Population Covered By The Guidance
This pathway provides guidance on the imaging of adult patients with suspected acute spinal cord compression.
Lead Researcher: Sian Chin
Experts & Contributors: Scott Davies, Ferry Dharsono, Ravinder Dhillon, Stephen Honeybul
Date reviewed: April 2018
Date Published: June 2018
Cervical Spinal Stenosis
Cervical Spinal Stenosis
- A detailed history and thorough clinical examination is required prior to imaging
- Patients should be urgently assessed by a senior clinician, which includes emergency or medical physicians and surgeons
- MRI is the first line modality in the assessment of suspected spinal cord compression
- If MRI is contraindicated, CT +/- myelography may be an alternative
Date of literature search: March 2018
The search methodology is available on request. Email
References are graded from Level I to V according to the Oxford Centre for Evidence-Based Medicine, Levels of Evidence. Download the document
- Patel ND, Broderick DF, Burns J, Deshmukh TK, Fries IB, Harvey HB, et al. ACR appropriateness criteria low back pain. J Am Coll Radiol. 2016;13(9):1069-78. (Guideline). View the reference
- Todd NV. Guidelines for cauda equina syndrome. Red flags and white flags. Systematic review and implications for triage. Br J Neurosurg. 2017;31(3):336-9. (Review article). View the reference
- Ropper AE, Ropper AH. Acute spinal cord compression. N Engl J Med. 2017;376(14):1358-69. (Review article). View the reference
- Schiff D. Spinal cord compression. Neurol Clin. 2003;21(1):67-86, viii. (Review article). View the reference
- Yanez ML, Miller JJ, Batchelor TT. Diagnosis and treatment of epidural metastases. Cancer. 2017;123(7):1106-14. (Review article). View the reference
- Moulopoulos LA, Kumar AJ, Leeds NE. A second look at unenhanced spinal magnetic resonance imaging of malignant leptomeningeal disease. Clin Imaging. 1997;21(4):252-9. (Level III Evidence). View the reference
- Cook AM, Lau TN, Tomlinson MJ, Vaidya M, Wakeley CJ, Goddard P. Magnetic resonance imaging of the whole spine in suspected malignant spinal cord compression: impact on management. Clin Oncol (R Coll Radiol). 1998;10(1):39-43. (Level II evidence). View the reference
- van der Sande JJ, Kröger R, Boogerd W. Multiple spinal epidural metastases; an unexpectedly frequent finding. Journal of Neurology, Neurosurgery, and Psychiatry. 1990;53(11):1001-3. (Level II-III evidence). View the reference
- Husband DJ, Grant KA, Romaniuk CS. MRI in the diagnosis and treatment of suspected malignant spinal cord compression. Br J Radiol. 2001;74(877):15-23. (Level II Evidence) View the reference
- Cook AM, Lau TN, Tomlinson MJ, Vaidya M, Wakeley CJ, Goddard P. Magnetic resonance imaging of the whole spine in suspected malignant spinal cord compression: impact on management. Clin Oncol (R Coll Radiol). 1998;10(1):39-43. (Level IV Evidence). View the reference
- Heldmann U, Myschetzky PS, Thomsen HS. Frequency of unexpected multifocal metastasis in patients with acute spinal cord compression. Evaluation by low-field MR imaging in cancer patients. Acta Radiol. 1997;38(3):372-5. (Level III Evidence). View the reference
- Peacock JG, Timpone VM. Doing more with less: diagnostic accuracy of CT in suspected cauda equina syndrome. AJNR Am J Neuroradiol. 2017;38(2):391-7. (Level II-III evidence). View the reference
- Crocker M, Anthantharanjit R, Jones TL, Shoeb M, Joshi Y, Papadopoulos MC, et al. An extended role for CT in the emergency diagnosis of malignant spinal cord compression. Clin Radiol. 2011;66(10):922-7. (Level III Evidence) View the reference
- Klein MA. Lumbar spine evaluation: accuracy on abdominal CT. Br J Radiol. 2017;90(1079):20170313. (Level II-III evidence). View the reference
- van Rijn RM, Wassenaar M, Verhagen AP, Ostelo RWJG, Ginai AZ, de Boer MR, et al. Computed tomography for the diagnosis of lumbar spinal pathology in adult patients with low back pain or sciatica: a diagnostic systematic review. Eur Spine J. 2012;21(2):228-39. (Level II evidence). View the reference
- Notohamiprodjo S, Stahl R, Braunagel M, Kazmierczak PM, Thierfelder KM, Treitl KM, et al. Diagnostic accuracy of contemporary multidetector computed tomography (MDCT) for the detection of lumbar disc herniation. Eur Radiol. 2017;27(8):3443-51. (Level II evidence). View the reference
- Shafaie FF, Wippold FJ, 2nd, Gado M, Pilgram TK, Riew KD. Comparison of computed tomography myelography and magnetic resonance imaging in the evaluation of cervical spondylotic myelopathy and radiculopathy. Spine (Phila Pa 1976). 1999;24(17):1781-5. (Level IV Evidence). View the reference
Pathway User Guide
Yellow Boxes Denotes extra information. Some contain single or multiple white sub-boxes, click a white box to reveal detailed information in a pop-up.
