Acute Myelopathy Evaluation

VERSION: 1.0 CREATED: January 27, 2026 STATUS: Approved

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DIAGNOSIS: Acute Myelopathy Evaluation

ICD-10: G95.9 (Disease of spinal cord, unspecified), G95.89 (Other specified diseases of spinal cord), G37.3 (Acute transverse myelitis in demyelinating disease), G04.91 (Myelitis, unspecified)

CPT CODES: 85025 (CBC with differential), 80053 (CMP (BMP + LFTs)), 85652 (ESR), 86140 (CRP), 87040 (Blood cultures x2), 82947 (Blood glucose), 81003 (Urinalysis), 86900 (Type and screen), 84145 (Procalcitonin), 86255 (AQP4-IgG (aquaporin-4 antibody, serum) — cell-based assay), 82607 (B12, methylmalonic acid), 82390 (Copper and ceruloplasmin), 87389 (HIV 1/2 antigen/antibody), 86592 (RPR/VDRL), 86235 (Anti-SSA (Ro), anti-SSB (La)), 82164 (ACE level (serum)), 86334 (Serum protein electrophoresis (SPEP)), 70553 (MRI brain with and without contrast), 71046 (Chest X-ray), 78816 (PET-CT (whole body)), 95925 (Somatosensory evoked potentials (SSEPs)), 62270 (LUMBAR PUNCTURE), 89051 (Cell count with differential (tubes 1 and 4)), 84157 (Protein), 82945 (Glucose with paired serum), 83916 (Oligoclonal bands (paired with serum)), 86327 (IgG index), 88104 (Cytology), 96365 (IV methylprednisolone (empiric — inflammatory myelitis)), 36514 (Plasma exchange (PLEX))

SYNONYMS: Acute myelopathy, transverse myelitis, TM, spinal cord inflammation, myelitis, NMOSD myelitis, spinal cord lesion, spinal cord syndrome, cord compression, spinal cord injury

SCOPE: Acute or subacute spinal cord dysfunction — broad differential approach. Covers urgent MRI, LP, and comprehensive workup to differentiate compressive (epidural abscess, tumor, disc herniation, hematoma) from non-compressive causes (inflammatory/demyelinating, vascular, infectious). Compressive myelopathy is a surgical emergency. Excludes chronic cervical spondylotic myelopathy, cauda equina syndrome (separate template), and isolated radiculopathy.

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PRIORITY KEY: STAT = Immediate | URGENT = Within hours | ROUTINE = Standard | EXT = Extended/atypical cases | - = Not applicable to this setting

═══════════════════════════════════════════════════════════════ SECTION A: ACTION ITEMS ═══════════════════════════════════════════════════════════════

1. LABORATORY WORKUP

1A. Essential/Core Labs

Test	ED	HOSP	OPD	ICU	Rationale	Target Finding
CBC with differential (CPT 85025)	STAT	STAT	ROUTINE	STAT	Infection screen (epidural abscess); baseline; leukocytosis	Normal
CMP (BMP + LFTs) (CPT 80053)	STAT	STAT	ROUTINE	STAT	Renal/hepatic function for contrast and medication dosing; electrolytes	Normal
ESR (CPT 85652)	STAT	STAT	ROUTINE	STAT	Markedly elevated in epidural abscess (>20 in ~95%); elevated in inflammatory/autoimmune	Normal; >20 raises concern for abscess/infection
CRP (CPT 86140)	STAT	STAT	ROUTINE	STAT	Elevated in infection, inflammation; useful for monitoring treatment response	Normal
Blood cultures x2 (CPT 87040)	STAT	STAT	-	STAT	If epidural abscess or infection suspected; S. aureus most common	No growth
PT/INR, aPTT (CPT 85610, 85730)	STAT	STAT	-	STAT	Coagulopathy causing epidural hematoma; pre-LP; pre-surgical assessment	Normal
Blood glucose (CPT 82947)	STAT	STAT	ROUTINE	STAT	Diabetic risk factor for epidural abscess; baseline	Normal
Urinalysis (CPT 81003)	STAT	ROUTINE	ROUTINE	STAT	UTI as source for epidural abscess; baseline bladder function	Normal
Type and screen (CPT 86900)	STAT	ROUTINE	-	STAT	Potential surgical intervention	On file
Procalcitonin (CPT 84145)	URGENT	ROUTINE	-	URGENT	Bacterial infection differentiation	<0.5 ng/mL

1B. Extended Workup (Second-line)

