New back pain with neuro deficit (suspected cord compression)
Recommended: MRI entire spine without contrast is the preferred imaging study for new back pain with neuro deficit (suspected cord compression). Emergent total-spine MRI.
Recommended study
MRI entire spine without contrast
Emergent total-spine MRI. Add contrast if infection, abscess, or tumor suspected. CT myelogram if MRI contraindicated.
If the default doesn't apply
Concern for infection (epidural abscess, discitis)
MRI
MRI Spine with and without contrast
IV contrast
MRI contraindicated
CT
CT Myelogram
IV contrast
Watch-outs
Saddle anesthesia or bowel / bladder dysfunction
Cauda equina syndrome is a surgical emergency — image within hours and consult neurosurgery.
Known malignancy + new back pain
Image the ENTIRE spine — multi-level metastatic compression is common and changes radiation / surgical fields.
Pearls
- Symptoms can precede imaging findings — clinical exam (reflexes, tone, gait) drives urgency.
- Pre-treatment T2 hyperintensity within the cord (myelomalacia) is a poor prognostic sign.
- Steroid administration should not be delayed for imaging in suspected metastatic cord compression.