The current state-of-the-art of spinal cord imaging: Applications

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Review

The current state-of-the-art of spinal cord imaging — Applications

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C. Wheeler-Kingshott a,⁎, P.W. Stroman b, J.M. Schwab c,d, M. Bacon e, R. Bosma b, J. Brooks f,g, D.W. Cadotte h,T. Carlstedt a, O. Ciccarelli a,i, J. Cohen-Adad j, A. Curt k, N. Evangelou l, M.G. Fehlings h, M. Filippi m, B.J. Kelley n,S. Kollias o, A. Mackay p,q, C.A. Porro r, S. Smith s, S.M. Strittmatter n, P. Summers r, A.J. Thompson a,i, I. Tracey f,g

a NMR Research Unit, Queen Square MS Centre, UCL Institute of Neurology, London, England, UKb Centre for Neuroscience Studies, Queen's University, Kingston, ON, Canadac Wings for Life Spinal Cord Research Foundation, Salzburg, Austriad Charité, Universitätsmedizin Berlin, Germanye International Spinal Research Trust, Bramley, Surrey, UKf FMRIB Centre, Nuffield Department Clinical Neurosciences, University of Oxford, England, UKg FMRIB Centre, Nuffield Division Anaesthetics, University of Oxford, England, UKh Division of Neurosurgery and Spinal Program, University of Toronto, Toronto, ON, Canadai National Institute for Health Research, University College London Hospitals Biomedical Research Centre, London, England, UKj Institute of Biomedical Engineering, Ecole Polytechnique de Montreal, Montreal, QC, Canadak Balgrist University Hospital, Spinal Cord Injury Center, Zurich, Switzerlandl University of Nottingham, Nottingham, UKm Neuroimaging Research Unit, San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italyn Cellular Neuroscience, Neurodegeneration and Repair, Yale University, New Haven, CT, USAo Institute for Neuroradiology, University Hospital Zurich, Zurich, Switzerlandp Dept. of Radiology, University of British Columbia, Vancouver, BC, Canadaq Dept. of Physics & Astronomy, University of British Columbia, Vancouver, BC, Canadar Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Modena, Italys Department of Radiology and Radiological Sciences, Vanderbilt University, Institute of Imaging Science, Nashville, TN, USA

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⁎ Corresponding author at: University Reader in MagnUK. Fax: +44 20 7278 5616.

E-mail address: [email protected] (C. W

1053-8119/$ – see front matter © 2013 Published by Elhttp://dx.doi.org/10.1016/j.neuroimage.2013.07.014

Please cite this article as: Wheeler-Kingshothttp://dx.doi.org/10.1016/j.neuroimage.2013

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Article history:Accepted 4 July 2013Available online xxxx

Keywords:Magnetic resonanceSpinal cordFunctional MRIDiffusionSpinal cord injuryPathology

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RREA first-ever spinal cord imaging meeting was sponsored by the International Spinal Research Trust and the

Wings for Life Foundation with the aim of identifying the current state-of-the-art of spinal cord imaging,the current greatest challenges, and greatest needs for future development. This meeting was attended bya small group of invited experts spanning all aspects of spinal cord imaging from basic research to clinicalpractice. The greatest current challenges for spinal cord imaging were identified as arising from the imagingenvironment itself; difficult imaging environment created by the bone surrounding the spinal canal, physio-logical motion of the cord and adjacent tissues, and small crosssectional dimensions of the spinal cord,exacerbated by metallic implants often present in injured patients. Challenges were also identified as a resultof a lack of “critical mass” of researchers taking on the development of spinal cord imaging, affecting both therate of progress in the field, and the demand for equipment and software to manufacturers to produce thenecessary tools. Here we define the current state-of-the-art of spinal cord imaging, discuss the underlyingtheory and challenges, and present the evidence for the current and potential power of these methods.In two review papers (part I and part II), we propose that the challenges can be overcome with advancesin methods, improving availability and effectiveness of methods, and linking existing researchers to createthe necessary scientific and clinical network to advance the rate of progress and impact of the research.

© 2013 Published by Elsevier Inc.

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UContents
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0General overview of fMRI and DTI . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0

fMRI in the human spinal cord: Applications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0DTI in the human spinal cord: Applications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0

etic Resonance Physics, Department of Neuroinflammation, UCL Institute of Neurology, Queen Square, London WC1N 3BG,

heeler-Kingshott).

sevier Inc.

t, C., et al., The current state-of-the-art of spinal cord imaging — Applications, NeuroImage (2013),.07.014

http://dx.doi.org/10.1016/j.neuroimage.2013.07.014

mailto:[email protected]


http://www.sciencedirect.com/science/journal/10538119


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Spondylotic myelopathy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0Spinal cord injury . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0Pain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0

Evidence for a spinal metabolic response to nociceptive stimulation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0Human pain studies using fMRI . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0

Multiple sclerosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0Concluding statements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0Acknowledgments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0

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Introduction

Our ability to research and understand human spinal cord function,its role in pain processing, the effects of traumatic injury or diseasessuch as multiple-sclerosis, and our understanding of pain processing,is all significantly hampered by the limited accessibility of the spinalcord. In the part I of our two part series we have described the currentstate-of-the-art of spinal cord imaging, the current greatest chal-lenges, and the greatest needs for future development in order to sup-port non-invasive human spinal cord research (Stroman et al., 2013).The general assumption is that providing increased sensitivity andspecificity of spinal cord imaging in the context of well-defined clinicalreadouts will be instrumental to improve novel approaches in thediagnostic and treatment of spinal cord diseases. The objectives of thispaper are to:

1) describe the current state-of-the-art and capabilities of humanspinal cord imaging applications;

2) identify the greatest current needs, from a clinical point of view,that will drive forward future development.

