Adult-onset spastic paraparesis: An approach to diagnostic work-up

• Published in: Journal of the neurological sciences Vol. 346; no. 1-2; pp. 43 - 50
• Main Authors: Zhovtis Ryerson, Lana, Herbert, Joseph, Howard, Jonathan, Kister, Ilya
• Format: Journal Article
• Language: English
• Published: Netherlands Elsevier B.V 15.11.2014
• Subjects: Chronic; Diagnosis, Differential; Diagnostic evaluation; Differential diagnosis; Humans; Image Processing, Computer-Assisted; Magnetic Resonance Imaging; myelopathy; Neurology; Paraparesis, Spastic - diagnosis; Paraparesis, Spastic - etiology; Spastic paraparesis; Spinal Cord Diseases - complications; Chronic; Differential diagnosis; Spastic paraparesis; Magnetic resonance imaging; Diagnostic evaluation; myelopathy
• ISSN: 0022-510X; 1878-5883; 1878-5883
• DOI: 10.1016/j.jns.2014.09.015

Adult-onset, chronic progressive spastic paraparesis may be due to a large number of causes and poses a diagnostic challenge. There are no recent evidence-based guidelines or comprehensive reviews to help guide diagnostic work-up. We survey the literature on chronic progressive spastic paraparesis, with special emphasis on myelopathies, and propose a practical, MRI-based approach to facilitate the diagnostic process. Building on neuro-anatomic and radiographic conventions, we classify spinal MRI findings into six patterns: extradural; intradural/extramedullary; Intramedullary; Intramedullary-Tract specific; Spinal Cord Atrophy; and Normal Appearing Spinal Cord. A comprehensive differential diagnosis of chronic progressive myelopathy for each of the six patterns is generated. We highlight some of the more common and/or treatable causes of progressive spastic paraparesis and provide clinical pointers that may assist clinicians in arriving at the diagnosis. We outline a practical, comprehensive MRI-based algorithm to diagnosing adult-onset chronic progressive myelopathy. •Comprehensive differential diagnosis for spastic paraparesis is presented.•Practical MRI based algorithm to diagnosing progressive myelopathy is proposed.•Common and/or treatable causes for spastic paraparesis are discussed in detail.•References for entities on the differential diagnosis are provided in a table form.