How to Plan a Cervical Spine MRI Protocol

Intro to Cervical Spine MRIs

How to Perform a Cervical Spine MRI

This hardware setup is widely used in clinical practice. It balances acquisition time, image quality, and patient comfort.

3. Capture the Initial Localizer Images

Before we can perform any MRI protocol, we must always capture initial localizer images of the patient. These images act as a guide for planning the detailed scans we will perform next.

We should always capture localizers in three planes:

1. Axial
2. Sagittal
3. Coronal

Once acquired, upload the initial localizer images into the three viewports.

Then, scroll through each of the image stacks to locate a central slice that clearly shows the anatomy of the cervical spine.

✅ Correct Setup of Localizer Images for Cervical Spine MRI:

Part 2: Plan and Acquire the Protocol Sequences

When all preparations are ready, we can start planning and acquiring the protocol sequences.

Let's go through the pulse sequences a standard cervical spine MRI protocol includes, why we perform them, and how to set them up.

The 6 Sequences of a Standard Cervical Spine MRI Protocol

1. Sagittal T2 TSE
2. Sagittal T1 TSE
3. Sagittal STIR TSE
4. Coronal T2 TSE
5. Axial T2 TSE
6. Axial T1 TSE

We mainly use Turbo/Fast Spin Echo sequences for this study. These sequences provide fast, high-quality images with excellent soft tissue contrast and minimal artifacts, making them ideal for cervical spine diagnosis.

Turbo Spin Echo also lets us create multiple types of contrasts, including T2, T1, and inversion recovery for fat suppression. This helps us assess the spine's structure, detect abnormalities, and identify common pathologies like disc herniation, cord compression, and inflammation.

In the sections below, we go through how to plan and set up each sequence.

1. Planning Sagittal T2 TSE

✅ Correct Planning:

Planning Instructions:

• Use the spinal cord as your anatomical reference.
• Align the slices as follows:
  • Coronal localizer: Grab the slice and align it parallel to the spinal cord direction.
  • Axial localizer: Ensure the line passes through the middle of the vertebral body, following all the way back to the posterior processes of the vertebrae.
• Use appropriate geometry parameters:
  • Slice number: Enough to cover vertebral bodies from right to left (typically 15–20 slices).
  • Slice thickness: 3 mm, optimal for good resolution without sacrificing scan time or SNR.
  • Slice gap: 0.3 mm, minimal gap (10% of thickness) prevents crosstalk while maintaining continuity.
• Set the fold-over direction (phase encoding) to foot-to-head (FH) to align with CSF flow direction and minimize flow artifacts.

2. Planning Sagittal T1 TSE

✅ Correct Planning:

Planning Instructions:

• Copy the slice geometry and planning from the previous sagittal T2 sequence.
• Keep the same slice angulation, coverage, and positioning to ensure images of different contrasts can be clearly compared.

3. Planning Sagittal STIR TSE

✅ Correct Planning:

Planning Instructions:

• Copy the slice geometry and planning from the previous sagittal T1 sequence.
• Keep the same slice angulation, coverage, and positioning to ensure images of different contrasts can be clearly compared.

4. Planning Coronal T2 TSE

✅ Correct Planning:

Planning Instructions:

• Use the spinal cord as your anatomical reference.
• Align the slices as follows:
  • Sagittal localizer: Align slices parallel to the spine and center them.
  • Axial localizer: Slices should be perpendicular to the midline that passes through the vertebral body to the posterior processes.
• Use appropriate geometry parameters:
  • Slice number: Enough to cover from anterior cervical spine to posterior (typically 15–25 slices).
  • Slice thickness: 3 mm, consistent with sagittal sequences.
  • Slice gap: 0.3 mm, maintains consistency with other sequences.
• Set the fold-over direction (phase encoding) to foot-to-head (FH) to avoid flow artifacts, same as sagittal sequences.

5. Planning Axial T2 TSE

✅ Correct Planning:

Planning Instructions:

• Use the cervical spine and intervertebral discs as your anatomical references.
• Align the slices as follows:
  • Sagittal localizer: Slices should be perpendicular to the cervical spine.
  • Coronal localizer: Slices should run parallel to the intervertebral spaces.
• Use appropriate geometry parameters:
  • Slice number: Enough to cover all seven cervical discs (C1-C7), typically 20–25 slices.
  • Slice thickness: 3 mm, same as other sequences.
  • Slice gap: 0.3 mm, maintains consistency.
• Set the fold-over direction (phase encoding) to anterior-posterior (AP) to align with the axial anatomy shape.
• Place a saturation band on the patient's throat to suppress swallowing artifacts without covering the cervical discs.

6. Planning Axial T1 TSE

✅ Correct Planning:

Planning Instructions:

• Copy the slice geometry and planning from the previous axial T2 sequence.
• Keep the same slice angulation, coverage, and positioning to ensure images of different contrasts can be clearly compared.
• Keep the same saturation band placement on the throat.

How to Avoid Artifacts When Planning the Sequences

The table below lists the 5 common cervical spine artifacts, and what techniques you can use to avoid them:

Part 3: Review the Images

Finally, we will review the images to ensure all the anatomical information we need is clear.

