Case Diagnosis: Cervical myelopathy with radicular symptoms and unexplained T2 hyper-intense spinal cord signal out of proportion to spinal stenosis findings at C5-C6.
Case Description or Program Description: We present a 46 y.o. male with degenerative disc disease and chronic low back pain who presented to the PM&R clinic with acute neck pain radiating into the right upper extremity (RUE). His history was consistent with atraumatic C5-C6 radiculopathy, given paresthesias in the first and second digits and progressive weakness affecting grip strength and fine motor control. PT provided limited improvement. MRI revealed C5-C6 spinal canal narrowing to 8.2 cm, with a T2-hyperintense spinal cord signal just inferior to this level, out of proportion to the stenosis. Neurosurgery found no significant compressive pathology requiring surgery. Further workup, including B6, B12, copper, ESR, CRP, ANA, RF, SSA/SSB, anti-MOG, and NMO serology, was initiated. An EMG was scheduled to differentiate radiculopathy from peripheral neuropathy process.
Setting: KC-VA out-patient PM&R clinic
Assessment/Results: Workup thus far has not identified a clear explanation for the out of proportion T2 cord signal. While MRI findings remain inconclusive, imaging still supports the diagnosis of cervical myelopathy with radicular symptoms.
Discussion (relevance): T2-hyperintensity in the spinal cord is typically linked to compressive myelopathy, but in this case, C5-C6 narrowing does not fully explain the signal change. This discrepancy necessitates considering inflammatory, metabolic, vascular, and demyelinating disorders. Despite extensive testing, no definitive cause has been identified thus far, suggesting early or subclinical myelopathy from chronic mechanical stress or microvascular ischemia. Idiopathic myelopathy remains possible when conventional workups fail. Other considerations include neuroinflammatory conditions like MS or spinal cord ischemia.
Conclusions: Given the lack of clear compressive pathology, this case highlights the need for a multidisciplinary approach to spinal cord signal abnormalities. Follow-up with further re-imaging, neurology consultation, and EMG may refine the diagnosis and guide management to prevent neurological progression.
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