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Symposium – Cervical Spondylomyelopathy

Imaging in Cervical Myelopathy

Rajavelu Rajesh, Shanmuganathan Rajasekaran, Sri Vijayanand
Ganga Medical Centre and Hospitals Pvt. Ltd., Coimbatore, Tamil Nadu, India

Abstract
This is a narrative review. The objective of this study is to provide an overview on the imaging modalities and their utilization in cervical
myelopathy (CM). Using PubMed, studies published on the “imaging modalities in CM,” “cervical spondylotic myelopathy (CSM) imaging,”
“computed tomography (CT) and magnetic resonance imaging (MRI) in CM,” “imaging in ossified posterior longitudinal ligament (OPLL),”
“dural ossification in OPLL,” “diffusion tensor imaging (DTI) in CSM,” and “dynamic MRI, functional MRI, and magnetic resonance
spectroscopy (MRS) in CSM” were evaluated. The review addresses the evaluation of CM with various imaging modalities ranging from
radiographs, CT, and MRI to advanced imaging techniques such as DTI and MRS. Each investigation contributes specific detail to the disease
process in a different dimension. Specific parameters for CSM and OPLL, and their influence on outcome are discussed. Imaging in CM plays
an important role in analyzing the cause of myelopathy, defining the level of the lesion, parameters to assess the time of intervention and to
predict the outcome.

Keywords: Cervical myelopathy imaging, cervical spondylotic myelopathy, ossified posterior longitudinal ligament

Introduction osteophytes, abnormal ossifications (diffuse idiopathic

Degenerative cervical myelopathy (DCM) is defined as
symptomatic cervical myelopathy (CM) associated with a
broad variety of degenerative changes of the extradural spinal
tissues in the cervical spine. The spectrum includes cervical
spondylotic myelopathy (CSM), ossified posterior longitudinal
ligament (OPLL), and ossification of the ligamentum
flavum.[1] Radiological assessment in CM helps in establishing
the diagnosis and preoperative planning by localizing the
site, assessing the contributing factors and severity of the
disease.[2‑4] Various modalities of imaging with their unique
benefit are available ranging from roentgenogram to the more
advanced diffusion tensor imaging (DTI). Magnetic resonance
imaging (MRI) provides accurate and greatest range of
information including the disc, ligaments, and neural elements,
as compared to all the other available imaging.
Plain Radiographs in Cervical Myelopathy
Even in the presence of advanced diagnostic imaging, plain
radiographs are valuable initial radiological evaluation
tool of the cervical spine in CSM. Anteroposterior (AP),
lateral, and oblique radiographs show changes in the facet
and uncovertebral joints, vertebral body morphology,
skeletal hyperostosis), cervical alignment, and disc space.
Normal vertebral bodies are symmetric and rectangular.
A loss of disc space height with nonbridging and
nonmarginal osteophytes or syndesmophytes is a classic
finding in patients with degenerative spinal disease.[5] A
lateral radiograph must include from the base of the skull
to cervicothoracic junction, and an AP view should include
C3 to T1. Weight‑bearing plain lateral films in CM are used
to assess (a) sagittal canal diameter, (b) alignment, and (c)
evaluation of OPLL.
Assessment of sagittal canal diameter
Congenitally narrow spinal canal is proposed as a risk factor
for myelopathy in cervical spondylosis[6] and is assessed in
radiographs using Torg–Pavlov ratio (TPR). TPR [Figure 1]
is calculated from the lateral cervical radiographs by the ratio
between the distance between the midpoint of posterior surface
of the vertebral body to the closest point on the spinolaminar
line and the vertebral body diameter of the same level.[7]
Address for correspondence: Prof. Shanmuganathan Rajasekaran,
Ganga Medical Centre and Hospitals Pvt. Ltd.,
Coimbatore, Tamil Nadu, India.
E‑mail: sr@gangahospital.com

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DOI:
10.4103/isj.isj_63_18 How to cite this article: Rajesh R, Rajasekaran S, Vijayanand S. Imaging
in cervical myelopathy. Indian Spine J 2019;2:20-32.