These key structures must be clearly visible in a cervical spine MRI:

1. Spinal cord and central canal
2. Cerebrospinal fluid spaces
3. Intervertebral discs (C2-C3 through C7-T1)
4. Vertebral bodies (C1-C7 and T1-T2)
5. Neural foramina and nerve roots
6. Ligamentous structures
7. Surrounding soft tissues

Below, we will go through all the different image contrasts and explain their specific role in imaging the cervical spine.

T2 TSE – Highlights Fluid-Related Tissues and Conditions

T2-weighted imaging makes fluids appear bright. This contrast is ideal for tissues and abnormalities with high water content.

In cervical spine MRI, T2 sequences are the gold standard for detecting spinal cord compression, disc herniation, myelopathy, and cord edema. The bright cerebrospinal fluid provides excellent contrast against the darker spinal cord, making compression visible as narrowing of the bright CSF space around the cord.

We capture T2 images in three planes (sagittal, coronal, and axial) to provide comprehensive visualization of spinal pathology from multiple angles.

✅ Sagittal T2 TSE of the Cervical Spine – Correct Image Example:

Things to Look for in Sagittal T2:

• Bright CSF should surround the dark spinal cord without narrowing.
• Intervertebral discs should show normal hydration (bright signal).
• Look for disc herniations compressing the thecal sac.
• Assess for cord signal changes indicating myelopathy.

✅ Coronal T2 TSE of the Cervical Spine – Correct Image Example:

Things to Look for in Coronal T2:

• Neural foramina should be open and symmetric.
• Look for lateral disc herniations or foraminal stenosis.
• Assess spinal cord alignment and any lateral compression.

✅ Axial T2 TSE of the Cervical Spine – Correct Image Example:

Things to Look for in Axial T2:

• Central canal should be patent with bright CSF.
• Disc material should not indent the thecal sac.
• Neural foramina should be symmetric and uncompressed.
• Look for any soft tissue masses or ligamentum flavum hypertrophy.

STIR TSE – Clearest View of Fluid-Related Tissues and Conditions

STIR (Short Tau/TI Inversion Recovery) suppresses fat signals completely, which makes water-rich tissues stand out even clearer than with normal T2 TSE. This makes STIR ideal for detecting subtle fluid-related conditions – like edema, inflammation, and infections – where increased water content would otherwise be obscured by fat.

In the cervical spine, this contrast is particularly useful for identifying bone marrow edema, ligament tears, cord contusions, and infections like discitis or myelitis. STIR is crucial for detecting acute trauma injuries and inflammatory conditions where water content might not be visible on standard T2 sequences.

We capture STIR images in the sagittal plane to provide comprehensive assessment of inflammatory and traumatic changes.

✅ Sagittal STIR TSE of the Cervical Spine – Correct Image Example:

Things to Look for in Sagittal STIR:

• Fat should appear uniformly dark (well-suppressed).
• Look for bright signal in bones indicating marrow edema.
• Assess ligaments for tears or inflammation.
• Look for any inflammatory processes in soft tissues.
• Evaluate for cord edema or contusion.

T1 TSE – Highlights Fat-Containing Tissues and Structural Abnormalities

T1-weighted imaging makes fat appear bright and fluid dark. This contrast is ideal for fat-rich tissues and structural abnormalities. T1 shows anatomical structures clearly, since it helps us see where different solid tissues like muscle and fat meet.

In cervical spine MRI, T1 sequences are important for evaluating vertebral body integrity, bone marrow pathology, and anatomical landmarks. T1 is also useful for detecting subacute hemorrhage, tumors, and serves as a baseline before contrast administration.

We capture T1 images in sagittal and axial planes to provide structural detail complementary to the T2 sequences.

✅ Sagittal T1 TSE of the Cervical Spine – Correct Image Example:

Things to Look for in Sagittal T1:

• Vertebral bodies should show bright, uniform bone marrow signal.
• Look for dark lesions indicating metastases or fractures.
• Assess disc height and alignment.
• Evaluate pre-vertebral soft tissues for masses or swelling.

✅ Axial T1 TSE of the Cervical Spine – Correct Image Example:

Things to Look for in Axial T1:

• Bone marrow should appear bright and symmetric.
• Look for fat-containing lesions like lipomas.
• Assess vertebral body structural integrity.
• Evaluate surrounding soft tissue anatomy.

Final Checks:

Before finishing a cervical spine MRI, always check these 5 points to ensure diagnostic quality:

1. Complete Coverage: All sequences must cover from the pons to T1-T2, including all seven cervical vertebrae and their discs.
2. Spinal Cord Visibility: The spinal cord and CSF spaces must be clearly visible throughout the cervical region in all sequences.
3. Image Quality: All images must have strong SNR, sharp anatomical detail, and no significant motion, flow, or chemical shift artifacts.
4. Consistent Planning: Sagittal, coronal, and axial planes must be properly aligned to the spinal anatomy for accurate assessment.
5. Artifact Management: Check that saturation bands are properly placed, fold-over suppression is active, and bandwidth is optimized for the field strength.

‍