Test	ED	HOSP	OPD	ICU	Rationale	Target Finding
AQP4-IgG (aquaporin-4 antibody, serum) — cell-based assay (CPT 86255)	-	STAT	ROUTINE	STAT	NMOSD — longitudinally extensive transverse myelitis (≥3 segments); affects treatment (avoid interferon-beta, fingolimod)	Negative (positive = NMOSD)
MOG-IgG antibody (serum) — cell-based assay (CPT 86255)	-	STAT	ROUTINE	STAT	MOGAD — often presents as myelitis; treatment implications differ from MS and NMOSD	Negative (positive = MOGAD)
B12, methylmalonic acid (CPT 82607)	-	ROUTINE	ROUTINE	-	Subacute combined degeneration (posterior columns + corticospinal tracts)	Normal
Copper and ceruloplasmin (CPT 82390)	-	ROUTINE	ROUTINE	-	Copper deficiency myelopathy (mimics B12 deficiency pattern)	Normal
Zinc level	-	ROUTINE	ROUTINE	-	Zinc excess causes copper deficiency	Normal
HIV 1/2 antigen/antibody (CPT 87389)	-	ROUTINE	ROUTINE	-	HIV-associated vacuolar myelopathy; opportunistic infections	Negative
HTLV-1/2 antibody	-	ROUTINE	ROUTINE	-	HTLV-associated myelopathy/tropical spastic paraparesis (HAM/TSP)	Negative
RPR/VDRL (CPT 86592)	-	ROUTINE	ROUTINE	-	Syphilitic myelitis (tabes dorsalis = posterior columns)	Non-reactive
ANA, dsDNA (CPT 86235, 86225)	-	ROUTINE	ROUTINE	-	Lupus myelitis	Negative
Anti-SSA (Ro), anti-SSB (La) (CPT 86235)	-	ROUTINE	ROUTINE	-	Sjögren syndrome myelitis	Negative
ACE level (serum) (CPT 82164)	-	ROUTINE	ROUTINE	-	Neurosarcoidosis (spinal cord granulomas)	Normal
QuantiFERON-TB Gold	-	ROUTINE	ROUTINE	-	Spinal TB (Pott disease, TB myelitis)	Negative
Anti-thyroid antibodies (TPO, thyroglobulin)	-	ROUTINE	ROUTINE	-	Hashimoto encephalopathy/myelopathy	Negative

1C. Rare/Specialized (Refractory or Atypical)

Test	ED	HOSP	OPD	ICU	Rationale	Target Finding
Paraneoplastic panel (serum) — ANNA-1, CRMP-5, amphiphysin	-	ROUTINE	ROUTINE	-	Paraneoplastic myelitis (lung, breast, lymphoma); amphiphysin is classic for stiff-person / paraneoplastic myelopathy	Negative
Anti-GFAP antibody (serum and CSF)	-	EXT	EXT	-	GFAP astrocytopathy — autoimmune meningoencephalomyelitis	Negative
Antiphospholipid antibodies (lupus anticoagulant, anticardiolipin, β2-glycoprotein I)	-	ROUTINE	ROUTINE	-	Spinal cord infarction from hypercoagulable state	Negative
Serum protein electrophoresis (SPEP) (CPT 86334)	-	ROUTINE	ROUTINE	-	Multiple myeloma (spinal cord compression from plasmacytoma); POEMS	Normal
Lyme antibody (ELISA, Western blot)	-	ROUTINE	ROUTINE	-	Lyme myelitis (endemic areas)	Negative
CMV PCR (blood)	-	EXT	-	EXT	CMV myelitis (immunocompromised)	Negative
VZV IgM, VZV PCR (blood)	-	EXT	-	EXT	VZV myelitis (may follow shingles)	Negative
Sickle cell screen	-	EXT	EXT	-	Spinal cord infarction in sickle cell disease	Normal

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2. DIAGNOSTIC IMAGING & STUDIES

2A. Essential/First-line

Study	ED	HOSP	OPD	ICU	Timing	Target Finding	Contraindications
MRI entire spine (cervical, thoracic, lumbar) with and without gadolinium contrast (CPT 72156+72157+72158)	STAT	STAT	URGENT	STAT	IMMEDIATELY — within 4 hours of presentation maximum; faster if progressive deficit. Entire spine because multifocal lesions change differential (NMOSD, metastatic)	Compressive: epidural mass (abscess, tumor, hematoma), disc herniation. Non-compressive: cord signal change (T2 hyperintensity), enhancement pattern, longitudinal extent, location within cord cross-section	GFR <30 (give contrast anyway if emergent); gadolinium allergy (premedicate); pacemaker
MRI brain with and without contrast (CPT 70553)	URGENT	URGENT	ROUTINE	URGENT	Within 24h (same session if possible)	MS (periventricular/juxtacortical lesions), NMOSD (area postrema, hypothalamic), ADEM (multifocal white matter), metastatic disease, leptomeningeal enhancement	Same as spine MRI
CT spine (without contrast)	STAT	STAT	-	STAT	ONLY if MRI unavailable or contraindicated; far less sensitive for cord pathology	Fracture, bony compression, large epidural mass, disc herniation	Pregnancy (relative)
Chest X-ray (CPT 71046)	URGENT	ROUTINE	-	URGENT	Baseline; lung malignancy screening (metastatic cord compression); sarcoidosis (hilar adenopathy)	Normal

CRITICAL: If MRI shows compressive myelopathy → NEUROSURGERY STAT. Do not delay for additional workup.

