Imaging Guidelines for Suspected Myelopathy

Rationale for MRI

• MRI is superior to CT for detecting myelopathy and cord signal changes, with the ability to visualize edema, inflammation, ischemia, myelomalacia, or gliosis that appear as increased signal intensity on T2-weighted sequences, as recommended by the American College of Radiology 1, 2
• CT has limited sensitivity for soft-tissue injuries, including epidural hematoma, cord contusion, and ligamentous injuries, making it inadequate for definitive evaluation of suspected myelopathy, according to the American College of Radiology 3
• MRI provides superior intrinsic soft-tissue contrast and excellent spatial resolution for assessing the spinal cord, nerve roots, and surrounding structures in multiple planes, as stated by the American College of Radiology 2, 4

When to Add Contrast

• Contrast is NOT routinely needed for initial evaluation of suspected myelopathy from degenerative causes, as recommended by the American College of Radiology 2
• Add IV contrast only if "red flags" are present, including suspected infection or known or suspected malignancy, as suggested by the American College of Radiology 5, 7

Alternative: CT Myelography

• CT myelography is an acceptable alternative when MRI is contraindicated or when MRI findings are equivocal, according to the American College of Radiology 8, 9
• CT myelography can visualize cord compression and nerve root impingement but is invasive with documented procedural risks, as reported by the American College of Radiology 9

Clinical Correlation is Critical

• Imaging findings must correlate with clinical examination, as degenerative changes and cord signal abnormalities are frequently seen in asymptomatic individuals, as stated by the American College of Radiology 2
• Prompt neurosurgical referral is not explicitly mentioned with a citation, however, the American College of Radiology emphasizes the importance of clinical correlation in the evaluation of suspected myelopathy 2

Common Pitfalls to Avoid

• Do not rely on CT alone to exclude clinically significant spinal cord pathology when myelopathy is suspected, as recommended by the American College of Radiology 3
• Do not add contrast routinely without specific indications, as it provides no additional benefit for degenerative myelopathy, according to the American College of Radiology 2