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Rajesh, et al.: Imaging in myelopathy
According to Pavlov et al.,[8] cervical stenosis is present if the
ratio is ≤0.82.
Studies have shown that TPR is lower in patients with CM than
in normal people.[9‑11] In contrast, some studies[12,13] reported
that the TPR was not necessarily associated with spinal stenosis
in view of vertebral body size variability. However, the AP
diameter assessment in radiographs has been largely replaced
by computed tomography (CT) and MRI.[14]
Assessment of cervical alignment parameters
CSM has been associated with and potentially exacerbated by
cervical sagittal mal‑alignment. In CSM, loss of lordosis leads to
forced draping of the spinal cord against the vertebral bodies and
disc‑osteophyte complexes and may predispose to myelopathy.
With increase in kyphosis, tethering of the spinal cord may
increase intramedullary pressure and result in neuronal loss and
demyelination. Simultaneously, the smaller arterial feeders to
the cord will be compressed and flattened, resulting in further
cord injury.[4,15] Surgical decompression alone may not reduce
the cord tension due to kyphosis, if sagittal alignment is not
taken into consideration. Poor spinal cord posterior migration
and expansion, leading to poor neurological improvement after
Figure 1: Schematic diagram of Torg–Pavlov ratio (=A/B) measurement
Figure 2: Schematic diagram of lordosis and nonlordosis cervical alignments as seen is cervical myelopathy
Indian Spine Journal ¦ Volume 2 ¦ Issue 1 ¦ January-June 2019
laminoplasty, have been reported in patients with kyphotic
alignment.[16] Cervical curvature has been classified into lordosis
and nonlordosis; the latter includes straight, sigmoid, reversed
sigmoid, and kyphosis curvature[17] based on the relationship
with the line drawn between the posteroinferior corner of the
C2 body and posterosuperior corner of the C7 body (or the C6
body, if the C7 body was invisible behind the shadow of the
shoulders) [Figure 2].
Cervical alignment parameters are assessed in lateral cervical
radiographs, and it includes (1) cervical lordosis, (2) sagittal
plane translation, and (3) dynamic cervical parameters.
Cervical lordosis
The normal curvature of the cervical spine is lordosis, and
this is the result of cervical vertebra shape and to compensate
for the thoracic kyphosis. In normal volunteers, the mean
total lordosis is approximately 40°. The largest percentage
of cervical standing lordosis (75%–80%) is localized to C1–
C2, and relatively, little lordosis exists in the lower cervical
levels; only 15% of lordosis occurs at the lowest 3 cervical
levels (C4–C7).[18]
There are three methods to assess cervical lordosis including
Cobb angles [Figure 3a], Jackson physiological stress lines
[Figure 3b], and the Harrison posterior tangent method
[Figure 3c].[19] The most commonly used method is Cobb
angle, typically measured from C1 to C7 or C2 to C7. This is
described in Table 1.
Lee et al.[20] analyzed the influence of cervicothoracic junction
anatomy on cervical spine sagittal alignment in cervical sagittal
radiographs. The authors introduced the concepts of neck tilt (NT),
thoracic inlet angle (TIA), and T1 slope (T1S). NT was defined
as an angle between 2 lines both originating from the upper
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Rajesh, et al.: Imaging in myelopathy

a b c
Figure 3: Lateral cervical radiographs with lines showing the method of measuring C2–C7 Cobb angle (a): Angle between the line parallel to the inferior
endplate of C2 and another line parallel to the inferior endplate of C7, Jackson physiological stress lines (b) :Angle between two lines parallel to the
posterior surface of the C7 and C2 vertebral bodies, and the Harrison posterior tangent line (c) : Draw lines parallel to the posterior surfaces of each
cervical vertebral body from C2 to C7 and then summing the segmental angles for an overall cervical curvature angle