2B. Extended

Study	ED	HOSP	OPD	ICU	Timing	Target Finding	Contraindications
CT chest/abdomen/pelvis with contrast (CPT 71260, 74178)	-	ROUTINE	ROUTINE	-	If metastatic cord compression or sarcoidosis suspected	Primary malignancy; lymphadenopathy	Contrast allergy, renal impairment
CT angiography (CTA) of aorta	-	URGENT	-	URGENT	If spinal cord infarction suspected (especially post-aortic surgery)	Aortic dissection, aortic aneurysm, occlusion of artery of Adamkiewicz	Same as CT contrast
MR angiography (MRA) of spinal vessels	-	EXT	EXT	-	Spinal dural arteriovenous fistula (dAVF); spinal AVM	Abnormal vascular flow voids; fistula identification	Same as MRI
Conventional spinal angiography (DSA)	-	EXT	EXT	-	Gold standard for spinal dAVF/AVM; if MRA suggestive	Fistula or AVM identification and localization for treatment	Contrast allergy; coagulopathy
PET-CT (whole body) (CPT 78816)	-	EXT	ROUTINE	-	Occult malignancy search	Primary tumor	Pregnancy; uncontrolled diabetes
Repeat MRI spine	-	ROUTINE	ROUTINE	-	At 2-4 weeks for treatment response; earlier if clinical worsening	Improving signal; resolving enhancement	Same as initial
NCS/EMG (CPT 95907-95913, 95886)	-	ROUTINE	ROUTINE	-	If concomitant peripheral neuropathy suspected (e.g., GBS mimicking myelopathy)	Peripheral nerve involvement vs pure cord	None significant

2C. Rare/Specialized

Study	ED	HOSP	OPD	ICU	Timing	Target Finding	Contraindications
Somatosensory evoked potentials (SSEPs) (CPT 95925)	-	ROUTINE	ROUTINE	-	Assess dorsal column function; prognosis	Delayed or absent cortical potentials	None
Motor evoked potentials (MEPs)	-	EXT	EXT	-	Corticospinal tract assessment	Delayed or absent	Epilepsy (relative); implanted devices
Spinal cord biopsy	-	-	EXT	-	Extremely rare; only for diagnostic uncertainty when all other testing inconclusive and progressive decline	Tumor, vasculitis, infection, sarcoidosis	High morbidity; neurosurgical decision

LUMBAR PUNCTURE (CPT 62270)

Indication: ALL non-compressive myelopathies require LP. Perform AFTER MRI (need to exclude compressive cause and epidural abscess — LP through an abscess risks seeding meningitis).

Timing: URGENT — after MRI confirms non-compressive etiology.

Volume Required: 20-25 mL (many studies needed)

Study	ED	HOSP	OPD	Rationale	Target Finding
Opening pressure	URGENT	ROUTINE	ROUTINE	Elevated in some inflammatory conditions	Normal (10-20 cm H2O)
Cell count with differential (tubes 1 and 4) (CPT 89051)	URGENT	ROUTINE	ROUTINE	Pleocytosis: infection, inflammation. MS: mild. NMOSD: moderate with neutrophils. Infection: marked	Variable by etiology
Protein (CPT 84157)	URGENT	ROUTINE	ROUTINE	Elevated in GBS, infection, NMOSD, cord compression	Variable
Glucose with paired serum (CPT 82945)	URGENT	ROUTINE	ROUTINE	Low in TB, bacterial, fungal, leptomeningeal malignancy	Normal in most inflammatory causes
Oligoclonal bands (paired with serum) (CPT 83916)	-	ROUTINE	ROUTINE	Positive in MS (>90%); may be positive in NMOSD, sarcoidosis	Positive bands in CSF only = intrathecal synthesis (MS)
IgG index (CPT 86327)	-	ROUTINE	ROUTINE	Elevated in MS and other inflammatory conditions	Normal <0.7
AQP4-IgG (CSF)	-	ROUTINE	ROUTINE	NMOSD confirmation (serum is more sensitive; CSF adds specificity)	Negative
MOG-IgG (CSF)	-	ROUTINE	ROUTINE	MOGAD confirmation	Negative
Autoimmune encephalitis panel (CSF)	-	ROUTINE	ROUTINE	GFAP, NMDAR (rare spinal involvement)	Negative
Cytology (CPT 88104)	-	ROUTINE	ROUTINE	Leptomeningeal carcinomatosis, lymphoma	Negative
Flow cytometry	-	ROUTINE	ROUTINE	CNS lymphoma	Normal
VDRL (CSF)	-	ROUTINE	ROUTINE	Neurosyphilis	Non-reactive
ACE level (CSF)	-	ROUTINE	ROUTINE	Neurosarcoidosis	Normal
HSV 1/2 PCR	-	ROUTINE	ROUTINE	HSV myelitis (rare)	Negative
VZV PCR	-	ROUTINE	ROUTINE	VZV myelitis (may follow shingles)	Negative
CMV PCR	-	ROUTINE	ROUTINE	CMV myelitis (immunocompromised)	Negative
EBV PCR	-	ROUTINE	ROUTINE	EBV-associated lymphoma/myelitis	Negative
HTLV-1 antibody (CSF)	-	ROUTINE	ROUTINE	HAM/TSP confirmation	Negative
AFB smear and culture	-	ROUTINE	ROUTINE	Spinal TB	Negative
Bacterial culture	-	ROUTINE	ROUTINE	Bacterial myelitis (rare)	No growth
Cryptococcal antigen	-	ROUTINE	ROUTINE	Cryptococcal myelitis (immunocompromised)	Negative

