CT Spine Imaging Guidelines

Standard CT Spine Protocols

The American College of Radiology recommends using CT Spine Without IV Contrast to evaluate osseous integrity, fractures, alignment, and bony destructive changes, providing detailed analysis of fractures extending to the posterior column of the vertebra and for evaluating pedicle integrity and posterior cortex, although it poorly depicts intradural and spinal cord pathologies 1, 2.
The American College of Radiology suggests using CT Spine With IV Contrast to evaluate for epidural abscess in patients with suspected infection, as addition of IV contrast may help assess for epidural abscess, but generally doesn't provide significant additional information for fracture evaluation 1, 3.
The American College of Radiology states that CT Spine Without and With IV Contrast is not typically performed as there is no diagnostic advantage to performing a single study with both protocols compared to either alone 1, 4.

CT Myelography is useful for assessing patency of the spinal canal/thecal sac, subarticular recesses, and neural foramina, and has safety advantages over MRI for patients with implanted medical devices that are not MRI safe/conditional, although it requires lumbar puncture and intrathecal contrast injection 2, 4.
CT Myelography is occasionally more accurate than MRI in diagnosing nerve root compression in the lateral recess, and is useful in patients with significant artifact from metallic surgical hardware 2.

CT Thoracic Spine is used to assess integrity of fusion, hardware position, and spinal alignment in post-surgical patients 5, 6.
CT Lumbar Spine is commonly used to evaluate for osseous abnormalities, hardware assessment, and spinal stenosis 2, 4.

CT with SPECT or SPECT/CT can be helpful in evaluating for widespread osseous metastatic disease, assessing radiographically occult fractures, evaluating acuity of vertebral fractures, and cases of painful pseudoarthrosis or periprosthetic loosening in patients with previous lumbar fusion 1, 7.
FDG-PET/CT can be used to evaluate for widespread metastatic disease, distinguish between benign versus malignant compression fractures, and help differentiate benign from pathologic compression fractures when other imaging modalities are indeterminate 1, 8.

CT spine imaging is generally equal to MRI for predicting significant spinal stenosis and excluding cauda equina impingement, but inferior for evaluating marrow abnormalities, infection, and intradural pathologies 3.

The American College of Radiology recommends performing lumbar spine CT without intravenous (IV) contrast in the overwhelming majority of clinical scenarios because IV contrast adds no diagnostic advantage for assessing bone structures, fractures, alignment, spinal stenosis, or neural foramina. 9, 10, 11
The American College of Radiology states that non‑contrast CT is the standard protocol for lumbar spine evaluation, as it provides detailed analysis of posterior‑column fractures, pedicle integrity, posterior cortical continuity, and accurate assessment of spinal stenosis and neural foramina. 9, 10
The American College of Radiology notes that CT with IV contrast alone does not yield additional information over non‑contrast CT for evaluating spinal fractures, alignment, or degenerative changes. 9, 11
The American College of Radiology advises against routinely performing both non‑contrast and contrast‑enhanced CT together, because the combined approach offers no diagnostic benefit. 9, 11

Pre‑operative planning: Non‑contrast CT delineates osseous margins and assists in trajectory planning for spinal hardware fixation. Evidence level: not specified. 10
Fracture evaluation: Non‑contrast CT delivers detailed visualization of vertebral body fractures, especially those involving the posterior column. Evidence level: not specified. 9, 11
Spinal stenosis assessment: Non‑contrast CT is comparable to MRI for predicting clinically significant spinal stenosis and for excluding cauda equina impingement. Evidence level: not specified. 9, 10

Soft‑tissue evaluation: CT cannot adequately assess disc herniations, nerve‑root compression, or other soft‑tissue pathologies; MRI remains the superior modality for these indications. Evidence level: not specified. 9, 10
Post‑operative scar vs. recurrent disc herniation: CT cannot differentiate postoperative scar tissue from recurrent disc herniation; MRI with contrast is required for this distinction. Evidence level: not specified. 11

CT myelography (without IV contrast) is recommended as the appropriate alternative when MRI is contraindicated; it evaluates thecal‑sac patency and neural foramina but requires a lumbar puncture. Evidence level: not specified. 9, 10, 11