distance between a plumb line dropped from the center of the

Figure 4: Schematic diagram of relationship between thoracic inlet angle,
neck tilt, and T1 slope
end of the sternum with one being a vertical line and the other
connecting to the center of the T1 endplate [Figure 4a]. The TIA
has been defined as the angle between a line originating from the
center of the T1 endplate and perpendicular to the T1 endplate
and a line from the center of the T1 endplate and the upper end
of the sternum. T1S is the angle between horizontal plane and
T1 endplate. The authors found that large TIA increases T1 slope
and finally increases cervical lordosis to obtain a horizontal gaze
and vice versa [Figure 4b]. The normal calculated values in the
study were as follows: TIA – 69.5 ± 8.6°, T1S – 25.7 ± 6.4°, and
neck tilt – 43.7 ± 6.1°.
C2 sagittal vertical axis
Sagittal plane translation is assessed using C2 sagittal vertical
axis (CSVA) [Figure 5]. It is measured as the horizontal
C2 vertebral body and the posterior‑superior corner of C7.
The CSVA ranges from 15 to 17 ± 11.2 mm. Tang et al.[21]
reported that positive CSVA of >40 mm is correlated with poor
health‑related quality of life and neck disability index scores
following multilevel cervical fusion.
Dynamic cervical spine parameters
Lateral fl exion-extension views are used to assess the
dynamic parameters such as (i) assessment of cervical
instability, (ii) center of rotation, and (iii) cone of kinesis.
Cervical instability is when translation of >3.5 mm and sagittal
plane angulation of >11° are present [Figure 6].[22]
Role of plain radiographs in ossified posterior longitudinal
ligament
In OPLL, radiographs help in assessing the alignment and
measurement of K‑line and thus planning surgical procedures.
Fujiyoshi et al.[23] described the K‑line [Figure 7], which
connects the midpoints of the spinal canal at C2 and C7 on
neutral lateral radiographs, as a guide for making decisions
regarding the surgical approach for cervical OPLL patients.
Based on the position with that of OPLL, it may be K‑line (+)
or K‑line (−). K‑line (+) group has OPLL that does not exceed
this line while K‑line (−) group does. In K‑line (−) after
posterior decompression, lack of sufficient posterior shift of
cord and neurological improvement was noted due to anterior
compression. Hence, if OPLL mass falls behind the K‑line,
then anterior approach is preferred.[24]
Lee et al.[25] described kappa line [Figure 8] to assess the
postoperative neurological recovery and residual cord
compression in ≤4‑level laminoplasty. Kappa line is a straight
line connecting the midpoints of the spinal canal at 1 level