In order to achieve these objectives we provide a general overviewof two key techniques employed in clinical research, functional Mag-netic Resonance Imaging (fMRI) and Diffusion Tensor Imaging (DTI),and then focus on specific applications of spinal cord imaging onfour areas: investigations of cervical spondylotic myelopathy (CSM),spinal cord injury (SCI), pain and multiple-sclerosis (MS). Whereverapplicable, reference to quantitative imaging methods other thanfMRI and DTI, such as magnetic resonance spectroscopy (MRS) andmagnetization transfer (MT) imaging, will also be mentioned. Issuesrelated to spatial resolution, registration of subsequently acquiredvolumes, partial volume effects with the cerebrospinal fluid (CSF), aswell as the lack of a standard common template and the effects ofphysiological noise are still limiting the adoption of many techniquesinto the clinical setting, confounding quantitative MRI of the spinalcord to research studies. The overall goal of this work is therefore tofoster the development of novel and sensitive means of characterizingneural function and cellular structure in clinical populations that cansupplement or surpass current methods for patient assessment,serve as clinical trial endpoints, and be used for monitoring of diseaseprogression and efficacy of therapies.

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Table 1Examples of studies employing spinal cord fMRI:.

Healthy (uninjured) volunteers: Motor tasks (hand, and leg) (Kornelsen and Strothermal stimulation (hand, leg) (Stroman, 2009;2011) thermal pain (Brooks et al., 2008, 2012; Cet al., 2001, 2002a,b; Summers et al., 2010) vibra(Agosta et al., 2009c; Ghazni et al., 2010; SummfMRI with brief thermal stimulation (Figley and

Patients with carpal tunnel syndrome: Pressure on affected median nerve (Leitch et al.,Patients with spinal cord injuries: Thermal sensory stimulation (hands, legs) (Strom

Stroman, 2007)Patients with multiple sclerosis: Thermal sensory stimulation (Agosta et al., 2008

hand motor tasks (Agosta et al., 2008b; Valsasin

Please cite this article as: Wheeler-Kingshott, C., et al., The current state-ohttp://dx.doi.org/10.1016/j.neuroimage.2013.07.014

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General overview of fMRI and DTI

fMRI in the human spinal cord: Applications

A growing number of studies (summarized in Table 1) have beencarried out to investigate spinal cord function in response to varioussensory stimuli and motor tasks and to characterize the effects oftraumatic injury and pathology.

Determining the sensitivity and reliability of spinal cord fMRI is achallenging task in that there is no “gold-standard” method that canbe used to verify the results obtained in humans (Stroman et al.,2013). Even studies with animal models (Lawrence et al., 2004, 2007;Majcher et al., 2006, 2007; Malisza and Stroman, 2002; Malisza et al.,2003) can provide only limited validation because surgical interven-tions, anesthetics, and differences in emotional and cognitive factorscan all significantly alter neural activity in the spinal cord (Hochman,2007; Lawrence et al., 2004, 2007; van Eijsden et al., 2009). The reliabil-ity of spinal fMRI results must therefore be inferred from consistencyacross repeated studies, sensitivity to different stimuli or tasks, and cor-respondence with recorded responses and psychophysical ratings bythe participants.

The studies listed in Table 1 have shown active regions in the spi-nal cord that are consistent across groups of participants, and thatcorrespond with the region of the body being stimulated, or motortask being performed. A high degree of laterality has been demon-strated in comparisons of right-side and left-side motor activity orstimulation of the hand and shoulder (Maieron et al., 2007; Stromanet al., 2012). Although this is very encouraging, the relatively lowresolution and consequent partial volume effects need to be consid-ered when studying patients with severe spinal cord atrophy. SpinalfMRI studies in rats have provided further support by showing acorrespondence between areas of activity detected with spinal fMRIand cells labeled with c-fos staining stimuli, when a noxious electricalstimulus was applied (Lawrence et al., 2004). This body of results pro-vides strong evidence that signal changes related to neural activity inthe spinal cord can indeed be detected with spinal fMRI methods.Several of the studies have further shown that spinal responses varywith the intensity, andmodality of the stimulus. Most notably, applyingthermal stimuli of between 32 °C and 10 °C to the leg revealed areasof activity in the lumbar spinal cord where signal intensity responsesvaried with the temperature, and notably included an abrupt transition

man, 2004; Maieron et al., 2007; Stroman and Ryner, 2001; Stroman et al., 1999)Stroman and Cahill, 2006; Stroman and Ryner, 2001; Stroman et al., 2001, 2004b,ahill and Stroman, 2011; Eippert et al., 2009a, 2009b; Sprenger et al., 2012; Stromantion (Lawrence et al., 2008) electrical stimulation (Xie et al., 2012) light touchers et al., 2010) sensitization with capsaicin (Ghazni et al., 2010) event-relatedStroman, 2012)2009, 2010)an et al., 2002c, 2003, 2004a) leg motor tasks (active and passive) (Kornelsen and

b; Valsasina et al., 2010) proprioception (Agosta et al., 2008b; Valsasina et al., 2010)a et al., 2010)

f-the-art of spinal cord imaging — Applications, NeuroImage (2013),


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to higher signal intensity changeswhen the stimulus went below 15 °C,a level considered painful (Stroman et al., 2002c). Patient studies pro-vide further evidence of response sensitivity to pathological changessuggestive of a neuronal basis for spinal cord activity. Studies of peoplewith SCI and MS have demonstrated altered activity in the spinal corddepending on the injury severity or disease state (Agosta et al., 2008a,2008b; Kornelsen and Stroman, 2007; Stroman et al., 2004a; Valsasinaet al., 2010).

