Pancake‐Like Enhancement in Spondylotic Compressive Myelopathy

A 41‐year‐old man was initially admitted to hospital with a 12‐month history of progressive bilateral lower limb weakness, lower limb and upper limb paresthesia, and bladder urgency. Prior spinal magnetic resonance imaging (MRI) showed severe canal stenosis at C5/6 with T2 hyperintensity and swelling of the lower cervical cord, and a transverse band of gadolinium enhancement affecting white and sparing gray matter at the level of maximal compression (Fig 1A; top, T2 sagittal view; middle, T1 fat‐saturated contrast‐enhanced sagittal view; bottom, T1 fat‐saturated contrast‐enhanced axial view). He underwent decompressive surgery with partial improvement to symptoms.

FIGURE 1.

Cervical spine magnetic resonance imaging (A) before decompressive surgery, (B) 9 months post‐surgery, and (C) 4 years post‐surgery. For each panel, the top shows the T2‐weighted sagittal view, middle the T1‐weighted fat‐saturated contrast‐enhanced sagittal view, and bottom the T1‐weighted fat‐saturated contrast‐enhanced axial view.

MRI carried out at 9 months post‐surgery showed persistent cord signal change and enhancement (Fig 1B), prompting referral to the neuroimmunology clinic for opinion. Brain MRI was normal. Examination showed upper motor neuron signs of spasticity of the lower and upper limbs, brisk reflexes, and upgoing plantar responses. A diagnosis of spondylotic myelopathy with pancake‐like enhancement was made. The patient received symptomatic and supportive treatment, and serial monitoring and MRI surveillance.

At 4 years post‐decompression, the patient remained clinically stable, with MRI showing near‐complete resolution of enhancement with focal atrophy and mild T2 hyperintensity in keeping with myelomalacia (Fig 1C).

Cervical spondylosis is a common cause for myelopathy. ¹ , ² In patients with features suspicious for a progressive myelopathy, spinal MRI without contrast administration is often the first investigation. When contrast is administered, a pattern of “pancake‐like” enhancement may be seen in patients with spondylotic compressive myelopathy. ³ This pattern of enhancement is characterized by a transverse band of enhancement at or just below the level of maximal stenosis, and with involvement of white matter and sparing of the gray matter.

In patients with progressive myelopathy and spondylotic canal stenosis with T2 cord signal change, pancake‐like enhancement is an imaging finding strongly indicative for spondylotic compressive myelopathy. ³ , ⁴ However, its association with spondylotic compressive myelopathy is likely underrecognized. Its misrecognition for an inflammatory or neoplastic etiology may lead to unnecessary and sometimes invasive investigations (such as spinal cord biopsy), delays in management with decompressive surgery, or inappropriate immunosuppression.

Enhancement can persist for years after decompression, as was the case in the present patient, and does not necessarily indicate an alternative etiology. The present case is unique in illustrating the progress and imaging of our patient over longitudinal follow up to 4 years post‐surgery, which is longer than other reports with pancake‐like enhancement. Recognition of this imaging sign assists in prompt diagnosis of spondylotic compressive myelopathy and its appropriate management.

Author Contributions

W.Z.Y. contributed to conception of the report, data analysis, drafting the text, and preparing the figure. S.L. contributed to data analysis and critical revision of the text.

Potential Conflicts of Interest

Nothing to report.

Data Availability

Not applicable.