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Rajesh, et al.: Imaging in myelopathy
Figure 5: The distance between the C2 vertical line and C7 posterosuperior
corner represents the C2 sagittal vertical axis
above and 1 level below the decompressed segments on the
plain lateral radiograph in neutral position. Kappa (+) meant
that the OPLL mass did not pass the kappa line, while kappa (−)
meant that OPLL had grown posteriorly beyond the kappa line.
The authors reported that the kappa line predicted neurologic
recovery and remaining cord compression following ≤4‑level
laminoplasty more correctly than the K‑line.
K‑line was originally measured in cervical lateral standing
radiographs taken in neutral position. However, measurement of
the K‑line in CT images with sagittal reconstruction is being used,
stating that it can clearly reveal the precise size and morphology
of the ossification.[26] Ijima et al.[27] compared the K‑line measured
in standing lateral radiographs versus CT in lying position. About
11% showed a change from K‑line (+) to (−) when CT was used to
assess K‑line, and the authors stated that CT‑based measurement
Indian Spine Journal ¦ Volume 2 ¦ Issue 1 ¦ January-June 2019
Figure 6: Schematic diagram of cervical instability as described by White
and Punjabi et al.
is an over‑indication for anterior or posterior decompression and
fusion instead of laminoplasty which is optimal for K‑line (+)
patients and hence concluded that K‑line should be measured
with plain radiographs of standing patients.
Computed Tomography in Cervical Myelopathy
(a) Cervical spondylotic myelopathy
CT provides excellent information about the dimensions of
the spinal canal and helps in differentiating the various causes
for narrowing of the canal such as posterior osteophytes or
hypertrophied facet joints and ossified ligaments. It plays a vital
role in assessing the vertebral artery variations and cervical
pedicle morphology and its diameter and thus helps to choose
the surgical fixation modality. Anterior cervical compression
secondary to disc osteophyte complexes and their extent,
whether confined to the disc interspace or extension behind
the vertebral body as depicted by CT, is important to choose
the surgical procedure to address the pathology by either
discectomy and fusion or corpectomy and reconstruction,
respectively.[28]
(b) Ossified posterior longitudinal ligament (OPLL)
CT is essential in identifying the OPLL in lower cervical levels, less
densely calcified OPLL mass, associated dural ossification (DO),
and other ligamentous ossifications such as ossified ligamentum
flavum and to differentiate between osteophytes and segmental
OPLL.[29‑31] Sagittal image in CT helps in measurement of K‑line
and occupancy ratio, and to classify the type of OPLL. The axial
sequences help to assess the thickness, shape, and extension and
to localize the OPLL (central or paracentral).
Based on longitudinal extent, OPLL is classified into four types
[Figure 9]:
1. Continuous OPLL [Figure 9a]: a long lesion extending
over several vertebral bodies;
2. Segmental OPLL [Figure 9b]: one or several separate
lesions behind the vertebral bodies;
3. Mixed OPLL [Figure 9c]: a combination of the continuous
and segmental types; and
4. Circumscribed OPLL [Figure 9d]: mainly located posterior
to a disc space.
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a b
Figure 8: Cervical lateral X‑ray showing method to assess the K‑line (a)
Figure 7: Schematic diagram of K‑line and kappa line (b)

a b c d
Figure 9: (a-d) Computed tomography sagittal images showing the types of ossified posterior longitudinal ligament

a b c
Figure 10: Computed tomography axial images showing (a) square, (b) mushroom, and (c) hill shape of ossified posterior longitudinal ligament

Continuous or mixed types constrict the spinal cord more
severely.[32] In order of frequency, OPLL is found at levels
C4, C5, and C6.[32,33]
Space available for cord
The space available for cord (SAC) is measured by subtracting
the anterior to posterior distance of the OPLL from the spinal
canal. The risk of CM is high in patients with a SAC of <6 mm,
and the risk is low in patients with a SAC of >14 mm.[34] A
reduction of spinal canal AP diameter from 40% to 60%[35,36]
has been claimed as a high‑risk factor for the development of
myelopathy.
Based on ossified foci in transverse plane, three types have
been described [Figure 10]: (1) square, lines tangential to the
bilateral margin of the ossified mass are parallel; (2) mushroom

