Monday, September 01, 2008

I went to the neurologist with pain going down my right arm with slight numbness. The pain was constant and moved to my chest, back and left arm. I also have strange twitches or spasms down my legs, arms and back. The MRI showed 12 lesions in my brain and some on my spine. However, the lumbar puncture only showed two white blood cells and a normal IgG count. But I have the oligoclonal bands. The doctor doesn't want to put me on the disease-modifying drugs and won't conclusively say that I have MS. He wants to wait and see if I have more symptoms. How long is too long to wait to be put on the meds? Would the meds do me harm being on them and finding out it was something else?

The most important task is always making the correct diagnosis, and it sounds like you and your doctor are moving in that direction. The symptoms you describe could certainly be seen in multiple sclerosis, although these symptoms alone are not diagnostic, as a number of other neurological disorders could lead to similar symptoms.

An accurate and definitive diagnosis is guided by a composite of the symptoms you offer in your history, signs on neurological examination, findings on brain and spinal cord MRI, and findings in the spinal fluid. We are helped in this by a set of criteria, called the McDonald criteria, and these guidelines are revised every few years. These criteria incorporate the clinical information as well as the MRI and spinal fluid findings. In your case, the presence of abnormalities or “lesions” on the MRI and oligoclonal bands in the spinal fluid is certainly suggestive of multiple sclerosis. However, the size, location and shape of the MRI abnormalities are also extremely important as many “white spots” can be seen that are not typical of MS and can even be seen in completely normal individuals!

Once a firm diagnosis is established, we would recommend treatment with one of the disease-modifying drugs at the earliest possible time in an effort to reduce new symptoms or “flares,” to prevent the development of new abnormalities on the MRI, and to reduce the chance of any progression of disability. However, we would never encourage initiation of treatment until a definite diagnosis of multiple sclerosis has been established. Sometimes this does require a period of observation or follow-up MRI studies, and that would certainly be more appropriate than starting medication prematurely! Another opinion can also be very helpful in sorting out a diagnostic challenge.