Multiple Sclerosis (MS) – Diagnosis, Symptoms, and Treatment

What is Multiple Sclerosis (MS)?

Multiple sclerosis (MS) is a disorder characterized by neurologic deficits scattered in space and time.  It is an autoimmune disease in which the body attacks normal nerve tissue in the brain and spinal cord.  These brain and spinal cord lesions can produce debilitating symptoms that resemble a stroke – such as loss of vision and paralysis.  Symptoms tend to occur in flares that relapse and remit.

What Causes Multiple Sclerosis (MS)?

Multiple sclerosis is an autoimmune disease - this means that the body’s immune system attacks body organs and tissues inappropriately.  Our nerves are made up of three major parts: the nerve cell body, the axon, and the dendrite (the end of the nerve).  The axon is responsible for how fast a nerve can send its signal.  Nerve axons in the brain and spinal cord contain an insulating material called myelin, which helps speed up nerve signals even faster.

An autoimmune attack on myelin characterizes multiple sclerosis – this results in impaired nerve signaling and symptoms such as visual loss, double vision, weakness, numbness, paralysis, and confusion.  The hallmark feature is that these symptoms recur and relapse over time.

The most common risk factors for multiple sclerosis include:

•         Family history
•         Northern European descent
•         Living above the equator before puberty
•         Vitamin D deficiency

How Common is Multiple Sclerosis (MS)?

Multiple sclerosis is a relatively common neurologic condition that is frequently managed and treated in the neurology clinic.  It affects approximately 400,000 Americans.  It typically affects women of childbearing age (20-40) but can also be seen in men and other age groups.

Signs and Symptoms

The most common symptoms of multiple sclerosis include:

•         Visual loss & eye pain (optic neuritis)
•         Weakness
•         Numbness
•         Burning/shooting pain
•         Spinal paralysis (myelitis)
•         Muscle stiffness
•         Dizziness & gait instability
•         Impaired coordination

These symptoms tend to occur in flares that remit and relapse.

The optic nerve is the primary nerve responsible for vision.  This nerve frequently becomes inflamed in patients with multiple sclerosis, which results in pain and visual loss (optic neuritis).

Your doctor will often evaluate for specific findings on your physical examination, such as:

•         Visual acuity and field testing
•         Detailed eye examination using a funduscopic
•         Muscle strength & stiffness
•         Sensation in the faces and extremities
•         Reflexes in upper and lower limbs
•         Balance – testing balance with eyes closed (Romberg maneuver)
•         Coordination – finger-to-nose testing, rapid-alternating movements

Diagnosis

Multiple sclerosis is diagnosed based on symptoms, physical examination, and MRI findings.

Your doctor will typically order an MRI of your brain and spine.  Classic findings usually include white plaques located around the ventricles of the brain.  There may also be scattered lesions in the brainstem and spinal cord.

If the diagnosis is not clear, your doctor may recommend a spinal tap – during this procedure, a needle is inserted into the fluid-filled pocket surrounding your spinal cord.  This fluid is then extracted and sent to the laboratory to be analyzed for its color and appearance.  Further testing is usually performed to evaluate cell counts, protein, glucose levels, and bacteria.  Your doctor will usually test for a specific finding seen in multiple sclerosis called oligoclonal bands.

Multiple Sclerosis Medication and Treatment

Multiple sclerosis tends to occur in flares in which patients develop relapsing and remitting symptoms.  We have already discussed common symptoms of the disease, but one worth mentioning again is eye pain and loss of vision.  These symptoms are highly suggestive of optic neuritis – inflammation of the optic nerve.

Multiple sclerosis flares accompanied by mild symptoms that aren’t debilitating - such as mild sensory loss – can generally be treated on an outpatient basis with oral corticosteroids (e.g., prednisone).  Patients with moderate to severe symptoms (e.g., limb paralysis) and those with optic neuritis generally require hospital admission for intravenous corticosteroids (e.g., Solumedrol – methylprednisolone).

Corticosteroids work by reducing the amount of inflammation in the brain and spinal cord tissues.  Their long-term use should generally be avoided since it can lead to weight gain, diabetes, immune system suppression, osteoporosis, and stomach ulcers.

Patients with recurrent multiple sclerosis flares may benefit from long term control with the following medications:

•         Copaxone (glatiramer)
•         Interferon beta
•         Tysabri (natalizumab)
•       Gilenya (fingolimod)

These medications work by preventing and reducing inflammation in the nervous system – thereby decreasing the chances of flare-ups.  They are not typically associated with as many side effects as corticosteroids.

Symptoms associated with multiple sclerosis may also require therapy.  Muscle spasticity/stiffness is often treated with muscle relaxers such as Kemstro (baclofen) or Zanaflex (tizanidine).  Nerve or neuropathic pain is frequently treated with Neurontin (gabapentin) or Lyrica (pregabalin).

References:

1.     Saguil A, Kane S, Farnell E. Multiple sclerosis: a primary care perspective. Am Fam Physician. 2014 Nov 1;90(9):644-52 - https://www.ncbi.nlm.nih.gov/pubmed/25368924
2.     Goldenberg MM. Multiple sclerosis review. P T. 2012 Mar;37(3):175-84. - https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3351877/