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Rajesh, et al.: Imaging in myelopathy
Figure 11: Single‑ and double‑layer signs in ossified posterior longitudinal ligament with dural ossification
Figure 12: C sign of dural ossification in ossified posterior longitudinal
ligament
shaped, the two lines cross ventrally; and (3) hill shaped, the
lines cross dorsally.[37]
Dural ossification (DO) in ossified posterior longitudinal
ligament
DO increases the chance of dural tear and CSF leak in anterior
surgeries, and the DO can be detected using a bone window on
CT scans. Based on the appearance of DO in OPLL, three signs
have been described: (1) single‑layer sign, (2) double‑layer
sign[38] [Figure 11], and (3) unilateral or bilateral C signs.[39]
1. The single‑layer sign: An irregular but continuous ventral
OPLL mass
2. Double‑layer sign: Ventral hyperdense mass and dorsal
hyperdense intradural mass along with an intervening
hypodense area
Indian Spine Journal ¦ Volume 2 ¦ Issue 1 ¦ January-June 2019
Figure 13: Measurement of %width, the relative transverse diameter of the
ossified posterior longitudinal ligament in the spinal canal (left: b/a), and
%thickness, the relative anteroposterior diameter of the ossified posterior
longitudinal ligament in the spinal canal (right: [c − d]/c)
3. Unilateral or bilateral “C signs” [Figure 12]: OPLL
presenting laterally in the spinal canal with an angular
C‑shaped configuration; this sign indicated that the lateral
dura had become imbricated in the OPLL mass.
Chances of dural tear in DO with OPLL is in the following
order of frequency double‑layer, single‑layer, and C signs[39]
and if width >40% or thickness >50% [Figure 13].
Occupancy ratio
Occupancy ratio [Figure 14] was defined as distance
between largest width of OPLL and posterior spinal canal
divided by spinal canal diameter and multiplying by 100.
A ratio of 30%–60% is predictive of the development of
myelopathy, and in those with an occupancy ratio >60%, all
of them develop myelopathy,[40] and an anterior approach
gives better neurological recovery as compared to posterior
decompression.[24,41]
One other extended use of CT in the cervical spine is T1S and
helps in the measurement of cervical sagittal alignment. T1S
changes with various positions and age; hence, it cannot be
used as an absolute parameter for cervical lordosis; however,
TIA can be taken as a fixed reference value.[42]
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Figure 14: Occupancy ratio: (a/b) ×100
Role of Magnetic Resonance Imaging in Cervical
Myelopathy
MRI in CM provides better anatomical details of disc,
vertebral bone, ligamentous changes, alignment, and spinal
cord pathologies. Detailed MRI assessment is usually done
in conventional T1‑weighted (T1W) and T2‑weighted (T2W)
sagittal and axial sequences.[43] A minimum of 1.5‑Tesla
imaging is essential for spine imaging, and screening of the
whole spine in single mid‑sagittal plane of T2W MRI is a
routine to rule out the coexisting tandem lesions, the prevalence
of which is about 11%.[43‑45] Whole‑spine screening also helps
in identifying other pathologies, the incidence of which is
reported to be about 15.8%.[46] MRI gives a comprehensive
detail about the site, location and degree of compression,
tandem stenosis, and cord changes, thereby predicting
prognosis and planning appropriate intervention. However,
controversies exist around the prediction of neurological
recovery through signal intensity (SI) changes. [47‑54] The
recent advancements in MRI such as DTI and magnetic
resonance spectroscopy (MRS) attempt to address these issues
by providing micro‑architectural details and function of the
spinal cord.[43] In OPLL, MRI is less sensitive and specific
26
in diagnosis, but it is useful to assess the associated cord
compression and intramedullary cord lesions, such as cord
edema and myelomalacia.
Spinal cord compression and cervical spondylotic
myelopathy
The severity of cord compression can be evaluated by
various methods such as maximum spinal cord compression,
compression ratio (CR)[55] (CR ratio between the AP and
transverse diameter), or cross‑sectional area [56] at the
compression site [Figure 15]. These parameters are useful in
assessing severity of compression as well as to assess the cord
expansion postsurgically.
Signal intensity (SI) change in spinal cord and cervical
spondylotic myelopathy
In CM, SI change appears as hyperintense on T2 sequences and
hypointense on T1 sequences. Hypointensity in T1 sequences
indicates ischemic death of nervous tissue, while hyperintensity
in T2 is due to edema of the spinal cord[47,48,57,58] [Figure 16].
However, T1 hypointense signal change will not occur without
T2 hyperintensity signals, unless there is a hemorrhage. In
the early and intermediate stages of myelopathy, cord shows
a high SI on T2‑weighted image (T2WI), whereas in the late
stages, hypointensity on T1‑weighted images (T1WIs) and a
hyperintensity on T2WIs occur.[59]
The role of SI changes in recovery was analyzed in detail by
many with varied results. Patients with altered SI on both
T1WI and T2WI have a relatively poor outcome compared
with the patients with signal changes only on T2WI.[49,57] Most
studies show poor prognosis related to the presence of T1 (low)
signal change.[49,50] High SI changes on T2WIs indicated both
pathologically reversible and irreversible changes in the
spinal cord, while low SI changes on T1WI were considered
to reflect pathologically irreversible changes. [50] Better
recovery rate was noted if the SI decreased after surgery as
compared to those who had increased or persistence of signal
change postoperatively.[47‑50,60] In contrast, some studies[51‑54,61]
reported that the altered SI on T2WIs was not related to the
poor outcome. The size (sagittal extent and area) of T2WI
signal hyperintensity is significantly associated with surgical
outcome, indicating that the larger the signal change, the
lower the odds of achieving an Modified Japanese Orthopedic
Association (mJOA) ≥16.[62]
In a retrospective study to analyze the SI changes and its role in
prognostication of outcome in patients who underwent cervical
laminectomy,[63] the authors observed that resolution of signal
changes in T2WI was noted in most patients postsurgically and
found that there is no significant difference in the recovery
rate of patients with different grades of SI change in the T2WI
or with focal or multisegmental SI changes when pre‑ and
postoperative MRI images were compared; however, patients
with low SI changes in T1WI had poor surgical outcome and
concluded that out of all SI changes, low SI in T1WI is the
best predictor of surgical outcome.
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a b
c d
Figure 15: Cross‑sectional area (a and c) and compression ratio (b and d) in normal level and at the site of maximum compression, respectively
Figure 16: Magnetic resonance imaging sagittal image showing
hypointense signal intensity in T1‑weighted image and hyperintense
signal change in T2‑weighted image
Role of dynamic magnetic resonance imaging in cervical
spondylotic myelopathy
In CSM, the cord compression is due to both static and
Indian Spine Journal ¦ Volume 2 ¦ Issue 1 ¦ January-June 2019
dynamic factors. Dynamic MRI (dMRI) taken in both flexion
and extension separately allows to assess the complex
interaction between disc, spinal canal, neural foramina, and
segmental instability. dMRI is done typically using 1.5‑T
MRI with special functional positioning device. The ideal
angles for flexion and extension are 40°–45°.[64] Studies
have demonstrated more levels of compression in extension
position as compared to flexion and neutral position.[64‑67] The
hyperintense intramedullary lesions are visualized more often
in flexion MRI.[68] CM patients with increased intramedullary
signals during flexion had a greater degree of neurological
recovery.[69]
Role of diffusion tensor imaging (DTI) in cervical
spondylotic myelopathy
MRI is able to delineate the extent of anatomic lesion of
the cervical cord, but it is difficult to infer the degree of
cervical cord dysfunction from MRI findings. DTI is a recent
advancement in MRI that solves this physiological lacuna.[70]
DTI assesses the microstructural architecture by measuring
the three‑dimensional shape and direction of diffusion via
the apparent diffusion coefficient (ADC) and fractional
anisotropy (FA). It helps in identifying the compression earlier
as it shows the abnormalities well before the development of
SI changes in MRI.[70,71]
DTI is based on the principle of anisotropic diffusion of
molecules in biological tissues. Anisotropic diffusion refers to
the diffusion of molecules in a medium where the molecular
movement is restricted to one particular direction because of
physical barriers. Most biological tissues such as the muscle
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Table 1: Imaging parameters in cervical myelopathy

