This issue of Continuum is devoted to the diagnosis and management of disorders of the spinal cord, conditions integral to the clinical practice of neurology and so important to recognize as early diagnosis and management (whether the disorder is compressive or noncompressive) can so often be the key to preventing devastating disability. Guest Editor Brent P. Goodman, MD, has organized a wonderful volume written by such an impressive list of authors with expertise in the many aspects of spinal cord disorders, to guide us in the diagnosis and management of our many patients with myelopathies.
The issue begins with an article by Drs Tracey A. Cho and Shamik Bhattacharyya, who provide an overview of the clinical approach to myelopathy, including a primer on the neuroanatomy of the spinal cord and spinal cord syndromes, analysis of symptoms and signs of myelopathy, and imaging patterns that inform our diagnosis, all of which serve as an important introduction to the articles that follow. Next, Dr Christopher L. Kramer reviews the diagnosis and management of the vascular causes of spinal cord dysfunction, including spinal cord ischemia and infarction (and hemorrhage) from various etiologies and the vascular malformations and fistulas that present as myelopathic syndromes. Dr Robert N. Schwendimann then discusses the metabolic and toxic myelopathies, a particularly important cause of noncompressive spinal cord dysfunction as many of these disorders (particularly vitamin or mineral deficiency myelopathy) are reversible or preventable with urgent diagnosis and rapid initiation of therapy but are disabling if missed or treatment is delayed.
Dr Marie F. Grill then provides an encyclopedic review of myelopathies that can occur because of the many infectious (and postinfectious) processes that can involve the spinal cord (eg, bacteria, viruses, fungi, parasites) and the management specific for each organism. In the following article, Drs Jing Wu and Surabhi Ranjan review the diagnosis and management of the myelopathies that occur in the context of neoplasms (whether the myelopathy is the presenting feature or a complication of a known disorder), including primary spinal cord tumors, spinal cord compression from primary or metastatic neoplasms, and myelopathic complications of chemotherapy and radiation.
Dr Dean M. Wingerchuk then provides an extensive update on the immune-mediated myelopathies, including the most up-to-date information about the diagnostic criteria and management options for neuromyelitis optica and the recently characterized myelopathic disorder associated with myelin oligodendrocyte glycoprotein (MOG)-IgG antibodies. Dr Peter Hedera next presents an encyclopedic review of the hereditary causes of myelopathies, including the many hereditary spastic paraplegia syndromes as well as the spastic ataxias.
The following article by Dr Alejandro A. Rabinstein updates readers on the most current acute and subacute management options for patients with traumatic spinal cord injury, which neurologists need to be very aware of (even in cases where our involvement may tend to occur in the subacute phase and beyond). Drs Amro Maher Stino and Samantha J. LoRusso then review the diagnosis, imaging findings, and management options for our patients with myelopathies that occur from structural etiologies affecting the cervical or thoracic spine (and related elements), such as spondylosis, disk disease, thoracic cord herniation, and Hirayama disease.
In the final review article of the issue, Dr Goodman addresses an important site of neurologic dysfunction distal to the spinal cord itself, where urgent diagnosis and management of cauda equina disorders (particularly compressive causes) may stave off devastating motor, sensory, and bowel, bladder, and sexual dysfunction.
In the Ethical and Medicolegal Issues article, Associate Editor of Ethical and Medicolegal Issues Dr Joseph S. Kass provides four realistic clinical scenarios involving patients with spinal cord signs and symptoms to illustrate the concept of neurologists’ liability for referrals to other physicians and how to mitigate that risk.
I am thankful to Dr Goodman and all of the expert contributors to this issue for providing their expertise to so thoroughly inform and update us on these disorders, where so often timely and accurate neurologic diagnosis andmanagement can be of critical importance to the outcome of these patients.
We are also pleased to remind our readers of the recent increase in the maximum number of CME credits available for users of Continuum. After reading the issue and taking the Postreading Self-Assessment and CME Test written by Drs Douglas J. Gelb and Adam G. Kelly, you may earn up to 20 AMA PRA Category 1 CreditsTM toward self-assessment and CME or, for Canadian participants, a maximum of 20 hours toward the Self-Assessment Program (Section 3) of the Maintenance of Certification Program of the Royal College of Physicians and Surgeons of Canada. Additional credit can be obtained by listening to Continuum Audio interviews associated with this and other Continuum issues, now available to all subscribers, and completing tests on the new Continuum Audio web platform or app.
Disorders of the spinal cord and cauda equina are ubiquitous in outpatient and inpatient clinical neurologic practice. I am thankful to Dr Goodman and all of the expert contributors to this issue for providing their expertise to so thoroughly inform and update us on these disorders, where so often timely and accurate neurologic diagnosis and management can be of critical importance to the outcome of these patients. Finally, we hope that readers continue to enjoy our redesigned and reinvigorated Continuum issues, making for an optimal reading experience as you take your issue off the shelf and “decompress” while updating your knowledge.
STEVEN L. LEWIS, MD, FAAN