There are many disease processes which can have clinical manifestations similar to those produced by pathologies requiring surgical intervention. Demyelinating processes, such as multiple sclerosis, neurodegenerative disease such as amyotrophic lateral sclerosis, and infections such as HIV can all produce classic signs and symptoms of myelopathy. The spine surgeon much also be aware of nutrition deficiencies, such as B12 that can result in myelopathic symptoms. Extensive laboratory and neurodiagnostic imaging workups may be necessary to determine the etiology of a patient’s symptoms.