Parameters Description
TPR Ratio between the distance between the midpoint of posterior surface of the vertebral body to the closest point on
the spinolaminar line and the vertebral body diameter of the same level
C2–C7 Cobb angle Angle between the line parallel to the inferior endplate of C2 and another line parallel to the inferior endplate of C7
Jackson physiological stress lines Angle between two lines parallel to the posterior surface of the C7 and C2 vertebral bodies
for cervical lordosis
Harrison posterior tangent Draw lines parallel to the posterior surfaces of each cervical vertebral body from C2 to C7 and then summing the
method for cervical lordosis segmental angles for an overall cervical curvature angle
Neck tilt The angle between two lines both originating from the upper end of the sternum with one being a vertical line and
the other connecting to the center of the T1 endplate
TIA The angle between a line originating from the center of the T1 endplate and perpendicular to the T1 endplate and a
line from the center of the T1 endplate and the upper end of the sternum
T1 slope The angle between horizontal plane and T1 endplate
CSVA The horizontal distance between a plumb line dropped from the center of the C2 vertebral body and the
posterior‑superior corner of C7
K‑line Line which connects the midpoints of the spinal canal at C2 and C7 on neutral lateral radiographs. K‑line (+) has
OPLL that does not exceed this line while K‑line (−) does
Kappa line Line connecting the midpoints of spinal canal at 1 level above and 1 level below the decompressed segments on the
plain lateral radiograph in neutral position
DO signs in OPLL Single‑layer sign, double‑layer sign, and C signs
Occupancy ratio Distance between largest width of OPLL to posterior spinal canal divided by spinal canal diameter and multiplying
by 100
TPR: Torg–Pavlov ratio, TIA: Thoracic inlet angle, CSVA: C2‑sagittal vertical axis, DO: Dural ossification, OPLL: Ossified posterior longitudinal ligament

