Management of Cord Signal Abnormalities on Cervical Spine MRI
When MRI shows cord signal changes, immediately assess for neurological deficits and cord compression—these findings mandate urgent neurosurgical consultation and determine whether surgical decompression is needed. 1
Initial Clinical Assessment
Perform a focused neurological examination looking for:
- Motor weakness in upper or lower extremities
- Sensory deficits or sensory level
- Hyperreflexia or pathological reflexes (Babinski sign)
- Bowel/bladder dysfunction
- Gait abnormalities or coordination problems 1
The presence of neurological deficits with cord signal changes indicates potential spinal cord injury requiring immediate intervention. 1
Interpretation of MRI Cord Signal
MRI is superior to CT for identifying spinal cord pathology and should characterize:
- Extent of intramedullary hemorrhage (hypointense on T2, indicates worse prognosis)
- Length of cord edema (hyperintense on T2)
- Severity of cord compression from disc herniation, bone fragments, or hematoma
- Evidence of cord transection 1
These MRI findings directly predict neurological outcome and guide surgical decision-making. 1
Management Algorithm
If Neurological Deficits Present:
Urgent neurosurgical consultation is mandatory. 1 The severity and pattern of cord signal abnormality on MRI helps determine:
- Need for emergent surgical decompression
- Timing of intervention
- Surgical approach 1
MRI demonstrates compression sources (disc herniation, epidural hematoma, bone fragments) that may require surgical intervention. 1
If No Neurological Deficits:
Exercise extreme caution—cord signal changes without current deficits still represent significant injury risk. 1
- Maintain cervical immobilization
- Serial neurological examinations every 4-6 hours initially
- Neurosurgical consultation for risk stratification
- Consider repeat MRI if clinical status changes 1
Critical Pitfalls to Avoid
Do not rely on CT alone when cord injury is suspected—CT is significantly inferior to MRI for detecting cord contusion, epidural hematoma, and other soft-tissue pathologies causing neurological deficits. 1
Beware of MRI oversensitivity in trauma patients: In the trauma setting, MRI identifies soft-tissue abnormalities in 16.6-23.6% of patients with negative CT, but many findings are of uncertain clinical significance. 1, 2 However, cord signal changes specifically are clinically significant and should never be dismissed. 1
Do not assume stability based on MRI ligamentous findings alone: While MRI shows high sensitivity for ligamentous injury, it has poor specificity (64-77%) and false-positive rates of 25-40%. 3 Dynamic imaging or clinical assessment is needed to determine true instability. 1, 4
Special Considerations
In obtunded/comatose patients with cord signal changes: Even without examinable neurological deficits, cord signal abnormalities warrant continued immobilization and neurosurgical evaluation, as these patients cannot reliably demonstrate subtle neurological changes. 1, 5
Correlation with mechanism of injury: High-energy mechanisms (motor vehicle collision, falls from height) with cord signal changes have higher likelihood of requiring intervention. 2
Timing considerations: The average time between CT and MRI in trauma patients is 4-5 days, but cord signal changes with neurological deficits require urgent MRI (within hours, not days). 5
Follow-Up Management
For conservatively managed patients with cord signal changes:
- Maintain cervical immobilization until clinical and radiographic stability confirmed
- Serial neurological examinations
- Repeat MRI at 4-6 weeks to assess evolution of cord signal
- Physical therapy evaluation once cleared for mobilization 1
Surgical patients require:
- Postoperative MRI to assess adequacy of decompression
- Rehabilitation planning based on extent of cord injury
- Long-term neurological monitoring 1