Differential Diagnoses for Cervical Spine Lesions on MRI
The differential diagnosis for a cervical spine lesion on MRI is best organized by anatomic compartment (extradural, intradural-extramedullary, or intramedullary) and lesion characteristics (signal pattern, enhancement, longitudinal extent), with demyelinating disease, spondylotic myelopathy, infection, neoplasm, and vascular malformations representing the most common etiologies. 1
Approach by Anatomic Compartment
Intramedullary (Intrinsic Cord) Lesions
Demyelinating Diseases:
- Multiple Sclerosis (MS): Most common inflammatory myelopathy, affecting 80-90% of MS patients with cervical cord involvement most frequent 1. Lesions are characteristically short-segment, ovoid, peripherally located in the cord, typically well-defined 2, 3. MS lesions are usually found at C1-C3 levels, posterior in sagittal plane, central in axial plane, with normal or increased cord thickness 3.
- Neuromyelitis Optica Spectrum Disorder (NMOSD): Presents with longitudinally extensive transverse myelitis (LETM) spanning ≥3 vertebral segments 2, 4. Look for characteristic H-sign or trident sign on axial images representing central gray matter involvement 4.
- MOG-antibody Associated Disease (MOGAD): Can present with gray matter-predominant involvement 5, 4.
- Acute Disseminated Encephalomyelitis (ADEM): Spinal involvement in ~25% of cases 1.
Infectious/Inflammatory:
- Viral myelitis: Gray matter-specific involvement pattern 5.
- Chronic infections: Human T-cell lymphotropic virus, tuberculosis, schistosomiasis, HIV vacuolar myelopathy, tertiary syphilis 1.
- Bacterial/fungal: Spinal cord abscesses with characteristic rim enhancement 6.
Neoplastic:
- Primary intramedullary tumors: Ependymomas, astrocytomas - best evaluated with contrast-enhanced MRI 1.
- Metastases: Rare cause of intramedullary disease, requires contrast for detection 1, 5.
Vascular:
- Spinal cord ischemia: Gray matter-predominant involvement, typically no early enhancement 1, 5. Use diffusion-weighted imaging for early detection 1.
- Spinal dural arteriovenous fistula: Characteristic T2 hyperintensity with dorsal surface flow voids and patchy enhancement from venous hypertension 1, 5.
Metabolic:
- Subacute combined degeneration (B12 deficiency): Tract-specific white matter involvement, particularly dorsal columns 1, 5.
- Copper deficiency, nitrous oxide toxicity: Similar tract-specific patterns 1.
Other:
- Radiation myelopathy: Dose-dependent, localizes to prior radiation port 1.
- Paraneoplastic myelopathy: Autoimmune, tract-specific involvement possible 1, 5.
Intradural-Extramedullary Lesions
Limited differential, usually benign:
- Meningiomas: Most common 5.
- Schwannomas: Second most common 5.
- Arachnoid cysts/webs: May require CT myelography for confirmation 1.
- Idiopathic spinal cord herniation: Do-not-miss diagnosis, can mimic arachnoid pathology 5.
Extradural Lesions
Degenerative:
- Cervical spondylotic myelopathy (CSM): Most common cause of myelopathy overall. Lesions are ill-defined, located at C4-C7 levels, anterior in sagittal plane, with cord thinning or compression 3. Characteristic enhancement pattern immediately at and below stenosis level 1. Contrast typically not required for diagnosis 1.
- Disc herniation: Most common epidural mass 5.
Infectious:
- Spondylodiscitis/epidural abscess: MRI sensitivity 96%, specificity 93% 6. Look for disc signal abnormality, endplate changes, paraspinal inflammation, epidural collections with rim enhancement 6.
Neoplastic:
- Metastatic disease: Cervical spine is common site. MRI pooled sensitivity 90.6%, specificity 95.4% per patient 6. Contrast aids in detecting epidural extension, leptomeningeal involvement 6.
- Primary bone tumors: Less common 6.
Post-surgical:
- Adjacent level disease: Recurrent disc herniation, stenosis 1.
- Epidural hematoma: Early postoperative complication 1.
Key Imaging Features for Differentiation
Longitudinal extent:
- Short segment (<3 vertebral segments): MS, CSM, ischemia
- LETM (≥3 segments): NMOSD, neurosarcoidosis, infection
Axial location:
- Central/gray matter: NMOSD, ischemia, viral myelitis
- Peripheral/white matter: MS
- Anterior horns: Polio-like pattern (viral) 2
Enhancement pattern:
- Nodular/granulomatous: Neurosarcoidosis, tuberculosis 2
- Rim enhancement: Abscess
- Patchy intramedullary: Vascular malformation
- No early enhancement: Ischemia (suggests alternative if present) 1
Cord thickness:
- Normal/increased: MS, acute inflammation, tumor
- Decreased: CSM, chronic ischemia, atrophy
Critical Pitfalls
Do not mistake CSM enhancement for intrinsic myelopathy - characteristic pattern occurs at/below stenosis level 5. Do not miss spinal dural arteriovenous fistula - look for dorsal flow voids and T2 hyperintensity 5. NMOSD can start as short transverse myelitis - do not assume all short lesions are MS 2. Radiographs miss early infection - 30-40% bone destruction needed before detection, normal films do not exclude infection 6.
Imaging Protocol Recommendations
Contrast administration is mandatory for:
- Suspected infection (sensitivity/specificity optimization) 6
- Suspected neoplasm (soft tissue extension, epidural disease) 6
- Initial demyelinating disease evaluation 1
- Vascular malformations 1
Add diffusion-weighted imaging when:
Consider CT myelography when:
Brain MRI is mandatory when: