Cervical spine protocol (MRI)

Last revised by Amanda Er on 19 Aug 2023

The MRI cervical spine protocol encompasses a set of MRI sequences for the routine assessment of the cervical spine.

Note: This article aims to frame a general concept of an MRI protocol for the assessment of the cervical spine. Protocol specifics will vary depending on MRI scanner type, specific hardware and software, radiologist and perhaps referrer preference, patient factors e.g. implants, specific indications and time constraints.

The most common indications include 1,2:

Examinations of the spine are generally done on both 1.5 and 3.0 tesla systems. Postoperative examinations in patients with metallic implants, however, should be done on 1.5 tesla with metal artifact reduction sequence (MARS). Some examinations might profit from the improved spatial and contrast resolution of 3 tesla.

An MRI of the cervical spine is usually conducted with the patient in the supine position.

  • head and neck coil

  • in-plane spatial resolution: ≤0.7 x 0.7 mm

  • field of view (FOV): 200-240 (sagittal/coronal) 100-160 (axial)

  • slice thickness: ≤3mm 2-4

A typical MRI of the cervical spine might look as follows 1-4:

  • sagittal images:

    • angulation: parallel to the cervical spinal axis and the spinous processes

    • volume: includes the whole vertebral bodies and the facet joints, in a craniocaudal direction, should include the craniocervical junction up to the second thoracic vertebra

    • slice thickness: ≤3 mm

  • axial images (long stack):

    • angulation: perpendicular to the cervical spine

    • volume:

      • variable depends on the clinical question and/or the visible pathology

      • if clinical indication is generic, sufficient to include inferior half of C3 to superior half of T1

      • may acquire in upper and lower blocks depending on cervical curvature to ensure slices intersect perpendicularly with nucleus pulposus

    • slice thickness: ≤3 mm

  • coronal images*            

    • angulation: parallel to the cervical spinal axis and transverse processes

    • volume: includes the posterior pharyngeal wall and the ligamentum nuchae

    • slice thickness: ≤3 mm

The mainstay in spinal imaging is T1 weighted and T2 weighted images. 

The majority of MRIs of the cervical spine will be done for the evaluation of degenerative disc disease and do not require any contrast media, the latter is usually administered in the setting of tumors, infection and postoperative imaging such as suspected complications of spinal surgery. Depending on the exact indication the examination can be supplemented by several adjuncts 1-5.

  • T1-weighted

    • purpose: bone and/or soft-tissue characterization

    • technique: T1 fast spin echo

    • planes: sagittal, axial, coronal*

  • T2-weighted

    • purpose: bone and/or soft-tissue characterization, detailed anatomy, including ligament and tendon anatomy

    • technique: T2 Dixon / T2 fast spin echo

    • planes: sagittal, axial, coronal*

  • T2-weighted (fat-saturated)

    • purpose: bone and soft tissue characterization, assessment of inflammatory changes, fractures

    • technique: STIR / T2 Dixon, T2 FS fast spin echo, T2 GRE

    • planes: sagittal, axial*

  • chemical shift imaging*

  • phase-sensitive inversion recovery*

    • purpose: might improve detection of cord lesions in multiple sclerosis 1,6

    • technique: 3D PSIR 

    • planes: sagittal

  • diffusion-weighted imaging*

    • purpose: evaluation of spinal cord ischemia, differentiation spondylodiscitis vs degenerative changes 3,7

    • technique: DWI/DTI  

    • planes: sagittal

  • T1-weighted (fat-saturated)*

Some indications might benefit from the application of contrast media such as e.g. inflammatory conditions, spinal tumors and suspected complications of spinal surgery.

  • T1-weighted C+ (fat-saturated)

    • purpose: for inflammatory  conditions, suspected tumors

    • technique: T1 Dixon, T1 fast spin echo

    • planes: axial, sagittal

  • MR perfusion*

    • purpose: evaluation of tumors for their vascularization

    • technique: T1 GRE (DCE)

    • planes: sagittal or axial

(*) indicates optional planes or sequences

  • the protocol can and should be tailored to the specific indication or clinical question

  • a basic native protocol will consist of 4 sequences

  • coronal images might be added for the evaluation of the atlantoaxial/atlantooccipital joint

  • nowadays fat saturation can be conveniently achieved by Dixon images

  • contrast administration is typically reserved for spinal tumors or spinal vascular malformations

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Cases and figures

  • Case 1: normal cervical spine - T2 Dixon (water)
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  • Case 1: normal cervical spine - T2 Dixon (in)
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  • Case 2: traumatic C5/C6 disc protrusion with cord compression
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