From a clinical perspective, it is important to recognize that spinalfMRI has been demonstrated for group analyses but that there are stillsources of variability or uncertainty that count against its use for indi-vidual studies. Once these sources of variability and errors are charac-terized and understood, it is expected that methods can be adapted tooptimize the sensitivity to study and assess individuals.

DTI in the human spinal cord: Applications

Given the sensitivity and specificity of DTI to white matter integrity,this technique is sensitive to structural changes due to pathology. De-spite the technical challenges associated to spinal cord DTI, this methodhas been applied in healthy and diseased spinal cord in humans in vivo,as summarized in Table 2.

DTI has also proven to be sensitive to Wallerian degenerationthrough animal models of pericontusional traumatic axonal injury(Mac Donald et al., 2007), demyelinating lesion (DeBoy et al., 2007)and dorsal root axotomy (Zhang et al., 2009). The specificity of diffu-sion measurements to white matter pathology has been studied inanimal models of de/dysmyelination and suggests that axial diffusiv-ity is more specific to axonal degeneration whereas radial diffusivityis more specific to demyelination (Budde et al., 2007, 2008, 2009;DeBoy et al., 2007; Hofling et al., 2009; Kim et al., 2007; Kozlowskiet al., 2008; Mac Donald et al., 2007; Song et al., 2002; Xie et al.,2010; Zhang et al., 2009). Other studies however reported possibleinteractions between axial and radial diffusivities, thereby limitingthe specificity of these measures (Herrera et al., 2008; Sun et al.,2006; Wheeler-Kingshott and Cercignani, 2009; Wheeler-Kingshottet al., 2012). One argument refers to the pathophysiology of axondegeneration, as this process is known to be associated with demye-lination in several pathologies such as in MS (Schmierer et al., 2007)or in SCI (Cohen-Adad et al., 2011; Zhang et al., 2009). Anotherargument is related to the biophysical properties of DTI, in whichseveral physical parameters can influence diffusion metrics includingmyelination, axonal density, axonal diameter, or orientation of fiberbundles, as well as changes in the tissue matrix surrounding theaxons (Beaulieu, 2002; Sen and Basser, 2005; Wheeler-Kingshott andCercignani, 2009). Fig. 1 shows an example of corticospinal tract recon-struction from DTI data and their crossing in themedulla oblongata in a

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Table 2Examples of studies employing cervical spinal cord DTI:.

Healthy (uninjured) volunteers: Smith et al. (2010), Vedantam et al. (2013),Wheeler-Kingshott et al. (2002)

Spinal cord compressions Facon et al. (2005), Plank et al. (2007)Inflammatory diseases Renoux et al. (2006)Arteriovenous malformation Ozanne et al. (2007)Ischemia Thurnher and Bammer (2006)SCI Cohen-Adad et al. (2011, 2012), Ellingson et al.

(2008), Freund et al. (2012b), Lammertse et al.(2007), Shen et al. (2007)

CSM Sato et al. (2012), Uda et al. (2013)Multiple sclerosis Agosta et al. (2005, 2007a), Benedetti et al.

(2010), Ciccarelli et al. (2007), Hesseltineet al. (2006), Oh et al. (2013a, 2013b), Ohgiyaet al. (2007), Valsasina et al. (2005), Van Heckeet al. (2009)

Amyotrophic lateral sclerosis Agosta et al. (2009a), Cohen-Adad et al. (2013),Nair et al. (2010), Pradat et al. (2011), Valsasinaet al. (2007)


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healthy subject. Ultimately, it is always important to remember thatthe diffusion tensor is an imperfect model used to explain data andone must always look at the data and make sure that interpreta-tions in terms of axonal loss and demyelination are well supportedby the behavior of the underlying model (Wheeler-Kingshott andCercignani, 2009).

As extension of DTI, high angular resolution diffusion imaging(HARDI) and Q-Ball imaging (QBI) can represent more than one diffu-sion direction, and so alleviate some of the limitations of the diffusiontensor model in the presence of crossing fibers (Tuch, 2004). HARDIhas proven to be efficient in the detection of subtle axonal connec-tions in the spinal cord (Cohen-Adad et al., 2008; Lundell et al.,2009). The “model-free” q-space imaging approach appears to be fea-sible, if time-consuming, in the spinal cord and can be sensitive topathological changes (Farrell et al., 2008). Advanced models insteadare working towards characterizing axon diameter, density and dis-persion in the spinal cord, in order to achieve higher specificity ofthe imaging biomarkers. These studies are innovative and far frombeing available clinically but have a huge potential in terms of charac-terizing spinal cord pathology and predicting patient's outcome andtherefore need support from a network of scientists across centersin order to promote adoption into the clinical arena.

