Which imaging modality is best to evaluate soft tissue and spinal cord compression in suspected cervical myelopathy?

• A. CT with contrast
• B. MRI of the cervical spine
• C. X-ray of the neck in neutral
• D. Ultrasound of the neck

Answer: (B)

When cervical myelopathy is suspected, you want to see how the spinal cord is being compressed by surrounding soft tissues and assess any changes inside the cord itself. MRI of the cervical spine provides high-resolution, multiplanar images of the spinal cord, intervertebral discs, ligaments, and surrounding soft tissues, letting you identify disc herniation, ligamentum flavum thickening, ossification of the posterior longitudinal ligament, and other sources of compression. It also shows the cord directly and can reveal edema or myelomalacia as hyperintensity on T2-weighted images, which helps gauge the extent and potential reversibility of injury. While CT is excellent for detailing bone and is useful for surgical planning regarding bony stenosis, it does not visualize soft-tissue structures or cord signal changes as well as MRI. X-rays can show alignment and gross instability but miss soft tissue compression, and ultrasound is not able to evaluate the spinal canal. Therefore, MRI best addresses soft tissue and spinal cord compression in suspected cervical myelopathy.