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3. TREATMENT

3A. Acute/Emergent

Treatment	Route	Indication	Dosing	Contraindications	Monitoring	ED	HOSP	OPD	ICU
IV methylprednisolone (empiric — inflammatory myelitis) (CPT 96365)	IV	-	1000 mg :: IV :: daily :: 1000 mg IV daily x 3-5 days (infuse over 1-2h). Start empirically if inflammatory myelitis suspected (non-compressive cord lesion on MRI). Do NOT wait for antibody results	Active untreated infection (relative — treat infection concurrently if needed); uncontrolled diabetes	Glucose q6h; BP; GI prophylaxis (PPI); insomnia; psychosis (rare); weight; taper plan	-	STAT	-	STAT
Emergent surgical decompression	-	-	N/A :: - :: once :: For compressive myelopathy: epidural abscess, tumor with cord compression, acute disc herniation with myelopathy, epidural hematoma. Earlier decompression = better neurologic outcome. Within 24h is critical; within 12h is ideal	Medically unstable for surgery (optimize first)	Post-op neurologic exam; wound care; DVT prophylaxis	STAT	STAT	-	STAT
Empiric IV antibiotics (if epidural abscess suspected)	IV	-	15-20 mg/kg :: IV :: q12h :: Vancomycin 15-20 mg/kg IV q8-12h + ceftriaxone 2g IV q12h (or cefepime 2g IV q8h). Start BEFORE surgery. S. aureus is most common organism	See individual agents	Cultures; vancomycin trough; renal function	STAT	STAT	-	STAT
DVT prophylaxis: Enoxaparin	SC	-	40 mg :: SC :: daily :: 40 mg SC daily (start post-operatively or when not bleeding; within 24-48h)	Active bleeding; post-surgical (timing per surgeon); coagulopathy	Platelets q3 days	-	ROUTINE	-	ROUTINE
Pneumatic compression devices	-	-	N/A :: - :: continuous :: Apply bilaterally immediately — spinal cord injury patients are HIGH risk for DVT/PE	Acute DVT	Skin checks	STAT	STAT	-	STAT
Bladder management	-	-	200 mL :: - :: - :: Foley catheter if urinary retention (very common in myelopathy); measure post-void residual if not catheterized; intermittent catheterization if PVR >200 mL	N/A	I/O; bladder scan; transition to intermittent cath when possible	STAT	STAT	-	STAT
Bowel management	-	-	N/A :: - :: per protocol :: Bowel program: docusate + senna; digital stimulation if neurogenic bowel; avoid impaction	Bowel obstruction	Bowel function daily	-	ROUTINE	-	ROUTINE