Spondylotic myelopathy

Spinal cord compression can be caused by various pathologicalprocesses such as neoplasms, degenerative changes, inflammatoryprocesses and trauma. Degenerative spine disease is the mostcommon and may have enormous effects on the patients' quality oflife (Kara et al., 2011). Progressive compression of the spinal corddue to narrowing of the spinal canal is the main pathophysiology un-derlying the non-traumatic myelopathy. Early diagnosis and appro-priately chosen treatment may prevent further damage to spinalcord (Kara et al., 2011). Therefore, it is very important to visualizethe on-going pathological process as early as possible. Careful quanti-tative analysis reveals that the combination of increased T2-weightedand reduced T1-weighted signal intensities, a long segment of in-creased T2-weighted signal intensity or patchy areas of increasedT2-weighted signal intensity is predictive of reduced neurological re-covery in patients undergoing surgery for CSM. These data can beused by clinicians to manage patient expectations and to assist inclinical decision-making (Arvin et al., 2013). Although at more ad-vanced stages of disease, conventional T1- and T2-weighted MR im-ages are quite sensitive for confirming the presence of myelopathy,in the early stages however, there are discrepancies between theactual clinical status and the imaging findings. Oligodendrocyte apo-ptosis and consequent demyelination found to play central role inneurologic deterioration seen in cervical spondylomyelopathy atlater stages (Kara et al., 2011). Spinal application of newly designeddiffusion tensor imaging (DTI) sequences allows a more sensitiveevaluation of the normal appearing white matter. Fractional Anisotro-py (FA), Apparent Diffusion Coefficient (ADC) and Mean Diffusivity(MD) metrics derived from DTI are able to document and quantifyorientation changes of water molecules in normal appearing whitematter of the spinal cord (Budzik et al., 2011; Cui et al., 2011;Xiangshui et al., 2010). The findings of two subjects with cervical my-elopathy are shown in Fig. 2 and Fig. 3. FA metrics have been found tobe more sensitive to pathological changes in comparison with ADCand MD values (Budzik et al., 2011). In a recently published prelimi-nary study using DTI on a 3 T MR system, Kara et al. (2011) found de-creased FA values and increased ADC values in stenotic segments incomparison with nonstenotic ones (mean FA and ADC in stenoticsegment: 0.65 and 1.01 with SD 0.04 and 0.19, respectively), sugges-tive of myelopathic changes even without T2 signal alterations. Byapplication of orientation based entropy analysis in multi-level com-pression, it is possible to evaluate the contribution of each compression



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Fig. 1. Selective reconstruction of the corticospinal tracts with crossing in the medulla oblongata in a healthy subject. a) Coronal view of the non-diffusion weighted scan with theCSTs in red. b) axial view of the spinal cord FA, color coded with the direction of the principal eigenvector of the diffusion tensor, with the right and left CSTs in red and blue, comingout of the axial section and showing their crossing point.


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level to the overall picture (Cui et al., 2011). Another recent study at 3 Tconfirmed an increasedMD and a decreased FA in patients compared tohealthy controls. Here the authors assessed the diagnostic utility ofDTI indices and found that in their study the receiver operating char-acteristic (ROC) analysis had higher sensitivity and specificity for pre-diction compared to FA and MD changes (Uda et al., 2013). ADCvalues have also been assessed to determine their ability to predict clin-ical recovery after decompression surgery in another study and showedpromising results, suggesting that further work is warranted to deter-mine the bestway to include diffusion indices into the evaluation of cer-vical myelopathy (Sato et al., 2012).

Spinal cord injury

Improving our ability to assess tissue viability and detect residualneuronal function in the spinal cord, in order to identify and distin-guish morphological and functional changes, is key to advancing ourcapacity for clinical prognosis and management of spinal cord injurypatients. A recently published prospective longitudinal study inchronic SCI investigated the motor system, including cervical spinalcord, cranial corticospinal tract (CST) and motor cortex, in particularcorrelating parameters indicative of axonal loss and myelin integrityto clinical outcome, providing a comprehensive assessment of progres-sion using multi-modal MRI (Freund et al., 2013). A cross-sectionalstudy of traumatic SCI patients using structural and functional MRI re-vealed associations between cross-sectional spinal cord area, gray andwhite matter volume as measured using voxel based morphometry of

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Fig. 2. (a–d) Sagittal T2, axial T2, DWI and 3D reconstruction of the spinal cord in cervical sfiber tractography reconstruction (d) shows diffuse nerve fiber destruction, eventually exp


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Rthe brain, cortical activations following right-sided hand grip as wellas median and tibial nerve stimulation and cortical thickness, and dis-ability (Freund et al., 2011) confirming observed changes in the motorcortex and motor pathways following SCI (Wrigley et al., 2009). Inlight of the evidence of functional and structural changes of the motorsystem in SCI and the sensitivity of spinal cord quantitative measure-ments to damage (Cohen-Adad et al., 2011; Freund et al., 2011;Lundell et al., 2011; Petersen et al., 2012), one aim of spinal cord fMRIis to complement structure-sensitive techniques (e.g. atrophy, DTI,MT), by characterizing normal spinal circuits in healthy individualsand to delineate how these circuits become damaged after injury. Theextension of this characterization is to predict progression and monitorthe beneficial or deleterious effects of different treatment options.

Injury to the human spinal cord, regardless of the mechanism, re-sults in a complex cascade of events at the cellular level that may ormay not have an effect on the neurovascular coupling mechanismsthat underlie the signal changes detected with spinal fMRI. It is im-portant therefore, to bridge the research gap between our detailedunderstanding of the pathophysiology of SCI and the biophysicalmechanisms of the signal changes that are exploited for spinal cordfMRI. Primary injury refers to a destructive force that directly leadsto neural structure damage, as for example the sheer force, whichtears an axon, or a direct compressive force occluding a blood vesselthat results in ischemia. The primary destructive events initiate a seriesof cellular mechanisms that result in ongoing damage to the neuralstructures, termed secondary injury (Tator and Fehlings, 1991). Thepathological processes that occur at the cellular level include ischemia,

pondylomyelopathy. Although one observes faint signal changes on sagittal T2 (a), 3Dlaining the clinical status of a patient.



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Fig. 3. (a–e) C6/C7 root compression due to herniated disk, and its effect on neural tissue integrity. DTI metrics allows us to observe increment in ADC and decrement in FA not onlyin affected area but also in near proximity in patients with disk herniation in comparison with healthy subject (mean ADC of healthy volunteer: 0.78 ± 0.0; mean FA of healthyvolunteer: 61 ± 5).


