What is MS?
When MS Attacks the Spinal Cord
A larger number of spinal cord lesions are often seen in progressive forms of multiple sclerosis.
By Quinn Phillips
Medically Reviewed by Samuel Mackenzie, MD, PhD
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Virtually everyone with multiple sclerosis (MS) has signs of lesions in the brain, as shown by magnetic resonance imaging (MRI) scans. In fact, according to the National Multiple Sclerosis Society, about 95 percent of people with MS show brain lesions at the time of their diagnosis.
But the brain isn’t the only area where lesions can develop — MS can also attack the spinal cord. Because finding these lesions involves more-elaborate imaging tests, spinal cord lesions in MS are studied less often, and many people with MS aren’t aware of the role these lesions may play in the disease process.
Researchers, too, have knowledge gaps about this feature of the disease, but one thing that seems clear is that filling these gaps may lead to a better understanding of progressive forms of multiple sclerosis.
How MS Lesions Form
Spinal cord lesions in MS “probably” form through the same mechanisms as those in the brain, according to Anthony Reder, MD, a multiple sclerosis specialist and professor of neurology at the University of Chicago in Illinois.
“For some unknown reason, white blood cells escape from the bloodstream, go through the blood–brain barrier, and get into the brain tissue,” says Dr. Reder. These cells cause inflammation mostly in the white matter — but also the gray matter — of the brain and spinal cord.
According to Reder, toxic chemicals produced by these cells strip the myelin insulation off the connections between nerves. The resulting lesions tend to be 1 to 2 centimeters in length or diameter.
While there are several potential explanations for why certain people with MS have more lesions in their brain or spinal cord, ultimately the reasons remain unknown, says Reder — but they are being actively investigated by researchers worldwide.
What we do know, he notes, is that spinal cord lesions “are more common in the more progressive forms of MS, and more common in men, with later onset” than in other forms of MS.
How Lesions Are Related to MS Symptoms
Because of the role the spinal cord plays in transmitting signals to and from the brain, spinal lesions should — at least in theory — be worse than most brain lesions.
But in practice, how damaging a spinal cord lesion may be seems to depend on other factors, including your age and type of MS.
One study, involving about 500 patients and published in July 2005 in the journalSpinal Cord,found that spinal lesions in relapsing-remitting MS were associated with early disease onset and mild or minimal progression of the disease, while those in primary-progressive MS were associated with later disease onset and faster progression of disability. This indicates that disability was more closely tied to MS type than to the location of lesions.
A more recent study, published in March 2011 in theJournal of Neuroimaging,found that among several different areas of the brain and spinal cord that were imaged using MRI, only in the very top area of the spinal cord — near the second and third cervical vertebrae — was atrophy (caused by lesions) significantly associated with a greater level of self-reported disability. Even so, no specific areas of atrophy or lesions were associated with better or worse performance on a timed 25-foot walking test.
Developing Potential Therapies
According to Reder, most studies of progressive forms of MS — even those whose subjects have a high number of spinal cord lesions — don’t image the lesions regularly or use them as an outcome to be measured. That, he says, is because of both the cost and the difficulty of imaging the spinal cord.
Instead, says Reder, walking is typically the outcome measured in trials involving progressive MS.
But Reder notes that studies of another inflammatory condition, called neuromyelitis optica (NMO), have examined the effect of drug therapies on spinal cord lesions, and some of this research may be useful in studying MS. NMO attacks the myelin sheaths of the optic nerves and spinal cord but, at least in earlier stages of the disease, typically spares the brain.
According to the National Multiple Sclerosis Society, the most common treatments for NMO are Imuran (azathioprine), CellCept (mycophenolate mofetil), and Rituxan (rituximab) — the last of which is currently also used to treat some cases of MS.
But Reder says that it remains to be seen whether any therapy can help slow or halt the accumulating spinal cord lesions that affect some people with progressive MS and that are very difficult to treat.
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