How to Interpret Cervical Spine MRI: A Step-by-Step Guide

A Comprehensive Guide to Interpreting Cervical Spine MRI: Key Sequences, Patterns, and Pathologies

Magnetic Resonance Imaging (MRI) of the cervical spine is an essential tool in diagnosing and managing a range of conditions affecting the bones, ligaments, spinal cord, and surrounding soft tissues. This guide walks you through an effective approach to analyzing cervical spine MRIs, highlighting critical sequences, alignment considerations, and pathology identification. By understanding normal anatomy and learning to spot abnormalities, radiologists can provide valuable insights for patient care. How to Interpret Cervical Spine MRI: A Step-by-Step Guide

Key Sequences and Their Roles

1. Sagittal T1-Weighted Imaging

• Purpose: Optimal for assessing bone anatomy and marrow pathology.

• Approach:

  • Start at the skull base and examine each vertebra down to the visible thoracic spine.

  • Look for fractures, lesions, or marrow abnormalities.

  • Assess alignment at the cranio-cervical junction (C1-skull base) and C1-C2 articulation.

• Alignment Check:

  • Trace the anterior and posterior vertebral lines to detect anterolisthesis (forward vertebral slippage) or retrolisthesis (backward slippage).

  • Evaluate facet joints for subluxation or dislocation, particularly in trauma cases.

2. Sagittal T2-Weighted Imaging

• Purpose: Provides excellent contrast for evaluating the spinal cord and fluid-filled spaces.

• Approach:

  • Check the spinal cord for signal abnormalities, which could indicate:

    • Neoplasms

    • Radiation-related changes

    • Trauma or demyelination

    • Compression effects from degenerative changes or herniated discs.

  • Assess the spinal canal for narrowing, which could signify stenosis.

3. Short Tau Inversion Recovery (STIR) Imaging

• Purpose: Highly sensitive to soft-tissue and ligamentous injuries.

• Approach:

  • Pathology typically appears as bright hyperintense areas.

  • Use STIR to identify:

    • Bone marrow edema (suggesting fractures or tumors).

    • Ligamentous injuries, which present as hyperintensities within the ligament structures.

  • Double-check for cord abnormalities, as STIR can highlight subtle changes better than T2 in some cases.

4. Axial Imaging

• Purpose: Provides cross-sectional views of the canal and neural foramina.

• Approach:

  • Inspect the spinal canal for:

    • Epidural abnormalities such as hematomas or abscesses.

    • Stenosis from bony or soft tissue structures compressing the cord.

  • Evaluate the neural foramina for stenosis due to:

    • Uncovertebral joint hypertrophy.

    • Facet joint arthritis.

    • Disk osteophyte complexes.

Stepwise Search Pattern

1. Start with Bones (T1 Imaging):

   • Check for fractures, lesions, and alignment.

   • Pay particular attention to any abnormal marrow signals or suspicious bony overgrowth.

2. Assess Alignment:

   • Trace the vertebral bodies anteriorly and posteriorly.

   • Look for dislocations, perched facets, or alignment issues at the craniocervical junction.

3. Examine Disk Spaces (T2 Imaging):

   • Assess for disk height loss or degeneration, often seen in older patients.

   • Look for bulging or herniated disks contributing to canal or foraminal narrowing.

4. Focus on the Spinal Canal and Cord:

   • Check the canal for significant narrowing, epidural abnormalities, or spinal cord compression.

   • Identify any cord signal changes, which could signify myelopathy.

5. Use STIR for Ligament and Bone Detail:

   • Identify any bright hyperintensities in ligaments or bone marrow.

   • Confirm findings with other sequences to ensure accurate pathology identification.

6. Grade Stenosis:

   • Use both sagittal and axial sequences to grade stenosis (mild, moderate, or severe).

   • Document specific levels and possible causes (e.g., osteophytes, herniated disks).

   
   
   
   

Common Pathologies and Red Flags

1. Epidural Hemorrhage:

   • Appears as a mixed signal intensity collection on T1/T2 sequences.

   • Causes cord displacement, requiring urgent surgical consultation.

2. Cervical Stenosis and Myelopathy:

   • Narrowing of the canal, often due to osteophytes or disk protrusions.

   • Look for cord signal hyperintensity on T2/STIR, indicating myelopathy.

3. Infectious Pathologies (Phlegmon or Abscess):

   • Epidural abscesses may appear as enhancing collections post-contrast (if used).

   • Check for adjacent bony changes or prevertebral soft tissue swelling.

4. Trauma-Related Findings:

   • Fractures (visible as bright marrow signals on STIR).

   • Ligament injuries (hyperintensity in ligaments on STIR).

   • Evaluate the facet joints for subluxation or dislocation.

5. Neoplastic Conditions:

   • Tumors can appear as focal marrow hyperintensities on T1/STIR.

   • Look for associated soft tissue masses or canal compromise.

   
   

Practical Tips

• Understand Normal Anatomy: Familiarize yourself with normal findings using resources like Radiopaedia.

• Sequence Correlation: Always correlate findings across T1, T2, STIR, and axial images.

• Be Systematic: Develop a consistent search pattern to avoid missing subtle abnormalities.

• Collaborate with Clinicians: Provide clear, actionable findings, especially when identifying emergencies like hematomas, infections, or severe stenosis.

By adopting this structured approach, radiologists can ensure thorough evaluation of cervical spine MRIs, aiding in accurate diagnoses and effective patient care.