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vasospasm, ion-mediated cellular damage, excitotoxicity, oxidativecellular damage, neuroinflammation, and cell death. Changes in thecorrespondence between fMRI signal changes and neural activity maytherefore also depend on the time since the injury occurred, thus com-plicating interpretation.

There are a number of clinical outcomes that follow traumatic spi-nal cord injury as a consequence of either adaptive or maladaptiveplasticity. Adaptive plasticity refers to the concept of natural recoverywhereby an individual who sustained motor deficits, sensory impair-ment or both following SCI recovers to some degree in the monthsafter injury (Fawcett et al., 2007). Maladaptive plasticity refers to neu-rological symptoms that arise as a result of spinal circuits reorganizingthemselves in a way that provides no useful function such as neuro-pathic pain, spasticity, disruption of autonomic function and the lackof motor and sensory recovery (Gwak and Hulsebosch). One potentialadvantage of spinal fMRI will be to investigate the longitudinal effectsof various stimulation paradigms as they relate to clinical symptomssuch as the recovery of motor function, sensation or the developmentof neuropathic pain. A better understanding of the spinal circuit changes


that are associated with maladaptive plasticity may lead to more accu-rate diagnoses and the ability to objectively monitor treatment.

Studies of the effects of spinal cord injury that have been carried outto date using spinal cord fMRI have all focused on the chronic stages at1 year or more after the injury occurred. Potential confounding effectsinclude on-going changes in cellular function and ionic metabolism,each of which may alter mechanisms of neurovascular coupling andthe subsequent hemodynamic response. Nonetheless, the studies car-ried out to date have demonstrated that fMRI of the spinal cord candetect important changes as a result of traumatic injury in both thecervical and lumbar regions of the spinal cord (Goldfarb et al., 2011;Kornelsen and Stroman, 2007; Stroman et al., 2004a).

The first spinal cord fMRI study carried out on participants with spi-nal cord injuries investigated activity in the lumbar spinal cord, belowthe level of injury, in response to a noxious cold stimulus applied toleg (L4 dermatome) (Stroman et al., 2004a). This study demonstratedsignificant activity in all participants, including SCI patients, in thelumbar segments of the spinal cord, below the level of injury. Moreoverparticipants with SCI who could feel or had some altered sensation of



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the cold stimulus, had spatial patterns of activity that were similar tothat observed in healthy participants.

A more recent study of thermal responses in the cervical spinalcord and brainstem investigated responses to warm thermal stimuliin regions both above and below the level of injury (Saranathanet al., 2012). Results corresponded with the level and extent of injury,with responses above the level of injury being generally similar tothose seen in healthy participants, and responses below the levelof injury being altered depending on the injury severity. Right- andleft-side differenceswere also demonstrated, as well as correspondingactivity in the brainstem (Fig. 4).

Collectively, these results demonstrate the sensitivity of the fMRImethod to changes as a result of trauma and the feasibility of usingfMRI as a research tool for studying the effects of injury. Future clini-cal applications will require demonstration that the results obtainedin each participant are sufficiently sensitive and reliable to be suitablefor diagnostic purposes or monitoring of treatment outcomes. As spi-nal fMRI emerges as a tool to investigate spinal cord injury, we musttread cautiously with the interpretation of results. One limitation, forexample, is our lack of understanding of how the neurovascular cou-pling response may change after injury. Currently, the hemodynamicresponse function utilized in model-based fMRI data analysis is de-rived from healthy neural tissue. It will be important to investigate

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Fig. 4. Example of results obtained in a healthy female participant (top) and an age-matcheFour dermatomes were stimulated, corresponding to the right and left C5 and C8 spinal corsponses to right- and left-side stimulation of the little finger side of the palm (C8 dermatomeof the spinal cord in the C8 segment, with a high degree of laterality corresponding to the sideobtained in the participant with SCI show nearly normal responses on the left side of the spinin the medulla. In spite of an apparently extensive span of tissue damage in the cervical spin


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if damaged neural tissue also exhibits the same hemodynamic re-sponse function (both in temporal as well as spatial aspects) to agiven stimulus, because the accuracy of the predicted response canimpact on the sensitivity of the fMRI method for detecting neuralactivity. In addition, the technical challenges of spinal cord fMRI thathave been detailed in part I of this review (Stroman et al., 2013) mayneed to be reduced or eliminated before its sensitivity and reliabilityare acceptable for clinical applications.

In complement to the evidence for responses to stimuli that spinalfMRI can provide, there is an important place for DT-MRI in providinginformation about the structural integrity of spinal cord tissue after in-jury. It has been shown for example, that diffusion indices, based onadvanced acquisition and analysis protocols, are sensitive to severityof the damage, although no specific correlations were found with sen-sorimotor scores when looking at sensory-motor tracts. Correlationof DTI indices with electrophysiological measures have also beendemonstrated (Petersen et al., 2012) as well as correlation of spinalcord DTI indices with retrograde CST changes and disability (Freundet al., 2012a). Wallerian degeneration of white matter pathwayshave been shown to reach the cortico-spinal-tract in the brain andto correlate with functional reorganization (Freund et al., 2012b).These few early studies indicate that structural changes followinginjury have an effect on the diffusion properties of the tissue, which

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d participant with an incomplete (ASIA B) spinal cord injury (SCI) in the cervical level.d segments, and results are shown in selected axial and sagittal slices showing the re-). Results obtained in the healthy participant show activity in the ipsilateral dorsal hornof the body being stimulated, as well as activity in themedulla of the brainstem. Resultsal cord, and slightly altered responses on the right side, as well as corresponding activityal cord, the neural activity detected is only slightly altered.



