Advanced Spine Imaging: Technical Updates and Practice Recommendations

Advanced spine imaging has historically lagged behind brain and neck imaging for implementation into clinical practice. This is largely due to unique technical challenges including rectangular FOV, anatomic curvature, small cross-section, multiple tissue interfaces, physiologic motion, and surgical hardware. For common indications such as low back pain, advanced imaging may not be necessary for routine care. However, for complex problem-solving, improved anatomic and functional spine assessment can have profound impacts on patient diagnosis, interventional planning, and outcomes. Advanced techniques can sensitively and quantitatively interrogate vertebrae, intervertebral discs, spinal canal, neural foramina, spinal cord, and nerves. This comprehensive review from the American Society of Spine Radiology Education and Standards Committee synthesizes technical principles and applications of advanced spine imaging for routine clinical use, complex problem-solving, and ongoing investigation. We present a didactic categorization of diffusion, perfusion, parametric, CSF, dynamic, anatomic, metabolic, functional, and miscellaneous techniques. Each section provides a high-level summary of technical background, key advantages and disadvantages, clinical readiness, and recommended use cases with correlative imaging examples.