C1-2 Cord Signal Changes: Diagnostic Approach and Management

Diagnostic Imaging

• MRI with and without IV contrast is the definitive imaging modality for evaluating C1-2 cord signal changes, as it provides superior soft-tissue resolution and multiplanar capability essential for identifying both compressive and non-compressive etiologies, according to the American College of Radiology 1, 2

Compressive Etiologies

• Spondylotic myelopathy is the most common cause of extrinsic cord compression in the cervical spine, resulting from degenerative changes, disc herniations, epidural lipomatosis, and malalignment, as reported by the American College of Radiology 3
• Congenitally short pedicles can accentuate compression at the C1-2 level, as noted by the American College of Radiology 3

Non-Compressive Etiologies

• Multiple sclerosis affects the cervical cord in 80-90% of cases and is characterized by lesions disseminated in space and time, fulfilling the 2016 MAGNIMS criteria, according to the American College of Radiology 1, 2, 5
• Diffusion-weighted imaging should be included whenever spinal cord ischemia is suspected, as it demonstrates signal changes earlier than T2-weighted sequences, as recommended by the American College of Radiology 2, 4

Diagnostic Evaluation

• Contrast-enhanced imaging is recommended for initial diagnostic evaluation of all demyelinating conditions, according to the American College of Radiology 1, 5
• Comprehensive neurological examination must systematically test all upper extremity myotomes, reflexes, gait, lower extremity function, and sensory distribution to accurately correlate imaging findings with clinical myelopathy, as suggested by the American College of Radiology 7