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should be investigated in larger patient studies to prove their true po-tential as imaging biomarkers of tissue damage or integrity. Further-more, larger studies are needed to fully establish this technique as aclinical tool. It must be acknowledged however, that the challengesof spinal cord DT-MRI are worsened by the presence of metal implantsin SCI patients and therefore large population studies may be verydifficult to perform.

Clinical applications of spinal cord MRS to patients with SCI havebeen scarce and limited to a few studies that were carried out inpatients with cervical spondylotic myelopathy (Holly et al., 2009),chronic whiplash (Elliott et al., 2012) and brachial plexus injury(Kachramanoglou et al., 2013). Although most of these studies pub-lished so far are limited by small cohort sizes and technical limitations,they have shown the potential of MRS, which may provide informa-tion on the underlying mechanisms of the disease by reflectingpathological changes that are not detectable with conventional MRItechniques. Advanced diffusion imaging methods, such as diffusionkurtosis and q-space imaging have also shown great potential in cor-relating with disability in patients with spondylotic myelopathy(Hori et al., 2012), but are beyond the scope of the present review.

Pain

The spinal cord (and brainstem) is the first point in the centralnervous system that processes nociceptive signals arriving from thebody, and which ultimately may produce a sensation of pain. Func-tional imaging of the spinal cord aims to record this activity and canhelp to better understand how these signals are processed andwhether altered spinal cord function underlies chronic or neuropathicpain states in humans. Nociceptors, free nerve endings located in skin,muscles and viscera, respond to potentially tissue-damaging stimulisuch as temperature, pressure, extreme pH and other noxious stimuliby producing afferent volleys that signal the location, nature and in-tensity of the threat. Indeed, functional imaging studies have demon-strated widespread activity across the brain (Jones et al., 1991; Talbotet al., 1991) in response to painful stimuli. The development ofnon-invasive imaging techniques to record spinal activity providescritical information needed to interpret nociceptive processing inhealth and disease, andmay help explain the patterns of brain activityobserved in response to noxious stimulation in healthy controls andin patients suffering from pain. Furthermore, it has already providedimportant information about the modulation of spinal nociceptiveprocessing induced by analgesic drugs or by other non-pharmacologicaltreatments.

Evidence for a spinal metabolic response to nociceptive stimulation

For a long time the focus on understanding hownociceptive signalsare processed within the central nervous system has been targeted tothe spinal cord (McMahon et al., 2006; Wall, 1964). Anatomists andelectrophysiologists have described in great detail the laminar organi-zation of the spinal cord (Watson, 2009), with peripheral nociceptorsforming synaptic connections within different dorsal horn layers.More recently, the response of the spinal cord in awake or anesthetizedanimals has been studied using immunological and metabolic imagingtechniques. Bullitt (1991) used c-fos immunolabelling (Hunt et al.,1987) to record the response to acute prolonged nociceptive stimula-tion (e.g. hindpaw pinch), which increased gene expression in responseto neuronal activity in the ipsilateral dorsal horn, extending over severalsegments; these findings have been extended in other experimentalmodels of nociception (see reviews in (Coggeshall, 2005; Porro andCavazzuti, 1993)). Increasedmetabolic demanddue to neuronal activitycan be visualized using radiolabelled tracers such as 2-deoxyglucose(2-DG), and quantified using autoradiographic techniques (Coghillet al., 1991; Porro et al., 1991). An interesting observation is that, inthe awake rat, responses were observed bilaterally. The contralateral


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activation observed in unanesthetized animals could be due both tomotor behavior, and to “mirror” nociceptive processing (Aloisi et al.,1993). Note that the studies mentioned above utilized prolonged stim-ulation, and therefore the results may reflect changes in the tonic excit-ability of the cord (potentially reflecting pro-nociceptive input from thebrainstem).

Human pain studies using fMRI

The first study in humans using stimulation likely to activatenociceptors (electrical stimulation of the median nerve), wasperformed by Backes et al. (2001). In response to electrical stimula-tion at the elbow, cardiac gated BOLD-sensitive echo-planar imagesacquired in the sagittal plane revealed signal increases (uncorrectedp b 0.01) in lower cervical segments. Activity was not reliably de-tected in slices acquired in the transverse plane. Also in some in-stances bilateral activation was found. One issue relating to the useof supra-threshold (i.e. painful) electrical stimulation is that it excitesa wide range of nerve fibers that convey information relating to senseof touch/vibration, limb position, and nociception, making interpreta-tion of patterns of spinal activity difficult. Nonetheless, in other BOLDfMRI studies of the spinal cord (Brooks et al., 2012; Kong et al., 2012),patterns of cervical spinal activity were recorded in response to pain-ful thermal and punctate stimulation and compared across a group of18 subjects; a predominantly ipsilateral response was demonstratedusing a mixed effects model and corrected (voxel-level) statistics(Brooks et al., 2012). However, not all reports of spinal activity in re-sponse to nociceptive stimuli have demonstrated lateralized activityin the cord. In response to painful laser stimulation of the dorsumof the left hand, activating predominantly Aδ fibers, activity wasobserved to be bilateral in the cervical spinal cord (Summers et al.,2010). Importantly, this was the first study to directly assess thefalse-positive detection rates in spinal cord activity, and the numberof activated voxels in response to laser stimulation was found toexceed the false-positive level. Concerning the absence of lateralizedsignals in response to nociceptive stimulation, it should be notedthat this assessment was made on the basis of sub-dividing the cordinto right and left halves, so any bilateral motor-reflex activity inresponse to stimulation (involving activity in both anterior horns)might have concealed increased ipsilateral dorsal horn activity.

