The knowledge gained from this issue will strike a chord with each of us as we attempt to provide the most informed care to reverse, improve, or prevent the disability that can occur from myelopathic disorders.
Expertise in the recognition, diagnosis, and management of myelopathies is an essential aspect of neurologic practice. It is therefore fitting that an entire issue in the CONTINUUM curriculum should be devoted to those disorders that can affect the spinal cord, whether via direct (eg, metabolic, inflammatory, or ischemic) or indirect (eg, compressive) mechanisms. For this issue, Guest Editor Dr Tracey A. Cho has assembled a remarkable group of expert authors and educators to provide us with a thorough and up-to-date review of the many causes of myelopathy that we encounter in our daily practice of clinical neurology.
The issue begins with two introductory articles that serve as important primers for the rest of the articles in the issue. First, Dr Cho provides a detailed and extremely accessible overview, reminding us of the functional anatomy of the spinal cord and the many clinicoanatomic spinal cord syndromes that inform our clinical approach to the diagnosis of patients with disorders of the spinal cord (or cauda equina). Next, Dr Joshua P. Klein provides us with his thoughtful, clear, and practical approach to spine and spinal cord imaging that we can emulate as we order and interpret our patients’ images of the spine, spinal cord, and nerve roots.
Next, the issue tackles the various categories of disease processes that can affect the spinal cord, beginning with the article by Drs Jinny O. Tavee and Kerry H. Levin, who thoroughly review and update us on the many causes of compressive myelopathy that occur due to degenerative and structural processes involving the spine (both common and less common) and their current management. Dr Alejandro A. Rabinstein then provides an indepth explanation and review of the pathophysiology and management of the myelopathies that occur due to vascular etiologies, such as spinal cord infarction due to various causes, and arteriovenous fistulas causing spinal cord dysfunction from venous hypertension. Dr Brent P. Goodman next provides an encyclopedic review of the causes, diagnosis, prevention, and management of the many spinal cord disorders that occur due to metabolic and toxic etiologies. Dr Jennifer L. Lyons provides an equally comprehensive review of the diagnosis and treatment of the manymyelopathies that occur due to infectious agents, whether via direct infection, inflammation of the cord, or via compressive mechanisms. Drs Benjamin M. Greenberg and Elliot M. Frohman then carefully review the various causes of inflammatory and demyelinative myelopathies (myelitides), with an emphasis on neuromyelitis optica and multiple sclerosis. Dr Marc C. Chamberlain next thoroughly details the diverse causes of myelopathy that occur in patients with neoplasms, whether as a direct effect from tumor, a remote effect, or as a complication of the treatment of neoplastic disorders.
In an issue devoted primarily to disorders of the spinal cord, Dr Cho and I also felt that it was important for the issue to delve somewhat caudal to the spinal cord, although still within the spinal canal. For this reason, Dr Andrew W. Tarulli provides an important additional discussion about those processes, especially compressive ones, which can affect the cauda equina, an important consideration given the clinical similarities (and differences) between cauda equina and spinal cord dysfunction and the severe disability that can occur with cauda equina dysfunction alone.
Drs Deborah M. Stein and Kevin N. Sheth bring a unique combination of expertise in trauma surgery and neurocritical care in their review and update for all neurologists on the current state of the art of diagnosis and management of acute traumatic spinal cord injury. Finally, the review articles in this issue conclude with a comprehensive discussion by Drs Gary M. Abrams and Karunesh Ganguly on the management and rehabilitation of patients with chronic spinal cord dysfunction.
In this issue’s Ethical Perspectives piece, Dr Amy Tsou discusses the complex ethical considerations involved in counseling patients about “stem cell tourism,” an issue that can arise in the context of caring for patients with disorders of the spinal cord as well as other neurologic disorders. In this issue’s Practice piece, Dr Marcus Ponce de Leon outlines how a multidisciplinary and team-based approach can be utilized to manage and reduce the risk of skin breakdown—an important cause of morbidity— in patients with disorders of the spinal cord. Finally, Dr Jeffrey Buchhalter presents four brief and very illustrative case examples as springboards to review the considerations involved in coding spinal cord dysfunction (due to disease or traumatic injury) with ICD-10-CM as compared to ICD-9-CM.
An update in the American Board of Psychiatry and Neurology’s (ABPN’s) selfassessment requirements has prompted an important change in CONTINUUM CME activities. The ABPN no longer requires the completion of a pretest in order be eligible for Self-Assessment (SA) (part 2) credit for Maintenance of Certification, so beginning with this issue, the CONTINUUM Self-Assessment Pretest has been eliminated. By taking the Postreading Self-Assessment and CME Test, carefully crafted by Drs Douglas Gelb and D. Joanne Lynne, after reading the issue, youmay earn up to 12 AMA PRA Category 1 Credits™ toward self-assessment and CME.
The Patient Management Problem, thoughtfully and expertly written by Dr Cho, follows a 39-year-old woman from her presentation in the emergency department with sensory and motor symptoms in the lower extremities through the diagnosis and management of her disorder. By following this case and answering multiple-choice questions corresponding to important pathophysiologic, clinicoanatomic, diagnostic, and management decision points along her course, you will have the opportunity to earn up to 2 AMA PRA Category 1 CME Credits.
I would like to give my sincere thanks to Dr. Cho for his dedication to this volume and similar thanks to his entire group of experts for providing the most up-to-date information about the diagnosis and management of the wide variety of disorders of the spinal cord (and cauda equina) that we encounter in our daily practices of clinical neurology, both in the hospital and in the clinic. The knowledge gained fromthis issue will strike a chord with each of us as we attempt to provide the most informed care to reverse, improve, or prevent the disability that can occur from myelopathic disorders.
—Steven L. Lewis, MD, FAAN