3B. Second-line / Specific Treatments

Treatment	Route	Indication	Dosing	Contraindications	Monitoring	ED	HOSP	OPD	ICU
Plasma exchange (PLEX) (CPT 36514)	-	Steroid-refractory inflammatory myelitis; NMOSD exacerbation; severe transverse myelitis	N/A :: - :: once :: 5-7 exchanges over 10-14 days (every other day); 1-1.5 plasma volumes per exchange	Hemodynamic instability; sepsis	BP; electrolytes; Ca2+; fibrinogen	-	URGENT	-	URGENT
IVIG (CPT 96365)	-	Alternative to PLEX if PLEX unavailable; MOGAD (may be preferred); steroid-refractory	0.4 g/kg :: - :: daily x 5 days :: 0.4 g/kg/day x 5 days (total 2 g/kg)	IgA deficiency; renal failure	Renal function; headache; thrombosis	-	URGENT	-	URGENT
Oral prednisone taper (after IV pulse)	IV	Inflammatory myelitis; NMOSD	1 mg/kg :: PO :: - :: 1 mg/kg/day (max 60-80 mg) tapered over 4-8 weeks for first episode; longer taper for NMOSD/MOGAD	See steroid contraindications	Glucose; BP; bone health	-	ROUTINE	ROUTINE	-
Gabapentin	PO	Neuropathic pain, spasticity	300 mg :: PO :: qHS :: 300 mg PO qHS → titrate to 900-1800 mg TID	Severe renal impairment	Sedation; dizziness	-	ROUTINE	ROUTINE	ROUTINE
Baclofen	PO	Spasticity	5 mg :: PO :: TID :: 5 mg PO TID; increase by 5 mg/dose q3 days; max 80 mg/day	Seizure history (lowers threshold); abrupt withdrawal causes seizures	Sedation; falls; do NOT stop abruptly	-	ROUTINE	ROUTINE	-
Tizanidine	PO	Spasticity (alternative)	2 mg :: PO :: TID :: 2 mg PO TID; max 36 mg/day	Hepatic impairment; concurrent CYP1A2 inhibitors (ciprofloxacin)	LFTs; sedation; hypotension	-	ROUTINE	ROUTINE	-
Oxybutynin	PO	Neurogenic bladder (overactive)	5 mg :: PO :: BID :: 5 mg PO BID-TID	Urinary retention; angle-closure glaucoma	Anticholinergic side effects; PVR	-	ROUTINE	ROUTINE	-
Acetaminophen	PO	Pain	650-1000 mg :: PO :: q6h :: 650-1000 mg PO q6h; max 4g/day	Hepatic disease	LFTs	STAT	ROUTINE	ROUTINE	STAT

3C. Disease-Modifying Therapy (Once Diagnosis Established)

Treatment	Route	Indication	Dosing	Pre-Treatment Requirements	Contraindications	Monitoring	ED	HOSP	OPD	ICU
MS disease-modifying therapy	-	-	N/A :: - :: per protocol :: Per MS-specific template; high-efficacy preferred if myelitis presentation	-	-	Per agent	-	-	-	-
Rituximab	PO	-	375 mg/m2 :: PO :: - :: 375 mg/m2 weekly x 4 weeks OR 1000 mg x 2 (14 days apart); maintenance q6 months	-	-	CD19/20; immunoglobulins; infection	-	-	-	-
Eculizumab	IV	-	900 mg :: IV :: - :: 900 mg IV weekly x 4 → 1200 mg q2 weeks	-	-	Meningococcal vaccination (≥2 weeks before); complement levels; infection	-	-	-	-
Inebilizumab	IV	-	300 mg :: IV :: - :: 300 mg IV x 2 (14 days apart); then 300 mg q6 months	-	-	CD19; infection	-	-	-	-
Satralizumab	SC	-	120 mg :: SC :: - :: 120 mg SC at weeks 0, 2, 4, then q4 weeks	-	-	LFTs; infection	-	-	-	-
Azathioprine	PO	-	2-3 mg/kg :: PO :: - :: 2-3 mg/kg/day PO	-	-	TPMT genotype; CBC weekly x 4, then biweekly, then monthly; LFTs	-	-	-	-
Mycophenolate mofetil	PO	-	1000-1500 mg :: PO :: BID :: 1000-1500 mg PO BID	-	-	CBC; LFTs; pregnancy test (teratogenic)	-	-	-	-
Anti-TB therapy	-	-	N/A :: - :: per protocol :: RIPE x 12-18 months	-	-	LFTs; visual acuity	-	-	-	-
IV penicillin G	IV	-	18-24 million units :: IV :: daily :: 18-24 MU/day IV x 14 days	-	-	RPR q3-6 months	-	-	-	-
Radiation + surgery + steroids	IV	-	10 mg :: IV :: q6h :: Per oncology; dexamethasone 10 mg IV load → 4 mg IV q6h while radiation planned	-	-	Glucose; GI prophylaxis	-	-	-	-

