Definition
A chronic immune mediated demyelinating disease of the central nervous system, with lesions disseminated in time and space. Orthopaedic presentations include gait disturbance, spasticity, falls and fragility fractures.
Epidemiology
- Onset between 20 and 40 years
- Women affected about three times as often as men
- Higher prevalence at higher latitudes
Classification
- Relapsing remitting disease in about 85% at onset
- Secondary progressive disease may follow relapsing remitting disease
- Primary progressive disease from onset in about 10 to 15%
- Diagnosis by the 2017 McDonald criteria
Clinical Features
- Optic neuritis, internuclear ophthalmoplegia and sensory symptoms
- Lhermitte sign, an electric shock down the spine on neck flexion
- Spasticity, hyperreflexia and extensor plantar responses
- Uhthoff phenomenon, with symptoms worse in heat
- Spasticity drives equinus, hip adduction and knee flexion contractures
- Falls, immobility and steroid exposure raise fracture risk
Investigations
- MRI brain and spine shows periventricular, juxtacortical, infratentorial and spinal cord lesions
- CSF oligoclonal bands support dissemination in time
- Visual evoked potentials show delayed conduction
- Brisk reflexes in a patient with arm symptoms warrant MRI before attributing them to radiculopathy
Differential Diagnosis
- Cervical myelopathy
- Radiculopathy
- Syringomyelia
- Motor neurone disease
- Subacute combined degeneration from B12 deficiency
Management
- Disease modifying therapy. Neurologist led, reduces relapse rate
- Physiotherapy and orthoses. Ankle foot orthosis for foot drop and gait stability
- Antispasticity agents. Baclofen, tizanidine or botulinum toxin for focal spasticity
- Tendon lengthening or release. Fixed contracture limiting gait, seating or hygiene
- Bone health. Vitamin D and antiresorptive therapy for osteoporosis
Complications
- Higher complication and dislocation rates after hip arthroplasty, see THR in neurological conditions
- Pressure injury and contractures in non ambulant patients
References
- Thompson AJ, Baranzini SE, Geurts J, Hemmer B, Ciccarelli O. Multiple sclerosis. Lancet. 2018, 391(10130), 1622-1636. PubMed
- Thompson AJ, Banwell BL, Barkhof F, Carroll WM, Coetzee T, Comi G, Correale J, Fazekas F, Filippi M, Freedman MS, Fujihara K, Galetta SL, Hartung HP, Kappos L, Lublin FD, Marrie RA, Miller AE, Miller DH, Montalban X, Mowry EM, Sorensen PS, Tintoré M, Traboulsee AL, Trojano M, Uitdehaag BMJ, Vukusic S, Waubant E, Weinshenker BG, Reingold SC, Cohen JA. Diagnosis of multiple sclerosis. 2017 revisions of the McDonald criteria. Lancet Neurol. 2018, 17(2), 162-173. PubMed
Reviewed by Professor Phong Tran, Head of Orthopaedic Surgery, Western Health. Last updated 19 October 2026.