This issue of Continuum, ably and enthusiastically chaired by Dr Neeraj Kumar, represents a microcosm of the neurology universe. While less often encountered than disorders of the brain and those involving the peripheral nervous system (all things considered), disorders of the spinal cord, roots, and plexuses run the gamut of neurologic disease categories. Dr Kumar has recruited an outstanding faculty to produce this exciting, highly clinically relevant issue.
The complexity of the spinal cord, so densely packed into an organ hardly larger than a thumbnail, never ceases to amaze. The first section’s eloquent discussion of the intricate organization of the spinal cord by Drs Gregory Gruener and José Biller helps us exercise that core principle of neurologic diagnosis, precise anatomic localization. Armed with this information, we are better prepared to digest the subsequent disease-focused offerings.
Infectious and inflammatory disorders are described by Dr Dean Wingerchuk, who highlights developments in our understanding of transverse myelitis, as well as emphasizes the excitement surrounding neuromyelitis optica (NMO) and the implications of the recently discovered NMO-Ig antibody, which is directed against aquaporin-4, the major water channel in the CNS. Although the previous issue of Continuum was devoted entirely to neurogenetics, diseases of the spinal cord exemplify the importance of this field. Dr John Fink, rather than providing a mind-bending litany of syndromes, focuses on a systematic way to approach patients with potential genetic disorders of the cord.
Although vascular diseases of the spinal cord are relatively infrequent, certainly in comparison to cerebral strokes, they nonetheless pose interesting clinical scenarios. Drs David Geldmacher and Lubdha Shah present a lucid discussion not only of arterial syndromes but also of venous disorders and arteriovenous malformations. An incredible variety of toxic-metabolic disorders can affect the spinal cord. In addition to reviewing many familiar disorders, Dr Kumar himself discusses some conditions that have more recently gained in importance, such as copper deficiency myelopathy and other syndromes associated with the rapidly expanding use of bariatric surgery.
Among the most important categories of spinal cord disease are compressive myelopathies and traumatic injuries. It is critically important that neurologists recognize spinal cord compression, as early intervention may mean the difference in a patient’s ability to walk. Unfortunately, spinal cord injury too often reminds us of the vulnerability of the human condition and will remain a major problem in a world dependent on motor vehicles and with those too frequently operated by intoxicated drivers. Drs Jeremy Fogelson and William Krauss educate us about these important conditions.
Our attention next switches to the peripheral nervous system as we move outside the spinal cord to the nerve roots and subsequently the brachial and lumbar plexuses. Dr Kerry Levin provides an extensive review of the anatomy of the spinal roots and guidance on recognition of radiculopathies, followed by a discussion of the often-controversial issues of management. Finally, Dr Devon Rubin analyzes the complex anatomy of the plexuses innervating the upper and lower limbs, respectively, along with offering a clear discussion of the relatively unusual afflictions of these anatomic structures.
Complementing these chapters is the ethical discussion by Dr Thomas Cochrane that analyzes issues concerning surrogate decision making in a patient with severe spinal cord injury. A patient management problem, neatly crafted by Dr Wingerchuk, reprises the points emphasized in his chapter. Don’t forget to solidify your knowledge by attempting the clinically oriented multiple-choice questions devised by Drs Ronnie Bergen and Douglas Gelb.
This issue of Continuum also features the bonus of Quintessentials. If you have never tried Quintessentials, this is a great time to plunge in and test your clinical skills on three important clinical vignettes. You will receive rapid feedback and the opportunity subsequently to repeat the exercise and see your progress. This tool has been cited as an outstanding instrument to help you accomplish what will ultimately be necessary for Maintenance of Certification.
As editor, I am most appreciative of the exceptionally high level of enthusiasm with which Dr Kumar and his colleagues approached the task of developing this issue of Continuum. I know you will reap the benefits!
—Aaron Miller, MD