A 46-year-old man presents to the office with pain radiating from his neck down into his right upper extremity. The radiating pain has been present for 4 months, and he has also had numbness in his right index finger during this time. He notes that his gait is unsteady. He has tried physical therapy, a tapering dose of oral steroids, and epidural steroid injections. Although all treatments resulted in mild, short-term relief, the pain and numbness in his right upper extremity persist. Sagittal magnetic resonance imaging (MRI) shows arthritis and disc herniations at C5-C6 and C6-C7 (Figure). A small “white spot” is noted in the cord at the level of C6. What does the white spot identified on MRI represent?
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Myelomalacia is pathologic softening of the cervical spine that appears as a white spot on MRI. 1,2 The white spot is best seen on T2-weighted sagittal images as high-intensity spinal cord changes at the level of spinal cord compression.1,2 Myelomalacia is one of the few signs suggesting a diagnosis of cervical spondylotic myelopathy. Myelomalacia occurs when there is insufficient blood supply to the spinal cord as a result of spinal cord compression. The spinal cord can be compressed by osteophytic overgrowth and disc desiccation. During neck extension, the ligamentum flavum buckles, causing narrowing of the spinal cord and worsening spinal cord compression.
Common causes of cervical spondylotic myelopathy and myelomalacia include sports-related injuries and degenerative disc disease. Myelomalacia is a significant finding on MRI as damage to the spinal cord is often permanent. Patients often present with myelopathic symptoms such as ankle clonus, Babinski sign, and a wide, unbalanced gait. When myelomalacia is seen on MRI and the patient presents with myelopathic symptoms, surgery is usually indicated.
Dagan Cloutier, MPAS, PA-C, practices in a multispecialty orthopedic group in the southern New Hampshire region and is editor-in-chief of the Journal of Orthopedics for Physician Assistants (JOPA).
- Al-Mefty O, Harkey LH, Middleton TH, Smith RR, Fox JL. Myelopathic cervical spondylotic lesions demonstrated by magnetic resonance imaging. J Neurosurg. 1988;68(2):217-222.
- Moore D. Cervical myelopathy. Ortho Bullets. Accessed July 19, 2018.