By using a combination of BOLD and SEEP contrast, Ghazni andco-workers reported changes in spinal cord and brainstem activityin response to painful and non-painful punctate stimuli (Ghazniet al., 2010). Activity in response to stimulation of the right thumbwith a light (2 g) and heavier (15 g) von Frey filament was observedthroughout the spinal cord, brainstem and thalamus. Surprisingly, ac-tivity in the ipsilateral cervical dorsal horn and brainstemwas highestfor the light-weight probe, which was interpreted as reflecting de-scending modulation from the brainstem. Of direct relevance to thestudy of descending pain modulation, two recent studies haverecorded the brainstem and spinal cord response during endogenousanalgesia due to placebo effects (Eippert et al., 2009a, 2009b). In re-sponse to thermal stimulation of the left forearm, in a region treatedwith an inert cream as a placebo, increased activity in periaqueductalgray matter (PAG) and rostral ventromedial medulla (RVM) wasobserved (Eippert et al., 2009a). Conversely, BOLD evoked signal in-creases were reduced in a restricted region of the spinal cord duringplacebo analgesia; this was interpreted as reflecting decreased noci-ceptive processing in the spinal cord due to descending pain modula-tion (Eippert et al., 2009b). The role of attention on patterns ofbrainstem and spinal cord activity in response to cold stimulation(18 or 15 °C) that produced “mild” to “strong discomfort”, was inves-tigated by Stroman et al. (2011). Similar to previous data examiningbrainstem responses following painful thermal stimulation (Traceyet al., 2002), increased activity was found in the PAG during distrac-tion conditions, perhaps relating to altered levels of discomfort.



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However, activity at the level of the spinal cord was opposite to whatmight be expected on the basis of descending inhibition of nocicep-tive input, with decreased activity during the no-distraction “rating”period when compared to the distraction condition. On the otherhand, a recent study by Sprenger et al. (2012) has demonstratedthat during a mentally demanding distraction task (n-back task), spi-nal cord activity in response to concurrent painful thermal stimula-tion is reduced when cognitive demand is high, and that thereduction in pain ratings (when compared to the low cognitivedemand condition) is significantly correlated with the change inBOLD signal. It is worth noting that developments in MR data acquisi-tion e.g. the use of slice dependent z-shimming (Finsterbusch et al.,2012) and region-selective radiofrequency (RF) excitation pulses(Finsterbusch, 2013; Finsterbusch et al., 2013) may improve our abilityto record BOLD signal changes in the human spinal cord. In particular,z-shimming has been already used to study spinal responses to noxiousstimulation (Eippert et al., 2009a, 2009b; Sprenger et al., 2012).

The studies of pain that have been reported to date demonstratethat by using spinal fMRI, researchers are already asking challengingquestions relating to the interaction of brain, brainstem and spinalcord and of our ability to endogenously control pain. Future researchassessing the impact of analgesic compounds on pain-related activityin the human spinal cord is already beginning.

Multiple sclerosis

Multiple sclerosis (MS) is the disease that has benefitted mostlyfrom advanced quantitative spinal cord imaging techniques, spanningfrom cord atrophy measurements, fMRI, DTI and also magnetizationtransfer ratio (MTR), myelin imaging and proton MRS, as describedin this session. Fig. 5 is showing an example of some of these tech-niques in a patient with MS at cervical level.

Cord lesions in MS are more frequently observed in the cervicalthan in other regions, are usually peripheral, limited to two vertebral

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Fig. 5. Spinal cord images acquired on a patient with multiple sclerosis. a) 3D Fast Field Echo (FFOV 240 × 180 mm2, TR 23 ms, TE 5 ms, flip angleα = 7°, number of averages = 8, voxel sizimaging (b—MT pulse ‘ON’; c—MT pulse ‘OFF’) acquiredwith the following parameters: 3D slaα = 9°), 22 axial slices, FOV = 240 × 180 mm2, voxel size 0.75 × 0.75 × 5 mm3 reconstructetor = 2, total acquisition time = 9 min. TheMTpulse characteristics were: Sinc-Gaussian shapDiffusion tensor imaging (DTI) derivedmaps (d— FA; e—MD). DW imageswere acquired axialof 64 × 48 mm2, SENSE factor = 1.5, acquisitionmatrix 64 × 48, voxel size = 1 × 1 × 5 mm3

directions evenly distributed over the sphere and 3 non-DWI (b = 0) volumes.


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segments in length or less, occupy less than half the cross-sectionalarea of the cord, and typically are not T1-hypointense (Lycklamaet al., 2003). Asymptomatic spinal cord lesions have been describedin 30–40% of patients at presentation with clinically isolated syn-dromes (CIS) and in up to about 90% of patients with definite MS(Lycklama et al., 2003). Although significant reduction of cervicalcord size can also be observed in the early phase of MS (Brex et al.,2001), cord atrophy is more severe in the progressive forms of MS(Lycklama et al., 2003). Some studies in MS patients found a correla-tion between atrophy of the cervical cord and disability, measuredusing the Expanded Disability Status Scale (EDSS) (Kidd et al., 1993;Lin et al., 2004; Losseff et al., 1996). Changes at a given time pointand over time in cord cross-sectional area (CSA) correlate betterwith clinical disability than changes of T2 lesion burden (Losseffet al., 1996). As example of a novel development that could rapidlybe adopted, recently, a new semi-automatic method based on an ac-tive surface (AS) model of the cord surface allowing segmentationof long portions of the cord (Horsfield et al., 2010) has shown toprovide reproducible measures of cord CSA from C2 to C5. Its abilityto give atrophy measures of potential clinical relevance has beendemonstrated in a group of 40 patients with relapsing–remitting(RR) and secondary progressive (SP) MS (Horsfield et al., 2010).The use of this method in a multicenter study to investigate the cor-relation between cord atrophy and clinical disability in a large sampleof MS patients has demonstrated that CSA differs significantly amongthe mainMS clinical phenotypes and it is correlated with EDSS, with adifferential effect among disease clinical phenotypes: no associationin either CIS patients or in benign MS; association in RRMS, SPMSand primary progressive (PP) MS (Rocca et al., 2011). Combiningthe ASmethodwith voxel based analysis of structural scans of the spi-nal cord has the potential to provide an insight into localized changesin patients with MS (Rocca et al., 2013; Valsasina et al., 2013). Theseresults suggest that cervical cord atrophy provides a relevant anduseful marker for the characterization of clinical heterogeneity of

