Diagnostic performance of zero-echo time (ZTE) MRI for preoperative evaluation of cervical OPLL complicated with...

To evaluate the diagnostic efficacy of zero-echo time (ZTE) magnetic resonance imaging (MRI) for cervical ossification of the posterior longitudinal ligament (OPLL) complicated by dural ossification (DO), compared with T1-weighted imaging (T1WI) and T2-weighted imaging (T2WI).

This retrospective single-center study included 73 consecutive OPLL patients (52 males, 21 females; mean age 55.5 ± 10.6 years) admitted between April 2025 and October 2025. All underwent 1-mm thin-slice computed tomography (CT) (gold standard) and 3.0T MRI (T1WI, T2WI, and ZTE). Two senior radiologists blindly assessed DO presence. Sensitivity, specificity, diagnostic accuracy, area under the curve (AUC), and Cohen's κ interobserver agreement coefficient were calculated, with McNemar's and DeLong's tests applied for interreader and pairwise AUC statistical comparisons, respectively.

CT confirmed 46 cases (63.0%) of cervical OPLL complicated with DO. For the ZTE sequence, the diagnostic sensitivity of the two readers was 93.5% and 95.7%, specificity was 96.3% and 88.9%, accuracy was 94.5% and 93.2%, and AUC was 0.949 and 0.923, respectively. These metrics were significantly superior to those of T1WI imaging (AUC 0.522-0.536) and T2WI imaging (AUC 0.550-0.572). DeLong's test confirmed that the AUC of ZTE was significantly higher than that of T1WI (P < 0.001) and T2WI (p < 0.001), while there was no significant difference between T1WI and T2WI (p > 0.05). Regarding interobserver consistency: the Cohen's κ value for ZTE was 0.854, while those for T1WI and T2WI were -0.043 and 0.466, respectively.

ZTE-MR imaging offers a nonionizing, highly sensitive, and reproducible approach for diagnosing cervical OPLL with DO and serves as a valuable adjunct to conventional sequences for preoperative evaluation.