How do I interpret a cervical and thoracic spine MRI in a patient with a history of trauma and chronic pain?

How to Interpret Cervical and Thoracic Spine MRI in Trauma and Chronic Pain

Initial Imaging Strategy

In patients with trauma history, CT is the gold standard for detecting fractures, but MRI is essential for evaluating soft tissue injuries, ligamentous damage, and spinal cord pathology that directly impact clinical management. 1

Start with CT for Bony Assessment

• Order CT cervical and thoracic spine without IV contrast as your primary imaging modality for any patient meeting high-risk criteria (midline tenderness, high-energy mechanism, age >60 years, or inability to examine due to altered mental status/intoxication). 1, 2
• CT has 94-100% sensitivity for detecting thoracolumbar fractures and is the gold standard for cervical spine fractures, vastly outperforming plain radiographs which miss approximately two-thirds of fractures visible on CT. 1, 2
• Sagittal and coronal reformats from existing chest/abdomen/pelvis CT provide equivalent diagnostic quality without additional radiation if already obtained for other trauma evaluation. 2

When to Add MRI

Obtain MRI cervical and/or thoracic spine without contrast immediately if any of the following are present: 1, 3

• Any neurological deficits (weakness, sensory changes, bowel/bladder dysfunction)
• Spinal cord injury suspected clinically
• Persistent neck or back pain despite negative CT (MRI identifies soft tissue injuries in 5-24% of patients with negative CT) 1, 4
• Inability to clinically clear the spine in obtunded/unexaminable patients with persistent cervicalgia 4

Systematic MRI Interpretation Approach

Sequences to Review and What They Show

T1-weighted sequences: 1, 3

• Assess bone marrow signal (look for marrow edema indicating occult fractures or contusions)
• Evaluate disc anatomy and alignment
• Identify epidural hematomas (appear bright on T1)

T2-weighted sequences (most important for acute trauma): 1, 5

• This is your primary sequence for detecting acute soft tissue injury 5
• Ligamentous disruption appears as high signal intensity or discontinuity
• Disc herniations and annular tears are best seen here
• Spinal cord edema/contusion shows increased signal

STIR or T2 fat-saturated sequences (essential for inflammatory/traumatic changes): 1, 3

• Bone marrow edema from occult fractures or contusions appears bright
• Ligamentous edema indicating acute injury
• Soft tissue inflammation and fluid collections
• Critical pitfall: Standard spine MRI protocols for degenerative disease may not include fat suppression—specifically request trauma protocol or inflammatory evaluation sequences 1

Anatomical Checklist for Systematic Review

Vertebral bodies: 1, 5

• Marrow signal abnormalities (edema, contusion, hemorrhage)
• Fracture lines (though CT is superior for this)
• Alignment and height loss

Intervertebral discs: 5, 4

• Traumatic disc herniation (present in 1.4% of trauma patients with negative CT) 4
• Disc space disruption or widening
• Annular tears

Ligamentous structures (critical for stability assessment): 5, 4

• Anterior longitudinal ligament (ALL): Look for discontinuity or edema on sagittal T2
• Posterior longitudinal ligament (PLL): Evaluate for disruption
• Ligamentum flavum: High signal or discontinuity indicates injury
• Interspinous/supraspinous ligaments: Widening or high signal suggests posterior ligamentous complex injury
• Ligamentous injury found in 16.6% of trauma patients with negative CT 4

Spinal cord: 1, 6

• Cord edema: Increased T2 signal (predicts neurological outcome based on extent and length) 1
• Cord hemorrhage: Central hypointensity on T2 (worse prognosis)
• Cord compression: From disc, bone fragments, or epidural hematoma
• Cord transection: Complete signal abnormality across cord

Epidural space: 6, 4

• Epidural hematomas (1.3% incidence in trauma with negative CT) 4
• Soft tissue swelling (4.3% incidence) 4

Paraspinal soft tissues: 5, 4

• Edema or hemorrhage indicating ligamentous injury
• Muscle injury patterns

Critical Clinical Correlations

Non-Contiguous Injuries

Always image the entire spine when one level is injured—20% of spine injuries have a second non-contiguous fracture. 1, 2, 7

• In cervical spine trauma, 28% have non-contiguous injuries at the cervicothoracic junction (C7-T5) that may be missed if imaging stops at C7. 7
• Axial compression injuries have the highest rate (35.3%) of non-contiguous CTJ/upper thoracic injuries. 7

MRI Findings That Change Management

MRI abnormalities after negative CT lead to continued cervical collar use in 86.7% of cases versus removal in 88.1% with normal MRI. 4

• Ligamentous injury requiring extended collar placement (most common finding at 16.6%) 4
• Surgical intervention needed in approximately 1.4% of cases (11 of 767 patients in multicenter trial) 4
• Cord compression requiring decompression 1

Chronic Pain Context

For patients with chronic pain and remote trauma history: 8

• Start with plain radiographs (AP and lateral views), recognizing they have only 52% pooled sensitivity for significant injuries 8
• Proceed directly to MRI without contrast if pain persists beyond 2-3 weeks or if any neurological symptoms develop (sensitivity 96%, specificity 93% for soft tissue pathology) 8
• MRI is superior for evaluating ligamentous injury, disc abnormalities, and spinal cord pathology that may explain chronic symptoms 8, 6

Common Pitfalls to Avoid

Do not assume negative CT excludes clinically significant injury: 1, 4

• Less than 1% of patients have instability on MRI not seen on CT, but this represents a critical miss 1
• The ReCONECT multicenter trial found 23.6% of patients with negative CT had abnormal MRI findings 4

Do not rely on plain radiographs in trauma settings: 1, 2

• Radiographs miss 18-51% of fractures and have only 49-62% sensitivity for thoracic fractures 2
• Flexion-extension views are frequently inadequate due to limited motion and poor visualization 1

Do not order standard degenerative spine MRI protocols for trauma/inflammatory evaluation: 1

• Specifically request fat-suppressed fluid-sensitive sequences (STIR or T2 fat-sat) 1
• Standard protocols may lack the sequences needed to detect bone marrow edema and ligamentous injury 1

Do not miss the cervicothoracic junction: 7

• Ensure imaging extends through T5 in cervical spine trauma 7
• 28% of cervical injuries have associated CTJ/upper thoracic pathology 7

Do not delay MRI when neurological deficits are present: 1, 3

• MRI characterizes the cause and extent of cord injury, guides surgical intervention, and predicts neurological outcome 1
• Immediate imaging is required for any progressive neurological symptoms 3