What MRI studies should be ordered for a 50‑year‑old woman with a history of assault‑related cervical and thoracic compression who now has progressive numbness and tingling in her hands, feet, and left lateral thigh, hand numbness worsened by elbow flexion and arm elevation, and autonomic instability with large blood‑pressure swings, sweating, and syncope?

MRI Imaging for Suspected Cervical and Thoracic Spinal Cord Compression with Autonomic Instability

Order MRI cervical spine without IV contrast and MRI thoracic spine without IV contrast as the initial imaging studies. 1, 2

Primary Imaging Recommendation

Your clinical presentation—progressive extremity numbness/tingling, positional hand symptoms (elbow flexion, arm elevation), lateral thigh numbness, and autonomic instability (blood pressure swings, syncope)—strongly suggests multilevel spinal cord compression with possible myelopathy following cervical and thoracic trauma. 1, 2

Cervical Spine MRI Protocol

• MRI cervical spine without IV contrast is the gold standard for evaluating soft-tissue injuries including disc herniation, epidural hematoma, ligamentous injury, and spinal cord compression that CT cannot adequately visualize. 1, 2

• The protocol should include high-resolution T1-weighted and T2-weighted sequences in sagittal and axial planes to evaluate the spinal cord, nerve roots, disc material, and sites of compression. 1, 3

• T2-weighted sagittal images are most useful for defining acute soft-tissue injury and cord edema, while T1-weighted images identify hemorrhage and anatomic detail. 4, 5

• Gradient-echo sequences should be added to increase conspicuousness of extradural disease and better visualize cord compression. 5, 3

Thoracic Spine MRI Protocol

• MRI thoracic spine without IV contrast is essential because your symptoms (progressive foot numbness, lateral thigh numbness) suggest thoracic cord involvement, and thoracic myelopathy from compression is a surgical emergency. 1, 2

• The thoracic protocol should mirror the cervical approach with T1-weighted and T2-weighted sequences in sagittal and axial planes to identify disc herniation, hematoma, or ligamentous injury. 1

• Image the entire spine when cord compression is suspected, as 20% of spine injuries have a second noncontiguous spinal injury. 2

Clinical Rationale for This Approach

Why MRI Without Contrast Initially

• MRI without contrast has 96% sensitivity and 94% specificity for spinal cord compression and provides optimal visualization of the epidural space, spinal cord, disc herniations, and hematomas. 2

• Contrast is not needed initially unless there is clinical suspicion for infection, tumor, or inflammatory disease—none of which are suggested by your trauma history. 1, 2

• Comparing pre- and post-contrast sequences is only essential when looking for abnormal enhancement patterns (infection, inflammation, neoplasm), which is not your primary concern. 2

Why Both Cervical and Thoracic Imaging

• Your hand symptoms worsening with elbow flexion and arm elevation suggest cervical nerve root compression or thoracic outlet syndrome, requiring cervical spine evaluation. 1

• Your progressive foot numbness and lateral thigh numbness indicate thoracic cord involvement, as these dermatomes are supplied by thoracic nerve roots. 1

• Autonomic instability (blood pressure swings, syncope, sweating) can occur with cervical or high thoracic cord compression affecting sympathetic pathways, making multilevel imaging mandatory. 1, 2

Critical Pitfalls to Avoid

• Do not rely on CT alone—CT is excellent for fractures but significantly inferior to MRI for identifying soft-tissue pathologies (disc herniation, epidural hematoma, ligamentous injury) that cause neurologic deficits and require surgical intervention. 1, 2

• Do not order plain radiographs—they have only 49-62% sensitivity for thoracic fractures and are inadequate for evaluating spinal cord compression. 2

• Do not delay imaging—progressive myelopathy with autonomic instability suggests evolving cord compression that may require urgent surgical decompression. 1, 2

• Avoid ordering MRI with contrast initially unless the non-contrast study is non-diagnostic or suggests infection/tumor, as this adds cost and time without improving detection of traumatic compression. 1, 2

When to Add Contrast or Alternative Imaging

• Add IV contrast only if the initial non-contrast MRI suggests infection (epidural abscess), tumor, or inflammatory myelitis—none of which fit your trauma history. 1, 2

• Consider CT myelography only if MRI is contraindicated (pacemaker, severe claustrophobia) or if surgical planning requires additional detail of bony anatomy and canal patency. 1

• CT without contrast may be added for preoperative planning to delineate osseous structures if surgery is planned, but should not replace MRI for initial diagnosis. 1

Autonomic Instability Considerations

• Your blood pressure swings, sweating, and syncope raise concern for high cervical or thoracic cord compression affecting autonomic pathways, which is a neurosurgical emergency requiring urgent imaging and evaluation. 1, 2

• Autonomic dysreflexia can occur with cord lesions above T6 and manifests as blood pressure instability, sweating, and other autonomic symptoms—your presentation warrants immediate spinal imaging. 1