Thursday, 4 August 2016

ClinicSpeak & ResearchSpeak: how healthy is your spinal cord?

Spinal cord lesions are associated with the subsequent development of disability! #MSBlog #MSResearch #ClinicSpeak #ResearchSpeak

"Have you had a spinal cord MRI? If yes, do you know how many MS lesions you have in your spinal cord? The study below shows that as MRI technology has matured many spinal cord lesions detected using MRI are in fact asymptomatic. What is more important is that the presence of spinal cord lesions, similar to posterior fossa lesions, are independently associated with a poor outcome."


"In this study the number of spinal cord lesions, change in lesions number with time and change in spinal cord cross-sectional area with time (atrophy) predicted disability progression over 5-years. Importantly, spinal cord activity (lesions) and end-organ damage (atrophy) was much more predictive of disability progression than brain lesion load and brain atrophy. I suspect this observation is linked to the outcome measure used. EDSS is essentially a walking scale, or in this context a spinal cord scale, and hence it is not surprising that spinal cord activity and atrophy is a better predictor of change in EDSS than the brain."


"Anything new here? Yes, this study may provide a stronger reason for assessing asymptomatic spinal cord lesion load at baseline. The presence of spinal cord lesions may nudge you towards higher efficacy, and potentially more risky, treatments. In other words the presence of spinal cord lesions at baseline will change your prognostic score. It also reinforces the message that the sub-clinical, or asymptomatic, lesion loads and activity, you carry with you plays out over time; in this study over the next 5-years. The study is also another example supporting early effective treatment; if you have asymptomatic spinal cord lesions, why would you want to develop any more lesions, or lose spinal cord volume? Similarly, if you have a pristine spinal cord, why would you want to take a chance of acquiring lesions if there are options to avoid this from happening? Although it doesn't state it the term 'Brain Health' also refers to 'Spinal Cord Health'; best to prevent spinal cord damage than to live with the consequences of damage."

Epub: Brownlee et al. Association of asymptomatic spinal cord lesions and atrophy with disability 5 years after a clinically isolated syndrome. Mult Scler. 2016 Aug 1. pii: 1352458516663034.

BACKGROUND: Spinal cord pathology is an important substrate for long-term disability in multiple sclerosis (MS).


OBJECTIVE: To investigate longitudinal changes in spinal cord lesions and atrophy in patients with a non-spinal clinically isolated syndrome (CIS), and how they relate to the development of disability.

METHODS: In all, 131 patients with a non-spinal CIS had brain and spinal cord imaging at the time of CIS and approximately 5 years later (median: 5.2 years, range: 3.0-7.9 years). Brain magnetic resonance imaging (MRI) measures consisted of T2-hyperintense and T1-hypointense lesion loads plus brain atrophy. Spinal cord MRI measures consisted of lesion number and the upper cervical cord cross-sectional area (UCCA). Disability was measured using the Expanded Disability Status Scale (EDSS). Multiple linear regression was used to identify independent predictors of disability after 5 years.

RESULTS: During follow-up, 93 (71%) patients were diagnosed with MS. Baseline spinal cord lesion number, change in cord lesion number and change in UCCA were independently associated with EDSS (R2 = 0.53) at follow-up. Including brain T2 lesion load and brain atrophy only modestly increased the predictive power of the model (R2 = 0.64).

CONCLUSION: Asymptomatic spinal cord lesions and spinal cord atrophy contribute to the development of MS-related disability over the first 5 years after a non-spinal CIS.

7 comments:

  1. R2=0.53 indicates that indeed there is correlation between EDSS and spinal cord lesions, but the relationship is not so strong, am I mistaken?

    In general, in statistics, if we simulate a time series whose correlation coefficient with our observations is 0.53, then our model has some performance, but it is not that great.

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  2. I guess this could explain the observations by the Mds' (medical doctors not mouse doctors) on the consultant360 website that in MS hemi-paresis is often insidious. (Their observation rings true with me, especially their association with optic neuritis). But YES, more evidence for time-is-brain/time-is-spine.

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  3. My spinal cord has lesions, one big one at least that I have seen on an MRI which causes problems. But that doesn't change the fact that my MS course has largely been one of slow progression since apparent onset, and that taking any of the DMTs involves potentially very severe side effects. And there is no option - as far as I know - to guarantee that I would acquire no more new spinal lesions. Only options to lessen the risk. But in my case, my challenge is probably mainly progression now, and for that, there is nothing. Only looking after my general health.

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  4. So a damaged SC = consider high-efficacy DMTs and a pristine SC = consider high-efficacy DMTs?!

    The risks associated with high-efficacy DMTs are largely mitigated by being detected and treated early.

    I had Alemtuzumab 2 years after diagnosis, even with EDSS 0 & no SC lesions. I had two posterior fossa lesions (pons & cerebellum) and wanted to decrease the risk of acquiring any more.

    Given the devastating & IRREVERSABLE consequences of ms, I can't understand why anyone would choose anything other than a high-efficacy DMT from the beginning.

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    Replies
    1. "The risks associated with high-efficacy DMTs are largely mitigated by being detected and treated early."

      For some of us, that wasn't / is no longer possible.

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    2. Do you mean because you were part of a trial when the risks were unknown? This applies to anyone starting a high-efficacy DMT at whatever stage they're at. The risks associated with the DMT apply from the time that DMT is commenced.

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    3. "Given the devastating & IRREVERSABLE consequences of ms, I can't understand why anyone would choose anything other than a high-efficacy DMT from the beginning."

      So true. So obvious. Can't even understand why low efficacy
      DMT's even exist. They should be banned and made illegal to use or prescribe.

      Delete

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