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4. OTHER RECOMMENDATIONS

4A. Referrals & Consults

Recommendation	ED	HOSP	OPD	ICU	Indication
Neurology (neuro-immunology if available)	STAT	STAT	STAT	STAT	All myelopathy; diagnostic workup direction; immunotherapy decisions
Neurosurgery	STAT	STAT	-	STAT	Compressive myelopathy (abscess, tumor, hematoma, disc); surgical timing critical
Spine surgery (orthopedic)	STAT	STAT	-	STAT	Alternative for compressive causes where neurosurgery unavailable
Radiation oncology	-	URGENT	-	-	Metastatic cord compression; radiation planning
Oncology	-	ROUTINE	ROUTINE	-	Newly diagnosed malignancy; systemic treatment
Infectious disease	-	ROUTINE	ROUTINE	-	Epidural abscess management; TB; HIV; unusual infections
Urology	-	ROUTINE	ROUTINE	-	Neurogenic bladder management; intermittent catheterization training; urodynamics
Physical therapy (PT)	-	STAT	ROUTINE	URGENT	Mobility assessment; strengthening; gait training; transfer training; wheelchair assessment
Occupational therapy (OT)	-	STAT	ROUTINE	URGENT	ADL assessment; hand function; adaptive equipment; home modifications
Rehabilitation medicine (physiatry)	-	ROUTINE	ROUTINE	-	Rehabilitation planning; SCI rehabilitation protocols; disposition
Speech-language pathology	-	ROUTINE	ROUTINE	-	If cervical myelopathy affecting swallowing
Respiratory therapy	-	URGENT	-	STAT	If cervical myelopathy affecting respiratory muscles; FVC monitoring
Social work	-	ROUTINE	ROUTINE	-	Discharge planning; DME; caregiver support; disability
Psychology	-	ROUTINE	ROUTINE	-	Adjustment disorder; depression; coping with disability
Pain management	-	ROUTINE	ROUTINE	-	Neuropathic pain refractory to standard agents
Wound care (if pressure injury)	-	ROUTINE	ROUTINE	ROUTINE	Immobile patients at high risk for pressure ulcers

4B. Patient Instructions

Recommendation	ED	HOSP	OPD
Return to ED immediately if: new weakness, worsening numbness, loss of bowel/bladder function, inability to walk, difficulty breathing	STAT	STAT	ROUTINE
Spinal cord injury can improve with treatment — recovery varies by cause (inflammatory often recovers well; vascular and compressive recovery depends on timing)	-	ROUTINE	ROUTINE
Bladder management is critical: perform intermittent catheterization as instructed; report urinary retention or incontinence	-	ROUTINE	ROUTINE
Bowel program compliance: maintain regular schedule; adequate fiber and fluids	-	ROUTINE	ROUTINE
Skin checks daily: pressure injury prevention (reposition every 2h if immobile; use pressure-relieving mattress)	-	ROUTINE	ROUTINE
Physical therapy exercises between sessions as instructed	-	ROUTINE	ROUTINE
Do NOT drive until cleared by neurology	-	ROUTINE	ROUTINE
Follow-up with neurology in 1-2 weeks; repeat MRI at 2-4 weeks	-	ROUTINE	ROUTINE

4C. Lifestyle & Prevention

Recommendation	ED	HOSP	OPD
Pressure injury prevention (positioning, specialized mattress, skin checks)	-	ROUTINE	ROUTINE
Fall prevention (assistive devices, home modifications)	-	ROUTINE	ROUTINE
DVT prevention (compression stockings long-term; anticoagulation per protocol)	-	ROUTINE	ROUTINE
Autonomic dysreflexia awareness (if thoracic/cervical injury: sudden hypertension, headache, flushing above level — emergency)	-	ROUTINE	ROUTINE
Bladder health (adequate fluid intake; catheterization technique; UTI prevention)	-	ROUTINE	ROUTINE
Mental health support (spinal cord injury carries high depression/anxiety rates)	-	ROUTINE	ROUTINE
Vaccination (if starting immunosuppression: complete vaccines before rituximab/eculizumab)	-	ROUTINE	ROUTINE
Smoking cessation	-	ROUTINE	ROUTINE

═══════════════════════════════════════════════════════════════ SECTION B: REFERENCE (Expand as Needed) ═══════════════════════════════════════════════════════════════

