Magnetic Resonance Imaging for Spinal Cord Compression

Diagnostic Capability of Non-Contrast MRI

The American College of Radiology recommends that non-contrast MRI is highly effective for evaluating spinal cord compression, allowing for excellent assessment of soft tissue abnormalities, including nerve root compression and spinal cord abnormalities 1, 2, 3.
In patients with chronic cervical pain and radiculopathy, non-contrast cervical spine MRI is usually the appropriate initial imaging modality, as it is the preferred method for evaluating soft tissue abnormalities, including nerve root compression 3.
Non-contrast MRI can show suggestive findings of spinal cord compression, including bone marrow or paraspinous muscle edema, abnormal fluid collections, areas of abnormal signal, and structural abnormalities of the involved spinal segment 4, 5.
The American College of Radiology states that non-contrast MRI offers similar evaluation to contrast-enhanced MRI for detecting compression, but is less sensitive for detecting soft tissue extension into the spinal canal and leptomeningeal involvement 2, 3.

In patients with suspected malignancy and acute cervical pain or radiculopathy, MRI with and without contrast is the appropriate initial modality, as contrast helps evaluate soft tissue extension, including epidural disease, leptomeningeal involvement, and intramedullary involvement 1, 2, 3.
In suspected or known spinal infection, MRI with and without contrast has a sensitivity of 96% and specificity of 94%, and contrast improves detection and characterization of complications such as epidural abscess, meningitis, and myelitis 1, 4, 5.
Contrast helps identify abnormal epidural fluid collections, define their size and extent, and determine the presence of spinal cord or cauda equina compression 4, 5.

For initial evaluation of spinal pain or radiculopathy without "red flags", start with non-contrast MRI, which is sufficient to diagnose disc herniation, spinal stenosis, and most degenerative conditions 6.
Add contrast when there is a history of previous spinal surgery with new or progressive symptoms 6, suspected malignancy (weight loss, night pain, history of cancer) 1, 2, 3, signs of infection (fever, elevated ESR, risk factors) 1, 4, 5, or immunocompromised state 6.

Non-contrast MRI has a sensitivity of 88% for predicting lesions in surgically confirmed cervical radiculopathy, compared to 81% for CT myelography 7.
Non-contrast MRI is particularly useful in cauda equina syndrome due to its ability to accurately depict soft tissue pathology and assess spinal canal patency 6.
Imaging findings should be correlated with clinical symptoms, as disc abnormalities are common in asymptomatic individuals 6.