White Boxes: Denotes standard pathway steps. (If inside a yellow box, they open a specific pop-up).
Zoom & Pan Controls: Use + / − or the slider to zoom. Reset returns to default. Tick Panning to drag the diagram when zoomed.
Blue “View Full Screen” Button: Opens the whole diagram in a large, full-screen pop-up window. Use Close to exit.
The relative radiation level (RRL) of each imaging investigation is displayed in the pop up box.
| SYMBOL | RRL | EFFECTIVE DOSE RANGE |
|---|---|---|
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None | 0 |
 |
Minimal | < 1 millisieverts |
 |
Low | 1-5 mSv |
 |
Medium | 5-10 mSv |
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High | >10 mSv |
Disclaimer
Status Of Recommendations Each pathway is designed to assist clinicians in situations when faced with a large array of possible diagnostic tests and examinations. However, it is recognised that diagnostic practice may differ from a particular pathway depending on local availability of equipment and expertise, as well as the experience of individual clinicians. Therefore each pathway is neither a rigid set of rules, nor a substitute for clinical assessment, and individual patient circumstances should always be considered.
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Magnetic Resonance Imaging
Magnetic Resonance Imaging
The imaging modality of choice for the investigation of suspected spinal cord compression
- The imaging modality of choice for the investigation of suspected spinal cord or cauda equina compression
- T1- and T2- weighted sagittal images are generally used with axial images also obtained through identified regions of interest
- Gadolinium contrast is preferred for visualisation of intradural and column metastases although tumour can be detected in many cases without gadolinium
- MRI is widely accepted as the best modality to evaluate spinal cord compression although there is a paucity of recent studies on the accuracy of current MRI technology for diagnosing spinal cord compression from metastatic and degenerative disc disease
- In metastatic disease, one third of patients have multilevel disease so the whole spine should be imaged
- Advantages:
- Non invasive
- It can identify bone lesions without epidural extension, intramedullary metastases and sometimes leptomeningeal disease
- Excellent soft tissue contrast resolution
- The entire spine can be imaged and multiple sites of compression identified
- Contraindicated with ferromagnetic prostheses such as some pacemakers, aneurysm clips, cochlear implants or ocular foreign bodies. Claustrophobia and the long scanning time may not be tolerated by some patients
Computed Tomography and Myelography
Computed Tomography and Myelography
May be an alternative if MRI is contraindicated
- If MRI is contraindicated or unavailable then computed tomography (CT) may be an alternative
- CT can also be useful in surgical planning to evaluate for spinal instability
- CT without myelography shows bony infiltration or vertebral collapse from tumour but is not sensitive for detecting cord compression
- A study found a sensitivity and specificity of 89 percent and 92 percent respectively for CT when compared to MRI for the detection of metastatic spinal cord compression
- There is evidence that CT is comparable to MRI for detecting disc herniation which is the most common cause of spinal cord compression
- CT myelography may be of use when metal prostheses result in artefact obscuring the area of interest
- CT myelography is an invasive procedure that involves the intrathecal administration of contrast medium followed by computed tomography at the level of thecal sac impingement
- Limitations:
- Associated small risk of exacerbating the neurological deficit
- May be contraindicated in the presence of raised intracranial pressure and coagulopathy