Magnetic resonance tractography of the cervical spine: Toward routine clinical use

Spinal cord injury and non-traumatic myelopathies are major causes of lifelong disability, yet conventional magnetic resonance imaging (MRI) can underestimate microstructural damage. Diffusion tensor imaging (DTI) and tractography map white-matter integrity by measuring fractional anisotropy (FA) and mean diffusivity (MD), but their adoption in spine imaging has been limited by long scan times and complex post-processing. Supsupin et al report a two-minute cervical DTI sequence integrated into routine MRI and applied to four representative pathologies - spinal cord contusion, metastatic compression, degenerative myelopathy, and multiple sclerosis - compared with five controls. Each lesion showed distinctive tractographic and quantitative patterns: For example, reduced FA with preserved MD in contusion and combined FA decrease and MD elevation in metastatic compression. These findings highlight the potential of tractography to improve diagnosis, guide surgical planning, and monitor treatment, while maintaining clinical feasibility. Remaining challenges include limited angular resolution, motion artifacts, and the need for multicenter validation and advanced reconstruction methods. This manuscript places the study in the context of current spinal diffusion imaging and outlines future directions toward routine, precision care.