5. DIFFERENTIAL DIAGNOSIS

Alternative Diagnosis	Key Distinguishing Features	Tests to Differentiate
Epidural abscess	Back pain + fever + neurologic deficit (triad in 10-15%); IVDU, diabetes, spinal procedure risk factors; ESR/CRP very elevated	MRI with contrast (ring-enhancing epidural collection); blood cultures; ESR >20
Metastatic cord compression	Known malignancy; progressive back pain (often worse at night); bony destruction	MRI (enhancing epidural mass with bony changes); CT body for primary; PET-CT
Disc herniation (acute)	Sudden onset; radiculopathy predominant initially; may progress to myelopathy	MRI (disc protrusion with cord compression)
Epidural hematoma	Anticoagulation; post-procedure; coagulopathy; sudden onset	MRI (epidural collection; T1 signal depends on age of blood); coagulation panel
Transverse myelitis (idiopathic)	Non-compressive; T2 cord signal change; may be partial or complete; often thoracic	MRI (T2 hyperintensity <3 segments); LP (pleocytosis); diagnose after excluding MS, NMOSD, MOGAD
MS (spinal cord relapse)	Partial myelitis (<3 segments); brain lesions present; prior episodes; young adult	MRI brain (periventricular/juxtacortical lesions); oligoclonal bands; short segment cord lesion
NMOSD	Longitudinally extensive transverse myelitis (LETM ≥3 segments); severe; often central cord/gray matter	AQP4-IgG antibody; MRI (LETM, central cord pattern); brain MRI (area postrema lesion)
MOGAD	LETM possible; conus/lower cord predilection; may have bilateral optic neuritis	MOG-IgG antibody; MRI pattern; generally better recovery than NMOSD
Spinal cord infarction	Hyperacute onset (minutes); anterior spinal artery syndrome (motor + pain/temperature loss, preserved proprioception/vibration); often thoracolumbar	MRI DWI (restricted diffusion, "owl eye" or pencil-like on axial); CTA aorta; vascular risk factors
Spinal dural AV fistula	Older male; progressive myelopathy with flow voids on MRI; dorsal cord; edema disproportionate to enhancement	MRI (flow voids, dorsal cord edema, enhancement); spinal angiography (gold standard)
GBS (axonal variant)	Ascending weakness; areflexia; may mimic acute myelopathy if rapidly progressive; CSF albuminocytologic dissociation	NCS/EMG; LP (elevated protein, normal cells); no cord signal on MRI
Neurosarcoidosis	Dorsal subpial enhancement; trident sign; may have pulmonary sarcoidosis	Chest CT; ACE level; biopsy; characteristic MRI pattern
Spinal TB (Pott disease)	Endemic area; systemic TB; vertebral body destruction with epidural abscess; gibbus deformity	MRI; AFB culture; TB PCR; QuantiFERON; chest X-ray
Neuromyelitis optica spectrum disorder — See NMOSD above
Syphilitic myelitis (tabes dorsalis)	Posterior column dysfunction (proprioception, vibration loss); lightning pains; Argyll Robertson pupils	CSF VDRL; RPR; FTA-ABS
Copper deficiency myelopathy	Posterior column + corticospinal tract (mimics B12 deficiency); gastric surgery, zinc excess	Serum copper and ceruloplasmin; zinc level
Radiation myelopathy	History of radiation; months to years after treatment; progressive; no enhancement (chronic)	Radiation history; MRI (cord atrophy, signal change within radiation field)
Functional neurological disorder	Non-anatomic sensory loss; Hoover sign; give-way weakness; normal MRI	Normal MRI; normal LP; clinical exam findings

6. MONITORING PARAMETERS

Parameter	ED	HOSP	OPD	ICU	Frequency	Target/Threshold	Action if Abnormal
Neurologic exam (strength, sensory level, reflexes, rectal tone)	STAT	STAT	ROUTINE	STAT	q4h x 48h, then q8h; sensory level marking on skin for tracking	Stable or improving; sensory level not ascending	If ascending level or worsening motor: STAT repeat MRI; neurosurgery if compressive
Bladder function (PVR, I/O)	STAT	STAT	ROUTINE	STAT	PVR with each void initially; I/O daily	PVR <200 mL; adequate output	If PVR >200: intermittent catheterization; Foley if >500 or unable to cath
Respiratory function (FVC, NIF) — cervical myelopathy	STAT	STAT	-	STAT	q4-6h if cervical; q2h if declining	FVC >20 mL/kg	If FVC <20: ICU; prepare for intubation
Blood pressure / autonomic function	STAT	STAT	-	STAT	q4h; orthostatic vitals when mobilizing	Stable BP; no orthostatic hypotension >20 mmHg	Volume; midodrine; compression stockings; if hypertensive crisis above level → autonomic dysreflexia → find and remove stimulus (distended bladder, bowel impaction)
Temperature	STAT	STAT	-	STAT	q4h	Afebrile	If febrile: infection workup; wound check; UTI screen
Skin assessment (pressure areas)	-	ROUTINE	ROUTINE	ROUTINE	q shift; at every reposition	Intact skin; no erythema >30 min	Pressure relief; wound care; specialty mattress
ESR / CRP (if infection)	-	ROUTINE	ROUTINE	-	q48-72h during treatment	Declining trend	If not improving: reassess antibiotic coverage; repeat imaging
Post-void residual (PVR)	-	ROUTINE	ROUTINE	-	With each void initially; daily once stable	<200 mL	Intermittent catheterization protocol
MRI response	-	ROUTINE	ROUTINE	-	At 2-4 weeks; 3-6 months; or sooner if worsening	Improving signal and enhancement	Adjust treatment; consider PLEX/escalation
AQP4/MOG antibody titers (if positive)	-	-	ROUTINE	-	At 3-6 months, then annually	Declining or stable	If rising with clinical worsening: relapse; adjust DMT

