Correspondence to:

For most patients presenting with a spinal cord syndrome MR scanning has become the key investigation in establishing the diagnosis. However, myelopathy with normal spinal imaging remains a common clinical conundrum. In this review we discuss the diagnoses to consider for the neurologist presented with a patient with ‘‘MR normal myelopathy’’. We will illustrate this scenario with a series of short cases and consider the further investigation of ‘‘MRI normal’ ’ myelopathy. ‘‘So the gait is spastic, the toes go up and even general physicians think it’s a cord problem—but the MRI is normal... now what to do?’’ S pinal cord syndromes are common, usually quite easy to recognise, and the level and even the nature of the lesion can sometimes be defined clini-cally without any imaging. Nonetheless, to exclude surgically treatable lesions, most com-monly extrinsic compression of the cord, an MR scan is essential; indeed, it is often undertaken early, before referral to a neurologist. However, because a range of conditions can present with a cord syndrome but with normal or near-normal MRI findings, a request to review a patient with a clinically diagnosed myelopathy but with a ‘‘normal MR scan’ ’ is not unusual. This scenario occurs in about one fifth of cases of myelopathy referred to a UK neurosciences centre.1 As ever, the first step for the neurologist is to re-take the history, examine the patient, and personally review the available radiology, ideally with an experienced neuroradiologist. Importantly, the clinical sensory level is quite often below the level of the lesion (and the available imaging may not have gone high enough), although with a spinal dural arteriovenous malformation, it may be many segments above the lesion