Cervical spondylotic myelopathy mimicking transverse myelitis

Objective: To describe two cases of cervical spondylotic myelopathy initially misdiagnosed as transverse myelitis. Methods: Case series. Results: A 44- and 56-year-old man presented with chronic progressive myelopathy. Initial work up revealed cervical spondylosis and an enhancing intramedullary cervical cord lesion. The younger individual was diagnosed with multiple sclerosis, and the other as an unspecified autoimmune demyelinating disorder. They were both treated with immune therapies, but had progression in their symptoms and functional decline, prompting re-evaluation. Due to persistent enhancement of the intramedullary cervical cord lesion on repeat imaging, lack of new lesion formation over time, and lack of intrathecal antibody production, all of which are atypical for a primary demyelinating disorder, both men ultimately underwent cervical decompressive surgery. Interestingly, though symptoms and disability level improved or stabilized, persistent enhancement of the intramedullary cord lesion years after surgery was noted for both individuals. Conclusion: Spondylotic myelopathy is an important consideration in the differential of inflammatory myelopathy, especially since misdiagnosis may result in serious consequences as was seen in the cases presented, including exposure to unnecessary costly treatments and irreversible neurological disability from delayed appropriate surgical intervention. Intramedullary spinal cord enhancement can occur with spondylotic myelopathies, albeit rare, and may persistently enhance for an extended period of time even after decompressive surgery.