Spinal Cord Injury and Disease Diagnosis

Clinical Significance and Differential Diagnosis

The American College of Radiology suggests that increased T2 signal intensity in the spinal cord on MRI indicates intramedullary pathology that can result from compression, inflammation, ischemia, demyelination, or trauma, and requires systematic evaluation to determine the underlying etiology and guide management 1
In patients with cervical spondylotic myelopathy, T2 hyperintensity reflects cord injury from chronic compression and appears in 65-80% of patients with moderate to severe disease 2
The signal change represents edema, gliosis, myelomalacia, or ischemic injury depending on chronicity 1, 2
Multisegmental T2 hyperintensity predicts worse surgical outcomes compared to focal changes or no signal abnormality 3
When T1 hypointensity accompanies T2 hyperintensity, this indicates more severe irreversible cord damage and portends particularly poor surgical prognosis 4, 3

Multiple sclerosis lesions appear as focal T2 hyperintensities, typically occupying less than half the cross-sectional cord area and extending less than 2 vertebral segments 5, 1
Neuromyelitis optica produces longitudinally extensive lesions with central cord predilection 1, 2
Acute disseminated encephalomyelitis involves the cord in 25% of cases 2
Contrast enhancement suggests active inflammation and is commonly associated with new clinical symptoms 5, 6

The American College of Radiology recommends minimum two sagittal sequences with different contrasts at ≥1.5T field strength with 3mm slice thickness 5, 6
Axial T2-weighted images should be used to verify sagittal findings and assess cross-sectional cord involvement 5, 6
Contrast administration is recommended for initial evaluation of suspected inflammatory/demyelinating disease 1, 2

Absence of T2 hyperintensity predicts best surgical recovery 3
Focal hyperintensity allows modest neurological improvement 3
Resolution of T2 signal after surgery correlates with improved neurological recovery 3
Multisegmental T2 hyperintensity predicts poor surgical prognosis 3
Combined T1 hypointensity with T2 hyperintensity suggests irreversible myelomalacia 4, 3

Acute onset: Consider ischemia, trauma, or acute inflammatory process 1, 2
Subacute/chronic: Consider compression, demyelination, or chronic inflammatory conditions 1
Expanded cord: Suggests acute edema, inflammation, tumor, or hemorrhage 1
Normal/atrophic cord: Suggests chronic compression, chronic ischemia, or remote injury 1
Focal signal pattern: MS, focal compression, small infarct 5, 1
Longitudinally extensive signal pattern: NMO, ADEM, extensive compression 1, 2
Enhancement present: Active inflammation, infection, tumor 5, 1
No enhancement: Chronic compression, ischemia, gliosis 1, 2