Is MRI with or without contrast recommended to evaluate for cord compression?

MRI for Cord Compression: Contrast vs Non-Contrast

For most cases of suspected cord compression, MRI without contrast is sufficient and should be the initial imaging modality, with contrast reserved for specific clinical scenarios including suspected infection, malignancy, post-surgical complications, or when the non-contrast study is equivocal. 1, 2

Initial Imaging Approach

MRI without contrast effectively detects cord compression and provides excellent visualization of:

• Spinal cord edema and signal abnormalities 1, 2
• Bone marrow and paraspinous muscle edema 1, 2
• Structural abnormalities including disc herniation and spinal stenosis 2
• Nerve root compression 1, 2
• Abnormal fluid collections 1, 2

The American College of Radiology confirms that non-contrast MRI offers similar evaluation to contrast-enhanced MRI for detecting compression itself, though it is less sensitive for detecting soft tissue extension into the spinal canal and leptomeningeal involvement 2.

When to Add Contrast

Add IV contrast in the following specific scenarios:

Suspected Infection

• MRI with and without contrast achieves 96% sensitivity and 94% specificity for spine infection 1
• Contrast is essential for identifying epidural abscess, defining its size and extent, and determining presence of cord or cauda equina compression 1
• Contrast helps distinguish superficial cellulitis from deeper infections including osteomyelitis and paraspinal abscess 1

Suspected or Known Malignancy

• Contrast is critical when evaluating for metastatic disease, primary spinal tumors, or leptomeningeal involvement 1, 2
• Helps assess soft tissue extension into the spinal canal and intramedullary involvement 2
• Essential for distinguishing tumor nodules from cysts and defining extent of disease 1

Post-Surgical Patients

• Late complications including recurrent disc herniation, epidural hematoma, seroma, or abscess require MRI with and without contrast 1
• Contrast helps differentiate scar tissue from recurrent pathology 1

Demyelinating Disease

• When MS, NMO, or ADEM is suspected, contrast-enhanced imaging is recommended for initial diagnostic evaluation 1
• Helps identify active lesions and fulfill diagnostic criteria 1

Vascular Malformations

• MRI with and without contrast demonstrates spinal cord edema from venous hypertension and enlarged veins 1
• Shows patchy intramedullary enhancement from blood-cord barrier breakdown 1

Other Inflammatory/Autoimmune Conditions

• Radiation-induced myelopathy, paraneoplastic myelopathy, and autoimmune myelitis benefit from contrast evaluation 1
• Metabolic causes (vitamin B12 deficiency, copper deficiency) and chronic infections are best evaluated with MRI, though contrast adds diagnostic value 1

Clinical Decision Algorithm

Start with non-contrast MRI if:

• Evaluating acute traumatic injury 3
• Suspected degenerative disease (spondylotic myelopathy) 1, 2
• No "red flags" present (fever, weight loss, night pain, history of cancer, immunocompromised state) 2

Proceed directly to MRI with and without contrast if:

• Fever, elevated ESR, or risk factors for infection present 1, 2
• History of malignancy or clinical suspicion for metastatic disease 2
• Previous spinal surgery with new or progressive symptoms 1, 2
• Immunocompromised state 2
• Clinical presentation suggests demyelinating disease 1

Important Caveats

Spondylotic myelopathy represents a common pitfall: IV contrast is typically not required for diagnosis, though characteristic enhancement patterns can be seen at and below stenosis levels 1. The key is that intramedullary cord signal changes on non-contrast MRI already provide prognostic information for surgical outcomes 1.

Always obtain pre-contrast images when using contrast: Post-contrast-only imaging is not useful because pre-contrast comparison is required to confirm enhancement 1. This is why the recommendation is "with and without" rather than "with only" 1.

Traumatic SCI studies show no significant advantage: Research comparing contrast-enhanced to non-contrast MRI in acute traumatic spinal cord injury found no significant difference in detecting major injuries (hematoma, edema), with contrast only providing marginal benefit for soft tissue evaluation 3.