Podcast Summary: MS Living Well – “MS & The Spinal Cord”

Host: Dr. Barry Singer, MD, Director of The MS Center for Innovations in Care
Guests: Prof. Gabriel DeLuca (University of Oxford) & Dr. Bruce Cree (UCSF)
Episode Date: August 20, 2024
Main Theme: The anatomy, pathology, symptoms, and imaging of spinal cord involvement in Multiple Sclerosis (MS), and how new scientific insights and technology are improving management and hope for patients.

Episode Overview

This episode explores how Multiple Sclerosis (MS) affects the spinal cord—disrupting communication between the brain and body and causing symptoms like numbness, weakness, and bladder issues. Host Dr. Barry Singer is joined by leading experts Prof. Gabriel DeLuca and Dr. Bruce Cree, who detail the underlying science, clinical implications, and advancing technology for diagnosing and managing MS spinal cord disease.

1. The Spinal Cord: Structure and Function

Guest: Prof. Gabriel DeLuca

• The spinal cord is about 17-18 inches long (40-45 cm) and functions as the body’s “information highway” between the brain and the peripheral nervous system.
  “Despite its diameter being so small. It's the main information highway for messages to be sent from the brain to our peripheral nervous system.” - Prof. DeLuca [01:57]
• It carries:
  • Motor instructions: movement of arms, legs, trunk
  • Sensory input: pain, temperature, light touch, vibration
  • Coordinating reflexes and walking
  • Control of involuntary functions: bladder, bowel, sexual function, fight-or-flight, rest-and-digest

2. How Often & How MS Affects the Spinal Cord

Guest: Prof. DeLuca

• Prevalence:
  • ~80% of people with MS have spinal cord lesions visible on MRI; most have more than one lesion [03:31].
  • Even in early MS, up to 83% show spinal cord demyelination.
  • Silent (asymptomatic) lesions are common, like in radiographically isolated syndrome (RIS)—about 35% have silent cord lesions.
  • Spinal cord lesions correlate with higher risk of disability progression.

“What's really fascinating… is that the presence of a spinal cord lesion not only increases the risk of later getting MS, but if someone has MS, having spinal cord lesions increases the risk of building up disability over time.” - Prof. DeLuca [04:33]

3. Types & Pathology of MS Lesions in the Spinal Cord

Guest: Prof. DeLuca

• Lesion Types: Based on location and inflammatory activity.
  • Active: Central inflammation (like “cracking an egg” analogy).
  • Mixed active: Inflammation at the borders.
  • Inactive: Inflammation has dissipated.
• Findings: Postmortems show almost 90% of MS cases have spinal cord lesions with active inflammation, even in older patients who had MS for decades [06:53].

“Almost 90% of Ms. Cases have spinal cord lesions that show signs of active inflammation at the time of autopsy.” - Prof. DeLuca [06:53]

4. Spinal Cord Anatomy in MS

Guest: Prof. DeLuca

• Anatomy:
  • Segments: Cervical (neck), thoracic (mid-back), lumbar/sacral (lower back).
  • Cervical and lumbar-sacral areas are bulkier (control arms/legs).
  • MS most often affects the cervical cord.

“In MS, it's actually that uppermost part, the cervical cord, that seems to be most affected.” - Prof. DeLuca [07:35]

• Discussion clarifies confusion: lumbar “spine” area doesn't contain spinal cord, so lumbar punctures don’t risk the cord [08:51].

5. Tracts and Symptoms: How Lesion Location Maps to Problems

Guest: Prof. DeLuca

• Main spinal tracts:
  • Corticospinal tract (side): Movement (motor function)
  • Spinothalamic tract (anterolateral): Pain & temperature
  • Dorsal column (back): Vibration & joint position
• Neurologists test tracts via tuning forks (vibration = dorsal columns) and pinprick (spinothalamic tract) [10:26].
• Lesions in:
  • Back (dorsal columns): Numbness/tingling in hands/legs
  • Side (corticospinal): Weakness/heaviness, fine motor loss
  • Thoracic (mid-back): “MS Hug” (painful grip/squeezing sensation) [12:32]
  • Lower cord/conus: Bowel, bladder, sexual dysfunction [13:08]

6. Progression Without Clear MRI Change

Guest: Prof. DeLuca

• Some patients get weaker without new MRI lesions—possibly due to ongoing inflammation or “critical lesions” not visible by current scans.
• Inflammation can occur without overt lesions, causing neuronal injury and persistent disability.

