Spinal cord involvement in patients with cirrhosis

Table 1 Differential diagnosis

Brain pathology

Demyelinating processes

Hydrocephalus

Parasagittal space-occupying lesion

Arnold-Chiari malformation

Other structural abnormalities at craniocervical junction

Spinal cord pathology

Compressive myelopathy: spondylogenic cervical > thoracical myelopathy

Vascular myelopathy: spinal cord infarction, bleeding, vasculitis

Spinal cord injuries

Genetic disorders: Hereditary spastic paraparesis, adrenoleukodystrophy (spinal forms), Freidrich's ataxia

Metabolic/Nutritional: Subacute combined sclerosis (vitamin B12 deficiency), vitamin E deficiency, copper deficiency, latyrism

Toxic myelopathy: Chemotherapy, Radiation

Neoplasms: Extramedullary or intramedullary tumors, metastatic lesions, lymphoma, paraneoplastic syndome

Myelitis: Viral infections (Virus varicella Zoster, Epstein Barr Virus, Herpes simplex virus, Citomegalovirus, myelopathy associated with acquired immunodeficiency syndrome (AIDS), Human T-Lymphotropic virus (HTLV-I)-associated myelopathy/Tropical spastic paraparesis); Fungal infections (Criptococcus, Apergillus); Sprirochetal infections (Lyme disease, Syphilis)

Table 2 Diagnostic evaluation of patients with hepatic myelopathy

History

Subacute bilateral lower limbs weakness; puppet-like walk or inability to walk in the setting of a chronic liver disease

Neurological examination

Spastic paraparesis, no sensory level, hyperreflexia, extensor plantar responses

Neuroradiological examination

Contrast enhanced MRI or computed tomography myelogram of the entire spine to rule out compressive etiology. MRI may show FLAIR signal prolongation in subcortical corticospinal tracts; Brain MRI to rule out demyelinating processes, hydrocephalus, parasagittal space-occupying lesion, Arnold-Chiari malformation and other structural abnormalities at craniocervical junction

Other diagnostic tools

Lumbar puncture - examination of cerebrospinal fluid to rule out spinal cord inflammation or if neuroimaging is unrevealing; Motor evoked potentials may disclose central conduction abnormalities even before the myelopathy is clinically manifest

Evaluation of spontaneous shunt

Abdomen ultrasonography, computed tomography, MRI (if no shunt visible, no history of portosystemic shunt or transjugular intrahepatic portosystemic shunt)

MRI: Magnetic resonance imaging.