When Chronic Neck Pain Isn’t Mechanical: Neurosarcoidosis Revealed Through Extensive Myelitis
Laura Green1, Brian Copeland2, Jesus Lovera3
1Neurology, LSUHSC- New Orleans, 2Neurology, LSU Health Sciences Center-New Orleans, 3Neurology, LSUHSC-New Orleans
Objective:
To present a case of neurosarcoidosis manifesting as extensive cervicothoracic myelitis and emphasize the importance of early recognition and treatment.
Background:
A 31‑year‑old male with a 4‑year history of neck pain and right‑arm paresthesias, refractory to conservative treatments, presented with progressive radicular pain, worsening sensory symptoms, and upper motor neuron signs.
Results:
Cervical and thoracic MRI demonstrated longitudinally extensive T2/STIR hyperintensity with enhancement from the medulla to T4, with additional lower thoracic lesions. CT chest revealed multiple pulmonary nodules and bilateral hilar and mediastinal lymphadenopathy. Endobronchial ultrasound–guided lymph node biopsy confirmed non‑necrotizing granulomatous inflammation, consistent with sarcoidosis. He was treated with 1 g IV methylprednisolone daily for 3 days, followed by an oral prednisone taper and long‑term immunosuppression with adalimumab and methotrexate, resulting in significant functional recovery and complete resolution of radicular pain.
Conclusions:
Spinal neurosarcoidosis is uncommon and typically presents as LETM, a pattern that overlaps with neuromyelitis optica spectrum disorder and other inflammatory myelopathies, complicating diagnosis. MRI features such as dorsal subpial or pial enhancement—including the characteristic “trident sign”—may help differentiate sarcoid myelitis from other etiologies. Tissue confirmation of non‑necrotizing granulomas remains essential and is most safely obtained from peripheral lymph nodes. High‑dose corticosteroids are first‑line therapy and often yield rapid improvement, while long‑term agents such as methotrexate or TNF‑α inhibitors (e.g., infliximab, adalimumab) are frequently required as maintenance therapy for disease control. Radiologic improvement may lag behind clinical response and often evolves over months to years.
This case underscores the importance of considering neurosarcoidosis in patients presenting with unexplained vague symptoms and longitudinally extensive myelitis, especially when accompanied by pulmonary or lymphatic findings. Early recognition, biopsy confirmation, and prompt initiation of immunosuppressive therapy are critical for preventing irreversible neurologic deficits and achieving favorable clinical outcomes.
Generative AI Usage
No, did not use generative AI in the drafting or editing in this abstract.
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