7. DISPOSITION CRITERIA

Disposition	Criteria
Discharge home	Mild myelopathy; stable or improving; ambulatory; independent bladder function; adequate outpatient follow-up; MRI and workup complete or schedulable outpatient
Admit to floor	Non-compressive myelopathy requiring IV steroids; moderate deficits; bladder dysfunction requiring catheterization; incomplete workup
Admit to ICU	Cervical myelopathy with respiratory compromise; post-surgical; ascending myelopathy; autonomic instability
Emergent surgery	Compressive myelopathy: epidural abscess, acute cord compression from tumor/hematoma/disc with neurologic deficit
Transfer to higher level	Need for neurosurgery not available; need for PLEX; MRI not available STAT; spinal cord injury center
Inpatient rehabilitation (SCI rehab)	Significant motor deficits; paraparesis/paraplegia; wheelchair-dependent; bladder/bowel dysfunction; able to participate in 3h/day therapy
Skilled nursing facility	Unable to tolerate intensive rehab; requires skilled nursing; ongoing IV antibiotics

8. EVIDENCE & REFERENCES

Recommendation	Evidence Level	Source
STAT MRI entire spine for acute myelopathy	Class I, Level B	AAN Practice Guideline; Transverse Myelitis Consortium Working Group (2002)
IV methylprednisolone 1g/day x 3-5 days for inflammatory myelitis	Class I, Level B	Consensus; extrapolated from MS relapse data (ONTT) and TM studies
PLEX for steroid-refractory inflammatory myelitis	Class IIa, Level B	Weinshenker et al. (Ann Neurol 1999); superior to sham in severe demyelinating attacks
AQP4-IgG (cell-based assay) for NMOSD diagnosis	Class I, Level A	Wingerchuk et al. IPND 2015 criteria
MOG-IgG for MOGAD diagnosis	Class I, Level B	Banwell et al. (Lancet Neurol 2023)
Surgical decompression within 24h for compressive myelopathy	Class I, Level B	Fehlings et al. (2012); earlier surgery = better outcomes
Epidural abscess: antibiotics + surgical drainage	Class I, Level B	Darouiche et al. (NEJM 2006)
B12 replacement for subacute combined degeneration	Class I, Level A	Well-established; early treatment may be reversible
Rituximab for NMOSD prevention	Class I, Level A	Multiple trials; standard of care
Eculizumab for NMOSD prevention	Class I, Level A	PREVENT trial (Pittock et al. NEJM 2019)
AQP4-IgG-positive NMOSD: avoid interferon-beta and fingolimod	Class III (Harm)	Case reports of worsening
LP after MRI (not before) in acute myelopathy	Class I, Level C	Risk of seeding infection through abscess; need anatomic diagnosis first
Bladder management with intermittent catheterization	Class I, Level B	Spinal cord injury guidelines; prevents UTI better than indwelling catheter
DVT prophylaxis in acute myelopathy	Class I, Level A	High thrombotic risk in immobilized SCI patients

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APPENDIX: MRI PATTERN RECOGNITION IN MYELOPATHY

Pattern	Diagnosis Suggested
Short segment (<3 vertebral segments), eccentric/dorsolateral	MS
Longitudinally extensive (≥3 segments), central cord/gray matter	NMOSD
Longitudinally extensive, conus/lower cord	MOGAD
Anterior cord (gray matter "owl eyes" on axial)	Spinal cord infarction
Dorsal cord, flow voids, extensive edema	Dural AV fistula
Ring-enhancing epidural collection	Epidural abscess
Enhancing epidural mass with bony destruction	Metastatic tumor
Posterior columns bilateral	B12 deficiency, copper deficiency, syphilis (tabes)
Dorsal subpial enhancement, "trident sign"	Neurosarcoidosis
Central cord, bright/enhancing, expansile	Cord tumor (astrocytoma, ependymoma)

APPENDIX: ANTERIOR SPINAL ARTERY SYNDROME (Spinal Cord Infarction)

Affected	Preserved
Motor function (corticospinal tracts)	Proprioception (dorsal columns)
Pain/temperature sensation (spinothalamic tracts)	Vibration sense (dorsal columns)
Bladder/bowel function (autonomic)	Light touch (partial — dorsal columns)

Classic pattern: bilateral motor weakness + bilateral pain/temperature loss BELOW level + PRESERVED proprioception/vibration