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Myelomalacia refers to softening and necrosis of spinal cord tissue, typically as a chronic sequela of spinal cord injury or prolonged ischemia, compression, or inflammation. It represents irreversible spinal cord damage and indicates gliosis, necrosis, and cavitation.

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Etiopathogenesis

Cause	Mechanism
Chronic spinal cord compression	e.g., cervical spondylotic myelopathy, disc herniation
Spinal cord infarction	Ischemia → liquefactive necrosis
Trauma	Direct contusion and ischemia of spinal cord
Hemorrhage	Pressure and toxicity lead to tissue breakdown
Infection/inflammation	Late-stage sequelae of transverse myelitis, abscess
Radiation	Delayed radiation myelopathy can result in cord necrosis

End-stage process of neuronal and glial degeneration with no potential for reversal.

Clinical features

Usually detected in patients with longstanding myelopathy or post-traumatic paraplegia.

Symptoms	Details
Weakness	Spastic or flaccid depending on level of damage
Sensory changes	Paresthesia, hypoesthesia, sensory level
Autonomic dysfunction	Bladder, bowel, sexual disturbances
Often asymptomatic	If found incidentally, especially in mild/moderate cases

Radiology

MR sequence	Imaging features
T2	• Hyperintense signal in spinal cord (gliosis, cystic change)
• Often well-defined, linear or flame-shaped
• Seen at the site of previous compression/injury
T1	Hypointense in areas of necrosis or cystic change
Post-contrast MRI	• No enhancement, confirming chronicity
• Enhancement suggests active inflammation or tumor
GRE/SWI	May show blooming if prior hemorrhage or hemosiderin deposition
Axial Images	• May show central or eccentric cord signal changes
• Cord atrophy may be evident in chronic stage

Radiological Patterns

Pattern	Implication
Focal linear T2 hyperintensity	Seen in cervical spondylotic myelopathy
Snake-eye appearance (axial T2)	Central necrosis of anterior horns (chronic ischemia)
Cystic cavitation	Advanced chronic myelomalacia
Diffuse cord atrophy	End-stage damage

Differentials

Condition	Key Differences
Acute myelitis (e.g., MS, NMO)	Enhancing, usually no atrophy; potentially reversible
Cord infarct	DWI restriction in acute phase; no chronic atrophy early
Intramedullary tumor	Enhancing, expansile lesion
Radiation myelopathy	History of prior spinal radiation, may enhance early
Syringomyelia	CSF-like cavity, well-defined central canal dilation

Management

Myelomalacia itself is irreversible. Management focuses on preventing further damage and managing symptoms.