For patients with multiple sclerosis (MS), sustained long-term disability is a problem that elicits considerable concern. There is the impact on independence and the potential burden that it may lead to for caregivers. While treatments for MS seem to multiply by the year, established disability remains the one area that is still refractory to treatment. Most of the current medications are excellent for preventing relapses but it is important to remember there is still no good evidence that these medications prevent long-term disability. The trials have not been done and it seems unlikely that they ever will be. There are global efforts directed at progressive forms of MS,  such as The International Progressive MS alliance which is seeking to bring together groups of researchers who are committed to developing new methods for treating progressive MS (http://www.progressivemsalliance.org) .

The importance of such endeavours is underscored by a manuscript in this month’s issue of JNNP.  Lukas et al have explored the contribution of cervical spine cord damage to the development of disability in MS http://jnnp.bmj.com/content/86/4/410.abstract . They have assessed radiological parameters in a large cohort of patients and have demonstrated that there is a change in the dimensions of the spinal cord that appears to occur in all forms of MS. These changes also predicted disease progression. Critically, the thinning of the cord occurred not only in patients with progressive MS, but also in patients with relapsing-remitting MS (RRMS). A number of these RRMS patients were on treatment with immunomodulatory mechanisms and it is sobering to think that the changes in the spinal cord occurred despite the potential benefits of being on drug treatment. This study is of importance as it highlights the importance of spinal cord disease in the development of disability. The authors also make the valid point that measures of spinal cord injury need to be incorporated into MS drug trials.