When is contrast (gadolinium-based contrast agent) recommended for an MRI (Magnetic Resonance Imaging) of the spine?

MRI Spine with Contrast: Clinical Indications

Gadolinium contrast should be added to spine MRI when there is clinical suspicion for infection (discitis/osteomyelitis, epidural abscess), neoplasm (primary or metastatic tumors), or inflammatory conditions (demyelinating disease, inflammatory arthropathies), and precontrast images must always be obtained first to accurately assess enhancement. 1

Primary Indications for Contrast Administration

Infection

• Discitis/osteomyelitis and epidural abscess are the most critical infectious indications, where contrast helps identify paraspinal soft tissue extension, epidural involvement, and spinal cord compression 1
• MRI without and with IV contrast is usually appropriate as initial imaging for suspected spine infection in patients with red flags including diabetes mellitus, IV drug use, cancer, HIV, dialysis, or recent spinal intervention 1
• Gadolinium enhancement demonstrates the extent of epidural disease and helps differentiate active infection from chronic changes 1

Neoplasm

• Primary and metastatic spinal tumors require contrast to assess tumor vascularity, extent, and relationship to neural structures 1
• Contrast-enhanced MRI with fat suppression is superior for detecting epidural, paravertebral, and intradural-extramedullary lesions, with some metastases visible only on contrast-enhanced fat-suppressed sequences 2
• Intraspinal masses benefit from contrast to localize the lesion relative to adjacent neural structures 1

Inflammatory Conditions

• Demyelinating diseases (multiple sclerosis, neuromyelitis optica, acute disseminated encephalomyelitis) require contrast-enhanced imaging for initial diagnostic evaluation per 2016 MAGNIMS criteria 1
• Inflammatory arthropathies and systemic inflammatory conditions (lupus, Sjogren syndrome, sarcoidosis) are well evaluated with contrast-enhanced MRI 1
• Transverse myelitis and other inflammatory myelopathies demonstrate characteristic enhancement patterns 1

Critical Technical Requirement

Precontrast images are mandatory when administering gadolinium because comparison between pre- and post-contrast sequences is essential to confirm true enhancement versus intrinsic T1 hyperintensity 1

• MRI with contrast only (without precontrast images) is not useful and should not be performed 1
• Fat-suppressed sequences should be used with gadolinium administration to improve lesion detection 1, 2

When Contrast Is NOT Needed

Mechanical/Degenerative Conditions

• Spondylolysis, disc herniation, and degenerative disc disease do not require contrast 1
• Mechanical back pain with normal neurologic examination is adequately evaluated without contrast 1

Trauma

• Acute fractures and bony injuries are best evaluated with non-contrast CT or MRI 1
• Postoperative hematoma evaluation may require contrast, but acute trauma does not 1

Spondylotic Myelopathy

• Cervical or lumbar stenosis causing cord compression typically does not require contrast for diagnosis 1
• Intramedullary signal changes from chronic compression are visible on non-contrast T2-weighted sequences 1

Special Populations and Considerations

Pediatric Patients

• In children with back pain and suspected infection, inflammation, or neoplasm, contrast is useful but precontrast images remain essential 1
• Discitis/osteomyelitis in children requires prompt MRI evaluation, with contrast helpful for assessing epidural extension and paraspinal soft tissue involvement 1, 3

Postoperative Spine

• Recent spinal surgery patients with suspected infection require MRI without and with contrast to differentiate postoperative changes from infection 1
• Early postoperative complications like hematoma are best evaluated with contrast-enhanced MRI 1

Renal Dysfunction

• Non-contrast MRI may be indicated when renal function precludes safe gadolinium administration 1
• Risk of nephrogenic systemic fibrosis has been largely eliminated since 2009 with proper screening and use of stable contrast agents 4, 5

Common Pitfalls to Avoid

• Do not order contrast-only sequences without precontrast images—this eliminates the ability to assess true enhancement 1
• Do not assume normal radiographs exclude infection—plain films have low sensitivity in early discitis/osteomyelitis, and MRI (with or without contrast) is required 1, 3
• Do not routinely use contrast for degenerative disease—this adds cost, time, and gadolinium exposure without diagnostic benefit 1
• Do not skip fat suppression when administering contrast for suspected neoplasm or infection—fat-suppressed sequences detect additional lesions not visible on standard T1-weighted images 2

Decision Algorithm

Clinical suspicion for:

• Infection (fever, elevated inflammatory markers, risk factors) → MRI without and with contrast 1, 3
• Neoplasm (known cancer, unexplained weight loss, night pain) → MRI without and with contrast 1
• Inflammatory/demyelinating disease (neurologic deficits, systemic symptoms) → MRI without and with contrast 1
• Mechanical pain (activity-related, normal exam) → MRI without contrast 1
• Trauma (acute injury) → CT without contrast or MRI without contrast 1
• Spondylotic myelopathy (chronic compression) → MRI without contrast 1