Spinal cord involvement in patients with cirrhosis

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.