Today, I review, link to, and excerpt from “Myopathy: Tips for recognition of spinal cord emergencies” from Emergency Medicine Cases‘ EM Quick Hits 65.*
*Helman, A. MacArthur, M. Chernoff, I. Rosenberg, H. Segeren, S. Long, B. Booth, K. EM Quick Hits 65 – Occipital Nerve Block, PoCUS in Pulmonary Embolism, Myelopathy, Team Resuscitation, Incidental Neutropenia, Peer Programs. Emergency Medicine Cases. June, 2025. https://emergencymedicinecases.com/em-quick-hits-june-2025/. Accessed August 9, 2025.
All that follows is from the above resource.
Hans Rosenberg on identification and management of myelopathy in the ED (29:13 – 35:25)
Myopathy: Tips for recognition of spinal cord emergencies
Myelopathy = spinal cord dysfunction from compressive or non-compressive causes.
- Compressive Causes: Degenerative cervical myelopathy, central cord syndrome, epidural abscess, tumor, vascular malformations
- Non-Compressive Causes: Myelitis (infectious/inflammatory/autoimmune), B12 deficiency, radiation, toxins, paraneoplastic syndromes
Key Clinical Clues:
- Urinary retention
- Dermatomal sensory loss
- Upper motor neuron signs: hyperreflexia, clonus, Babinski sign, spastic gait, Hoffman’s sign – flicking nail of middle finger → thumb/index finger adduction = cervical cord disease
Workup of suspected myelopathy
- MRI: Whole spine MRI is usually recommended to screen for multifocal disease/”skip” lesions
- LP: If non-compressive etiology suspected to help identify inflammatory/infectious causes
ED management of suspected myelopathy
- Compressive: Neurosurgical consult ± dexamethasone (for malignant compression) or antibiotics (for suspected abscess).
- Non-compressive: Neurology consult ± steroids or immunotherapy (in consultation with neurology).
- Rapidly progressive symptoms require urgent imaging and referral to sites with neurosurgical and neurology services.
- Outpatient workup may be appropriate in stable patients with mild progressive symptoms, although delayed diagnosis may risk irreversible deficits.
Bottom Line: Upper motor neuron signs with dermatomal sensory loss should raise suspicion for myelopathy. MRI is an essential diagnostic tool and patients may require whole spine imaging. Rapid recognition and referral to neurosurgery or neurology are critical for preventing irreversible deficits.
References
- MacDonald Z, Ferguson E, Rosenberg H. Just the facts: emergency department approach to myelopathy. CJEM. 2024 Dec;26(12):851-853. doi: 10.1007/s43678-024-00763-8. Epub 2024 Sep 5. PMID: 39237730.
