C1-2 Cord Signal Changes on T2-Weighted MRI

Compressive Etiologies

Spondylotic myelopathy from degenerative changes, disc herniations, epidural lipomatosis, and malalignment represents the primary compressive cause at the C1-2 level, according to the American College of Radiology 1
Congenitally short pedicles can accentuate compression specifically at C1-2, as noted by the American College of Radiology 1
Postoperative hematomas in the early surgical period can cause extrinsic cord compression, as reported by the Journal of the American College of Radiology 2
Intramedullary signal changes in spondylotic myelopathy serve as prognostic factors for neurosurgical outcomes, with T2-only changes indicating better prognosis than combined T1/T2 changes, according to the Journal of the American College of Radiology 2

Multiple sclerosis affects the cervical cord in 80-90% of cases, most commonly at the cervical level, with lesions disseminated in space and time fulfilling 2016 MAGNIMS criteria, as stated by the American College of Radiology and Praxis Medical Insights 1, 3
Primary progressive MS demonstrates more extensive spinal cord involvement than relapsing-remitting MS, according to the Journal of the American College of Radiology 3
Neuromyelitis optica (NMO) presents with longitudinally extensive transverse myelitis, characteristically longer than MS lesions, as reported by the Journal of the American College of Radiology 2
Acute disseminated encephalomyelitis (ADEM) involves the spinal cord in approximately 25% of cases, according to the Journal of the American College of Radiology 3

Spinal cord ischemia from atheromatous disease, aortic surgery complications, systemic hypotension, thoracoabdominal aneurysms, or sickle cell disease produces T2 hyperintensity, as noted by the Journal of the American College of Radiology 2
Diffusion-weighted imaging demonstrates signal changes earlier than T2-weighted sequences in cord ischemia and should be included whenever ischemia is suspected, according to the Journal of the American College of Radiology and Praxis Medical Insights 1, 3
Contrast enhancement is typically absent in early acute ischemia; if present, it suggests inflammatory or infectious etiology rather than vascular, as reported by the Journal of the American College of Radiology 2

MRI with and without IV contrast is the definitive imaging modality, providing superior soft-tissue resolution and multiplanar capability essential for identifying both compressive and non-compressive etiologies, according to Praxis Medical Insights 1
Contrast-enhanced imaging is recommended for initial diagnostic evaluation of all demyelinating conditions, as stated by the Journal of the American College of Radiology and Praxis Medical Insights 1, 3
Diffusion-weighted imaging should be included whenever spinal cord ischemia is suspected, according to the Journal of the American College of Radiology and Praxis Medical Insights 1, 3

Comprehensive neurological examination must systematically assess all upper extremity myotomes to detect bilateral weakness patterns, as noted by Praxis Medical Insights 1
Reflexes for hyperreflexia or pathologic responses should be assessed, according to Praxis Medical Insights 1
Gait assessment for spasticity or ataxia is necessary, as reported by Praxis Medical Insights 1
Lower extremity function for pyramidal tract involvement should be evaluated, according to Praxis Medical Insights 1
Sensory distribution to establish a sensory level must be assessed, as stated by Praxis Medical Insights 1

Do not assume isolated finger weakness correlates with C1-2 cord edema—cord pathology at this level produces bilateral upper extremity dysfunction, not isolated findings, as noted by Praxis Medical Insights 5
Contrast enhancement in suspected ischemia suggests alternative inflammatory or infectious etiology, not vascular pathology, according to the Journal of the American College of Radiology 2
Low CSF JC virus copy numbers may represent incidental findings in suspected progressive multifocal leukoencephalopathy, requiring clinical and radiographic correlation, as reported by the Journal of Neurology, Neurosurgery and Psychiatry 6