fibers and neurons are anisotropic, because the molecular
diffusion in them is restricted by physical barriers such as
the myelin sheath. In these tissues, the direction of molecular
diffusion is preferential along their longitudinal axis, and the
DTI characteristics are often quantified by FA and ADC. FA
is a diffusion index that indicates the directional preference
of the diffusion where 0 represents isotropic diffusion (along
all directions) and 1 represents completely anisotropic
diffusion (along single longitudinal direction). ADC represents
the mean diffusivity that is measured from 3 orthogonal
directions within the imaged structure. In neuronal axons,
where horizontal diffusion is restricted, diffusion of water
molecules primarily occurs along the length (parallel) of the
axon, and the FA values are closer to 1 [Figure 17].[70]
Acute compression of spinal cord tissue may result in a focal
decrease in ADC as well as a focal increase in FA. Progressive,
chronic compression of the spinal cord results in a significant
increase in ADC and decrease in FA.[70‑74] Patients with a higher
preoperative FA at the site of compression have better functional
recovery, implicating mean FA at the site of compression as a
biomarker for determining favorable surgical candidates.[73]
DTI parameters and ratios help in the prediction of functional
recovery after surgery.[75‑77] However, in contrast, Rajasekaran
et al. showed that the preoperative DTI datametrics are not
predictive of postoperative recovery;[70] the difference might
have been due to the magnitude (1.5 vs. 3 Tesla) of the MRI used.
Tractography gives a visual representation of fiber tracts,
which is generated by placing initial seed at C1–C2 level
covering the same region of interest that was used for
obtaining DTI datametrics. The criteria for cessation of
tracking are to be set at FA values >0.2. Four patterns are
described as completely intact, waisted, partially interrupted,
or completely interrupted [Figure 18]. Fiber indentation at the
compression level without interruption was taken as waisted
pattern. Fiber interruption across parts of the axial plane
was taken as partially interrupted. Fiber interruption across
the entire axial plane was taken as complete interruption.[70]
Tractography helps in prognostic prediction in CSM,[70,72,77]
and neurological improvement is more common in those with
intact tractography.[72]
Rajasekaran et al. analyzed DTI datametrics and tractography
and observed an increasing trend of preoperative DTI values
between control, ambulant, and nonambulant patients with
CSM.[70] The authors analyzed that the efficacy of DTI
anisotropy indices in predicting the postoperative recovery in
CSM patients and postoperative changes in the DTI indices
based on neurological recovery after surgery and found
that there was a significant improvement in postoperative
DTI indices in patients who showed neurological recovery;
however, the preoperative DTI evaluation could not
predict postoperative recovery for patients with CSM.[78] In
tractography, none of the patients had a normal tractography
whereas all the controls had normal pattern. However, the
distribution of abnormal patterns was variable between the
patients without any specific trend, and there was no significant
association with myelopathy severity,[70] while in multilevel
compressions, tractography helps in identifying the most
severely compressed level.[70] On comparing eigenvalues (E1 is
the longest vector along the long axis of the axonal cylinder and
represents the longitudinal diffusion in the white matter, and
E2 and E3 are minor eigenvectors representing the transverse
diffusion within the spinal cord), the authors observed that
minor eigenvectors had significantly higher values, denoting

