What is the next best step if a CT (Computed Tomography) scan of the cervical spine shows questionable findings of myelopathy or gliosis?

MRI Without Contrast is the Next Best Step

When CT of the cervical spine shows questionable findings of myelopathy or gliosis, proceed immediately to MRI of the cervical spine without IV contrast, as it is the reference standard for evaluating spinal cord pathology and soft-tissue abnormalities. 1

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 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 1

• MRI provides superior intrinsic soft-tissue contrast and excellent spatial resolution for assessing the spinal cord, nerve roots, and surrounding structures in multiple planes 1

• T2-weighted sequences are particularly valuable as they demonstrate increased signal intensity at points of cord compression, which may represent edema, gliosis, or myelomalacia 2

When to Add Contrast

• Contrast is NOT routinely needed for initial evaluation of suspected myelopathy from degenerative causes 1

• Add IV contrast only if "red flags" are present, including:

  • Suspected infection (fever, elevated inflammatory markers, immunosuppression, IV drug use) 1, 3
  • Known or suspected malignancy 1, 3
  • Concern for inflammatory or neoplastic processes 4

Alternative: CT Myelography

• CT myelography is an acceptable alternative when MRI is contraindicated (pacemakers, severe claustrophobia, metallic implants) or when MRI findings are equivocal 1

• CT myelography can visualize cord compression and nerve root impingement but is invasive with documented procedural risks (30% unexpected reactions, 14% severe pain during procedure) 1

Clinical Correlation is Critical

• Imaging findings must correlate with clinical examination, as degenerative changes and cord signal abnormalities are frequently seen in asymptomatic individuals 1, 3

• T2 signal changes carry prognostic significance: signal intensity that diminishes postoperatively correlates with clinical improvement, while persistent or worsening signal correlates with poor outcomes 2

• Prompt neurosurgical referral is warranted for any patient with clinical signs of myelopathy (decreased hand dexterity, gait instability, sensory/motor dysfunction) regardless of imaging findings, as delayed diagnosis leads to long-term disability 5

Common Pitfalls to Avoid

• Do not rely on CT alone to exclude clinically significant spinal cord pathology when myelopathy is suspected 1

• Do not delay MRI in patients with neurologic symptoms, as progressive myelopathy requires timely surgical evaluation 5, 4

• Do not add contrast routinely without specific indications, as it provides no additional benefit for degenerative myelopathy 1