“We know that there can be considerable amounts of inflammation in the spinal cord, even in the absence of lesions.” - Prof. DeLuca [14:11]

7. The Role of Immune Cells in Spinal Cord Damage

Guest: Prof. DeLuca

• Key immune cells: Microglia, macrophages (surveillance, “gobbling up” proteins, causing injury).
• T cells and B cells also cause inflammation, especially in the meninges (lining).
• Meningeal inflammation can secrete toxic substances harming neurons.

8. Outlook for Treatment: A Hopeful Message

Guest: Prof. DeLuca

• Identifying molecules and mechanisms of inflammation is crucial for developing better, targeted therapies—especially for progressive MS.
• Optimism around future advances; researchers are working “until no one suffers from brain diseases.” [18:14]

“I think this podcast is really important at disseminating information so that people can be equipped and… pave a pathway to a cure.” - Prof. DeLuca [18:14]

9. Clinical Perspective: Transverse Myelitis and Mimics

Guest: Dr. Bruce Cree

• Transverse Myelitis: Inflammation across both front and back of cord. Presents as numbness/tingling, sensory loss progressing upward, possible weakness, bowel, bladder involvement.
• Symptoms:
  • Numbness starting in feet, rising upward; hands/arms involvement implies higher (cervical) lesions [21:04]
  • Bowel, bladder, and sexual dysfunctions common [21:37]
  • “Lhermitte’s sign” (electric-shock down spine on neck flexion) often means cervical lesion, but not exclusive to MS [22:18]
• Differential diagnosis: Neuromyelitis optica (NMO), MOG Antibody Disease (MOGAD), infections, and sarcoidosis can also present with spinal inflammation [24:37].

10. Spinal Cord Lesions & Prognosis

Guest: Dr. Cree

• A severe initial spinal cord attack (with motor/sensory/bowel-bladder symptoms) predicts a worse prognosis, but most with MS will develop cord lesions eventually.
• Merely having lesions may not worsen prognosis, especially with early aggressive treatment.

“Simply having the presence of lesions in the spinal cord… doesn't really influence the overall prognosis of multiple sclerosis. That's especially true today, where we have the capacity to make diagnosis early… and initiate highly effective therapies…” - Dr. Cree [25:00]

• Treatment is focused on preventing progressive disability, not just relapse suppression [27:31].

11. Imaging the Spinal Cord in MS

Guest: Dr. Cree

• Best Practices:

  • Closed 3 Tesla MRI scanners favored for optimal imaging; open MRIs less sensitive.
  • MRI can detect lesions/plaques (“areas of inflammation”) and even subtle atrophy (shrinkage) of the spinal cord.

• Advanced Techniques: Quantify gray/white matter and cord atrophy (correlates with disability on EDSS scale) [30:01].

• Atrophy:

  • Spinal cord can shrink (“atrophy”) with MS, measurable by advanced imaging.
  • Atrophy occurs in normal aging but is worse and faster in MS [32:08].

12. Monitoring and Future Directions

Guest: Dr. Cree

• Frequency of MRI monitoring now depends on therapy efficacy; highly effective new drugs mean less frequent scans needed [34:47].
• Both brain and spinal cord should be monitored, especially in patients not on or on less effective treatment.
• Newer imaging allows for better detection and even clinical trial use, especially in progressive MS [36:15].
• Technological advances include research on 7-Tesla MRI for even higher detail, with goal of translating knowledge to clinical 3T scanners [37:32].

13. Key Takeaways & Notable Quotes

• “Protecting the spinal cord for my patients is paramount.” - Dr. Singer [36:15]
• “That is one of the features that we're trying to prevent happening in MS by use of our disease modifying therapies.” - Dr. Cree on myelomalacia [33:01]
• “We are in a very different position to be able to aspire to do that than we were 20 years ago.” - Dr. Cree on the power of modern MS treatments [29:03]
• “Advances in spinal cord imaging and treatment for chronic inflammation are definitely making the future much more optimistic.” - Dr. Singer [38:26]

14. Recommended Actions for Patients

• Early, aggressive treatment is critical for long-term outcomes and to prevent progression.
• Be vigilant about symptoms (even if imaging hasn’t changed), as damage and progression may not always show up as new lesions.
• Collaborate closely with healthcare providers for individualized monitoring and treatment decisions.

15. Future Directions and Optimism

• Researchers are working towards therapies addressing the progressive phase and inflammation not visible on scans.
• MRI technology is rapidly advancing, enabling earlier and more precise diagnosis, monitoring, and even potential new therapies.
• Global collaboration and patient education (like this podcast) are central to improving outcomes and moving closer to a cure.

For more details, visit the episode blog at mslivingwell.org