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the increased transverse diffusion and loss of anisotropy,
similar to the results shown by Kang et al.[79]
Magnetic resonance spectroscopy in cervical spondylotic
myelopathy
MRS helps in understanding the progressive cellular alteration
and provides metabolic information such as cellular biochemistry
and function of the neural structures.[80] It assays a series of
biochemical markers such as N‑acetylaspartate (NAA), lactate,
choline (Cho), myo‑inositol (Myo‑I), glutamine‑glutamate
complex (Glx), and creatinine (Cr), with particular sensitivity
to NAA and lactate.[81] NAA is found only in axons and neurons
and is considered as a marker for neuronal integrity.[82] Salamon
et al.[83] reported that the early MRS changes in patients with
a b
c d
Figure 17: Axial magnetic resonance imaging at the level of no
compression (a) and corresponding fractional anisotropy map (b) in
diffusion tensor imaging, whereas axial magnetic resonance imaging
at the level of compression (c) and corresponding level diffusion tensor
imaging with reduced fractional anisotropy values (d)
a b
Figure 18: Tractography patterns: (a) normal, (b) waisted, (c) partially interrupted, and (d) completely interrupted
Indian Spine Journal ¦ Volume 2 ¦ Issue 1 ¦ January-June 2019
cervical stenosis and without spinal cord signal changes had
higher Myo‑I and Glx compared to that of the control group
and suggested Myo‑I as a potential early marker for spinal
cord inflammation and early‑stage demyelination. Increased
Cho levels appear later as cervical spondylosis progresses to
a symptomatic state, and significantly, higher Cho/Cr ratio
is found in patients with spinal cord signal changes than the
control. Higher Cho/NAA ratio is significantly associated with
poorer neurological function, and Cho/NAA had a significant
correlation with the mJOA score, providing a useful radiographic
biomarker in the assessment of cervical spondylosis.
Imaging in postoperative period
Cervical spine imaging after surgery plays a vital role in the
evaluation of level of surgery, adequacy of decompression,
position of implants, restoration of cervical alignment, cervical
fusion assessment, diagnosis of pseudoarthrosis, spinal cord
signal changes and to correlate with clinical improvement
from myelopathy. Cervical fusion can be assessed by either
radiographs or CT. Multiple radiological fusion criteria have
been described. The four most commonly used are the presence
of bridging trabecular bone between the endplates, absence
of a radiolucent gap between the graft and endplate, absence
of or minimal motion between adjacent vertebral bodies on
flexion‑extension radiographs, and absence of or minimal
motion between the spinous processes on flexion‑extension
radiographs. However, <1 mm of motion between spinous
process on lateral flexion and extension radiographs is
considered as the most reliable indicator for fusion.[84] Although
assessment through CT is accurate, it overestimates the fusion
rate as it is taken in static position, while dynamic analysis is
done in radiographs.[85,86] Exact assessment of fusion requires
dynamic information obtained from fl exion-extension x-ray
in association with high-resolution static information from CT.
Conclusion
Cervical spine imaging in CM plays an important role in
c d
29
[Downloaded free from http://www.isjonline.com on Monday, September 2, 2019, IP: 106.208.1.127]
Rajesh, et al.: Imaging in myelopathy
analyzing the cause of myelopathy and defining the level of
the lesion and parameters to assess the time of intervention
and to predict the outcome preoperatively.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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