What is myelomalacia?

The last few podcasts have focus on disc damage and time dating injury based on imaging.   We have not covered all the ways to time date an injury based on imaging.  I wanted to spend some time today talking about what disc damage means to patients and not just the causation of the injury.  I will have to spend a few podcasts on this subject as well. 

One common theme with disc herniations is real estate.  Disc herniations can cause significant pain due to the recurrent meningeal nerve, which is the nerve that senses pain at the disc.  The tearing of the disc can cause local pain that can be intense, but if the herniation is not taking up the real estate that belongs to another type of anatomy the herniation is likely not as serious.  If the disc herniation is taking up the space of nerve tissue, then we likely have a more serious injury, although maybe not more painful.    Herniations will often take the real estate or space that belongs to cerebral spinal fluid, nerve roots or the spinal cord.  Again, the seriousness of a herniation is not associated with the amount of pain, but if the herniation is taking the space of nerve tissue.      

I wanted to share a 2023 study from the International Journal of Molecular Science titled “Edema after CNS trauma: a Focus on Spinal Cord Injury” published by Mostafa Seblani et al.  This study showed that the first observation after a spinal cord injury is edema.  What is edema?  They say that the term edema is one of the oldest medical terms still in use today.  The term edema encompasses many different observations, but all of the involve an increase in water content.  Edema comes from swelling and the lack of liquid elimination.  Edema is the main sign of inflammation.  Today’s study reported that the term now days most importantly means an imbalance in forces that control homeostasis within cells. 

This edema of increase of fluid can easily be seen on MRI.  Today we will specifically talk about spinal cord edema after an injury.  Edema in the brain or spinal cord leads to necrosis due to compression.  Necrosis is defined as cellular death.  This imbalance in the spinal cord or brain leads to excitotoxicity.  Excitotoxity is toxic actions of neurotransmitters around the cells.  This excitotoxity creates a cascade of inflammatory responses that lead to more cellular death and causes a secondary injury.  This study showed that spinal cord edema is correlated with severe impairment and poor recovery. 

Today’s study showed that a disc herniation that takes the space of cerebral spinal fluid or causes edema in the spinal cord will increase the cerebral spinal fluid.  This increase in CSF can lead to necrosis and cellular death.  Today’s study showed that edema starts to increase five minutes after an injury and continues to reach maximum intensity in five days after the injury.     

The spinal cord is part of the central nervous system and is vital to most human function.  A spinal cord injury can be very serious including life threatening.  If we have a spinal cord injury, we need urgent treatment.  Today’s study showed that treatment should be to treat edema with early surgical decompression and CSF drainage.  This study showed that quote “there is no proven effective medication that can successfully treat spinal cord edema” end quote.  If we have a disc herniation with spinal cord damage the surgical decompression is likely the best course of action and as seen in the study early surgical decompression is important. 

As a chiropractor my job is not to determine if a patient needs surgery, but to refer to the surgeon urgently when needed. 

Real World example

I had a young patient who at the time of the MVC was 22 years old.  He came in for his initial examination and it was clear right away he had neurological problems and a cervical spine MRI was ordered.  He waited 2 months after his MVC to come in for an examination.  The MRI came back showing spinal cord compression a the C5-6 disc level.  I never treated the patient and referred him right away to the neurosurgeon. 

I did not see the patient for a couple months and found out he was not interested in having surgery and never went to the surgical consultation.  His attorney sent him to a pain management provider who did injections and months later his symptoms were getting worse.  His attorney referred him to another surgeon who ordered another cervical spine MRI.  This new MRI showed high signal cord myelomalacia at the C5-6 level and he recommended surgery. 

The attorney met with me to go over the case.  They were attempting to settle the case without having surgery done.  The patient was not interested in surgery.  The attorney was frustrated and unsure how to settle the case.  I asked them about the myelomalacia seen on the MRI report.  They were unsure what that meant. 

Be honest how many of you knew what the high signal cord myelomalacia is?  High signal cord is edema in the cord. As seen on today’s study this will lead to cellular death and this is a progressive disorder.  Today’s study showed that this type of injury quote “correlated with severe impairment and poor recovery”.  The term myelo refers to the spinal cord and malacia refers to softening. 

If, the radiologist reported that the herniation at C5-6 is compressing or taking the space of the spinal cord and causing edema that has over time caused cellular death and is killing the cells in the spinal cord and this will likely lead to severe impairment and poor recovery, then the attorney would have known how serious this injury is and would be able to settle the case easier. 

I know most patients especially young patient’s do not want surgery.  The hesitation on this patient’s part led to a more serious spinal cord injury.  As seen in today’s study surgical decompression is the best treatment option for him.