Clinical Presentation and Causes of Non-traumatic Spinal Cord Injury: An Observational Study in Emergency Patients

Abstract

Introduction: Diagnosing non-traumatic spinal cord injury (NTSCI) is often challenging. However, clear discrimination from non-spinal pathologies, e.g., "myelopathy-mimics" (MMs), is critical in preventing long-term disability and death. In this retrospective study we (1) investigated causes of NTSCI, (2) identified clinical markers associated with NTSCI and (3) discuss implications for NTSCI management. Methods: Our sample consisted of 5.913 consecutive neurological and neurosurgical patients who were treated in our emergency department during a one-year period. Patients with a new or worsened bilateral sensorimotor deficit were defined as possible NTSCI. We then compared clinical and imaging findings and allocated patients into NTSCIs and MMs. Results: Of ninety-three included cases, thirty-six (38.7%) were diagnosed with NTSCI. Fifty-two patients (55.9%) were classified as MMs. In five patients (5.4%) the underlying pathology remained unclear. Predominant causes of NTSCI were spinal metastases (33.3%), inflammatory disorders (22.2%) and degenerative pathologies (19.4%). 58.6% of NTSCI patients required emergency treatment. Presence of a sensory level (p = <0.001) and sphincter dysfunction (p = 0.02) were the only significant discriminators between NTSCI and MMs. Conclusion: In our study, one-third of patients presenting with a new bilateral sensorimotor deficit had NTSCI. Of these, the majority required emergency treatment. Since there is a significant clinical overlap with non-spinal disorders, a standardized diagnostic work-up including routine spinal MRI is recommended for NTSCI management, rather than an approach that is mainly based on clinical findings.

Keywords: multiple sclerosis; myelopathy; myelopathy mimic; non-traumatic spinal cord injury; spinal lesions; spinal metastases.

Figure 1

Differential diagnoses of bilateral sensorimotor deficits. ALS, amyotrophic lateral sclerosis; CIM, critical illness myopathy; CNS, central nervous system; MS, multiple sclerosis; NMOSD, neuromyelitis optica spectrum disorder; PNS, peripheral nervous system.

Figure 2

(A) Etiologies of non-traumatic spinal cord injury (NTSCI). (B) Underlying tumor entities of spinal metastases. MS, multiple sclerosis; NSCLC, non-small cell lung cancer; NET, neuroendocrine tumor.

Figure 3

Myelopathy mimics: underlying pathologies.

Figure 4

Compressive and non-compressive myelopathies causing NTSCI. (A) Compressive myelopathy due to cervical spinal stenosis. (B) Compressive myelopathy due to spinal meningioma. (C) Myelopathy due to spinal cord ischemia. (D) Spinal lesions in multiple sclerosis. (E) Spinal metastasis (arrow) and vertebral metastases (arrowheads) in a patient with lymphoma. (F) Leptomeningeal carcinomatosis in a patient with non-small cell lung cancer (NSCLC).

Figure 5

Comparison of neurological examination and medical history in patients with NTSCI and myelopathy mimics. MRC, Modified Medical Research Council; MRI, magnetic resonance imaging; *p < 0.05; ***p <0.001 (p-values adjusted for multiple comparisons using false discovery rate (Benjamini & Hochberg).

Figure 6

(A) Leading symptoms of patients with multiple sclerosis in the emergency department. (B) Percentage of MS patients who received spinal MRI during hospitalization, with detected spinal lesions on MRI and with diagnosed spinal lesions on MRI and a new or preexisting bilateral sensorimotor deficit. MS, multiple sclerosis; sMRI, spinal magnetic resonance imaging.

Figure 7

Diagnostic pathway for suspected NTSCI in the emergency setting. ACS, acute coronary syndrome, CNS, central nervous system; CRP, c-reactive protein; CT, computed tomography scan; CT-A, computed tomography angiogram; DWI, diffusion-weighted imaging; ENG, electroneurography, GBS, Guillain-Barré syndrome; MRI, magnetic resonance imaging; N, no; NNO, optic neuritis; NTSCI, non-traumatic spinal cord injury; i.v., intravenous; Y, yes.