Spinal Cord Injury Imaging¶

Overview¶

Spinal cord injury (SCI) is a devastating consequence of spinal trauma that can result in permanent neurological deficits including paralysis, sensory loss, and autonomic dysfunction. MRI is the definitive imaging modality for evaluating the injured spinal cord, providing critical information about injury severity, prognosis, and the need for surgical intervention.

Clinical Syndromes¶

Understanding the clinical syndromes helps correlate imaging findings with neurological deficits:

Complete SCI — Total loss of motor and sensory function below the level of injury. Associated with the worst prognosis for recovery.

Anterior Cord Syndrome — Loss of motor function and pain/temperature sensation below the injury, with preservation of posterior column function (proprioception, vibration, light touch). Results from injury to the anterior two-thirds of the cord, typically from a flexion teardrop fracture or retropulsed disc/bone fragment.

Central Cord Syndrome — The most common incomplete SCI. Disproportionate upper extremity weakness compared to lower extremity weakness, with variable sensory loss and bladder dysfunction. Typically occurs in older patients with pre-existing cervical spondylosis after a hyperextension mechanism.

Brown-Séquard Syndrome — Hemisection of the cord resulting in ipsilateral motor paralysis and loss of proprioception/vibration, with contralateral loss of pain/temperature sensation. Results from penetrating trauma or unilateral cord compression.

Conus Medullaris Syndrome — Injury to the terminal spinal cord (conus, typically at L1–L2) causing symmetric lower extremity weakness, early bowel/bladder dysfunction, and saddle anesthesia.

Cauda Equina Syndrome — Injury to the nerve roots below the conus, causing asymmetric lower extremity weakness, radicular pain, and bowel/bladder dysfunction.

MRI Findings¶

Acute Spinal Cord Injury¶

T2-weighted sequences:

Cord edema — High T2 signal within the spinal cord at and surrounding the injury level. Indicates acute injury but may be partially reversible.
Cord hemorrhage — Low T2 signal centrally within the cord (deoxyhemoglobin in the acute phase), surrounded by high T2 edema. Cord hemorrhage is a poor prognostic indicator.
Cord transection — Complete disruption of cord signal continuity. Indicates complete and irreversible injury.

T1-weighted sequences:

Cord hemorrhage may appear as high T1 signal (methemoglobin) in the subacute phase
Cord swelling or compression is visible

STIR sequences:

Most sensitive for detecting cord edema
Also demonstrates surrounding soft tissue injury (ligamentous disruption, bone marrow edema)

Prognostic MRI Features¶

The extent and pattern of MRI signal abnormality within the cord correlates with neurological outcome:

Cord edema alone (no hemorrhage) — Better prognosis; some recovery expected
Cord hemorrhage — Poor prognosis; hemorrhage length >10 mm on sagittal T2 is associated with complete injury and minimal recovery
Cord edema length — Longer segments of edema correlate with worse outcomes
Maximum canal compromise (MCC) and maximum spinal cord compression (MSCC) — Greater compression correlates with worse outcomes

Clinical Pearl

On MRI, spinal cord hemorrhage appears as a central area of low T2 signal surrounded by a halo of high T2 edema — sometimes called the "snake eyes" or "owl eyes" pattern on axial images. This pattern indicates a severe injury with hemorrhagic necrosis and carries a poor prognosis. In contrast, isolated cord edema without hemorrhage is associated with potential for meaningful recovery.

Imaging Approach¶

CT first for all trauma patients — evaluates fractures, alignment, and canal compromise
MRI when neurological deficit is present or cannot be assessed — evaluates the cord, ligaments, discs, and epidural space
CT angiography when vertebral artery injury is suspected (cervical fractures, especially those involving the transverse foramina)

Chronic Spinal Cord Injury¶

In the chronic phase (months to years after injury):

Myelomalacia — High T2, low T1 signal in the cord representing gliosis and cystic degeneration
Post-traumatic syringomyelia — A CSF-signal cavity within the cord that may expand over time and cause progressive neurological deterioration
Cord atrophy — Reduced cord diameter at and below the injury level

Key Points¶

MRI is the definitive modality for spinal cord injury evaluation
Cord hemorrhage on T2 (central low signal with surrounding edema) indicates severe injury with poor prognosis
Cord edema without hemorrhage has a better prognosis for recovery
Central cord syndrome is the most common incomplete SCI, typically in elderly patients with spondylosis
Post-traumatic syringomyelia can develop months to years after injury and cause progressive deterioration
CT should always be obtained first; MRI is added when neurological deficit is present or suspected

References¶

Talbott JF, Whetstone WD, Readdy WJ, et al. The Brain and Spinal Injury Center score: a novel, simple, and reproducible method for assessing the severity of acute cervical spinal cord injury with axial T2-weighted MRI findings. J Neurosurg Spine. 2015;23(4):495–504. PubMed
Miyanji F, Furlan JC, Aarabi B, Arnold PM, Fehlings MG. Acute cervical traumatic spinal cord injury: MR imaging findings correlated with neurologic outcome — prospective study with 100 consecutive patients. Radiology. 2007;243(3):820–827. PubMed
Leypold BG, Flanders AE, Burns AS. The early evolution of spinal cord lesions on MR imaging following traumatic spinal cord injury. AJNR Am J Neuroradiol. 2008;29(5):1012–1016. PubMed
Roberts TT, Leonard GR, Cepela DJ. Classifications In Brief: American Spinal Injury Association (ASIA) Impairment Scale. Clin Orthop Relat Res. 2017;475(5):1499–1504. PMC
Kumar Y, Hayashi D. Role of magnetic resonance imaging in acute spinal trauma: a pictorial review. BMC Musculoskelet Disord. 2016;17:310. PMC
ASIA impairment scale for spinal injury. Radiopaedia.org. Radiopaedia
Brain and Spinal Cord Injury Center (BASIC) score. Radiopaedia.org. Radiopaedia