Assessment and Management of Mild Ventral Cervical Cord Flattening on MRI

Pathophysiology

Mild flattening of the ventral cervical spinal cord on MRI reflects anterior mechanical compression by degenerative structures such as disc‑osteophyte complexes or disc herniation, as described by the American College of Radiology (ACR). 1
The compression results from anterior structures deforming the normally rounded cord contour, producing a flattened appearance (mechanical compression). 2

Presence of T2‑hyperintense signal within the cord indicates edema, gliosis, or myelomalacia and converts a simple compressive finding into a pathologic cord injury (high‑risk feature). 2
Clinical signs of myelopathy—gait instability, hand clumsiness, hyperreflexia, Hoffmann’s sign, or Babinski sign—demonstrate that the ventral compression is functionally significant and warrants urgent attention. [1][3]
Involvement of a single cervical level is less concerning than multilevel compression for predicting clinical significance. 2

MRI of the cervical spine has high sensitivity for detecting soft‑tissue and compressive lesions but only modest specificity (approximately 64 %–77 %) for identifying injuries that are clinically significant. [4][5]

Mild flattening without cord signal change or myelopathic symptoms: Clinical observation with serial neurological examinations is appropriate; patients should be educated about warning signs and undergo repeat imaging only if symptoms develop. (ACR recommendation based on expert consensus.) 1
Mild flattening with T2 hyperintensity or overt myelopathic signs: Neurosurgical consultation is indicated because this scenario represents degenerative cervical myelopathy that may require surgical decompression. (ACR guideline). [1][3]
Imaging for surgical planning: MRI remains the gold standard for delineating the extent of intramedullary injury and guiding operative strategy. (ACR recommendation). [4][6]2
Correlation with clinical examination: Imaging findings must be interpreted in the context of the patient’s neurological exam; imaging alone should not dictate treatment decisions. (ACR guidance). [1][7]