians in making decisions regarding radiologic imaging and treatment. Generally, the complexity and severity of a patient's clinical condition should dictate the selection of appropriate imaging procedures or treatments. Only those exams generally used for evaluation of the patient's condition are ranked. Other imaging studies necessary to evaluate other co-existent diseases or other medical consequences of this condition are not considered in this document. The availability of equipment or personnel may influence the selection of appropriate imaging procedures or treatments. Imaging techniques classified as investigational by the U.S. Food and Drug Administration (FDA) have not been considered in developing these criteria; however, study of new equipment and applications should be encouraged. The ultimate decision regarding the appropriateness of any specific radiologic examination or treatment must be made by the referring physician and radiologist in light of all the circumstances presented in an individual examination.

An implementation strategy was not provided.

Living with Illness

Effectiveness

• Seidenwurm DJ, Brunberg JA, Davis PC, De La Paz RL, Dormont PD, Hackney DB, Jordan JE, Karis JP, Mukherji SK, Turski PA, Wippold FJ II, Zimmerman RD, McDermott MW, Sloan MA, Expert Panel on Neurologic Imaging. Myelopathy. [online publication]. Reston (VA): American College of Radiology (ACR); 2006. 11 p. [58 references]

Not applicable: The guideline was not adapted from another source.

1996 (revised 2006)

American College of Radiology - Medical Specialty Society

The American College of Radiology (ACR) provided the funding and the resources for these ACR Appropriateness Criteria®.

Committee on Appropriateness Criteria, Expert Panel on Neurologic Imaging

Panel Members: David J. Seidenwurm, MD; James A. Brunberg, MD; Patricia C. Davis, MD; Robert Louis De La Paz, MD; Pr. Didier Dormont; David B. Hackney, MD; John E. Jordan, MD; John P. Karis, MD; Suresh Kumar Mukherji, MD; Patrick A Turski, MD; Franz J Wippold II, MD; Robert D Zimmerman, MD; Michael W. McDermott, MD; Michael A. Sloan, MD, MS

Not stated

This is the current release of the guideline.

This guideline updates a previous version: Seidenwurm D, Drayer BP, Anderson RE, Braffman B, Davis PC, Deck MD, Hasso AN, Johnson BA, Masaryk T, Pomeranz SJ, Tanenbaum L, Masdeu JC. Myelopathy. American College of Radiology. ACR Appropriateness Criteria. Radiology 2000 Jun;215(Suppl):495-505.

The appropriateness criteria are reviewed annually and updated by the panels as needed, depending on introduction of new and highly significant scientific evidence.

None available

This summary was completed by ECRI on July 31, 2001. The information was verified by the guideline developer as of August 24, 2001. This summary was updated by ECRI on August 11, 2006. This summary was updated by ECRI Institute on May 17, 2007 following the U.S. Food and Drug Administration (FDA) advisory on Gadolinium-based contrast agents. This summary was updated by ECRI Institute on June 20, 2007 following the U.S. Food and Drug Administration (FDA) advisory on gadolinium-based contrast agents.