FE) image acquired in the axial plane with the following parameters: 10 contiguous slices,e = 0.5 × 0.5 × 5 mm3, total acquisition time = 13:34 min; b–c)Magnetization transferb-selective FFE sequencewith two echoes (TR = 36 ms, TE1/TE2 = 3.5/5.9 ms, flip angled to 0.5 × 0.5 × 5 mm3 to match the FFE scan resolution as in a), SENSE acceleration fac-edMT saturating pulse of nominalα = 360º, offset frequency 1 kHz, duration 16 ms. d–e)lywith the following parameters: TE = 52 ms, TR = 12 RRs (cardiac gated), reduced FOV. TheDW imaging protocol consisted of 30 b = 1000 s mm−2 DWI volumeswith gradient



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MSpatients. The stability of thismeasure among different centers sup-ports its use as surrogate marker to monitor disease progression inmulticenter trials.

Abnormal magnetization transfer and diffusion tensor MRI quanti-ties from the cervical cord have been shown in patientswith establishedMS, but not in those with clinically isolated syndromes (Agosta andFilippi, 2007). Conventional and diffusion tensor MRI of the cervicalcord was obtained from relapse-onset MS patients at baseline andafter a mean follow-up of 2.4 years (Agosta et al., 2007a): baselinecord cross-sectional area and FA correlated with increased disabilityat follow-up (Agosta et al., 2007a). Using magnetization transfer-weighted MRI a study showed that signal abnormalities in the dorsaland lateral columns of the spinal cord are correlatedwith vibration sen-sation and strength, respectively (Zackowski et al., 2009). Anotherstudy found that decreased magnetization transfer ratio (MTR) of thecentral gray matter of the cervical cord is related to EDSS score inpatients with relapsing-remitting (RR) MS (Agosta et al., 2007b). InRRMS, baseline cervical cord MTR was correlated with relapse rateand EDSS changes over 18 months (Charil et al., 2006). Recent studiesat 3 T have shown the sensitivity of DTI and MTR metrics to clinicallyrelevant differences in patients with MS, beyond conventional imagingmodalities (Oh et al., 2013a, 2013b).

A number of other quantitative MRI techniques have also been ap-plied in MS, although not as extensively as CSA, MTR and DTI indices.For example, a two year longitudinal study of cervical cord myelinwater in primary progressive multiple sclerosis found that at C2–C3the myelin water fraction decreased by 5% per year (Laule et al.,2010). Studies to assess metabolite concentrations in MS in the cervi-cal cord using MRS have been used both in cross-sectional and longi-tudinal studies. For example compared to controls, MS patients with acervical cord relapse have reduced NAA (N-acetyl-aspartate) concen-tration and lower structural connectivity in the lateral CST and poste-rior tracts, and such abnormalities were correlated with disability(Ciccarelli et al., 2007). Interestingly, spinal cord NAA levels partiallyincreased over time after an acute relapse, especially in patients whoimproved clinically (Ciccarelli et al., 2010a) suggesting that NAAmay reflect changes in axonal integrity and/or metabolism whichare clinically relevant. A recent paper has demonstrated that lowermyo-inositol/creatine values, possibly suggesting astrocytic damage,were consistently found within the NMO (neuromyelitis optica) le-sions in the spinal cord when compared with healthy controls andpatients with MS, who showed at least one demyelinating lesionat the same cord level, suggesting that the in vivo quantification ofmyo-inositol may distinguish NMO from MS (Ciccarelli et al., 2013).

Functional MRI has also been investigated in MS where an in-creased activation of the cervical cord has been demonstrated in allthe major MS clinical phenotypes and has been related to the severityof clinical disability and the extent of tissue damage (Agosta et al.,2009b, 2009c; Valsasina et al., 2010). Future studies will investigatefurther the potential derived from statistical modeling imaging mea-sures after the MRI post-processing, which may offer some informa-tion on the axonal,mitochondrialmetabolism (Ciccarelli et al., 2010b).

Concluding statements

Significant advances in spinal cord imaging methods have been re-alized in the past decade. The great potential of such methods to sup-port research into basic neuroscience and novel treatment strategies,as well as to improve clinical diagnoses, and the monitoring of treat-ment and rehabilitation outcomes have been well-demonstrated.The realization of methods to provide the desired research and clinicaltools still requires technological development. In part I we reported thegreatest technical challenges that are common across almost all of thespinal cord imaging methods that are currently being developed. Inpart II we have focused on some clinical application of cutting edgetechniques that need adoption into the clinical scenario for testing


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their real impact on clinical practice (diagnosis and prognosis of severalconditions). We propose that the fastest way to realize the potential ofthese methods is to make the most advanced techniques more widelyaccessible by engaging with equipment manufacturers and softwaredevelopers, as well as accelerating the development of new methodsby facilitating tools and data sharing across research groups.

Acknowledgments

This work is the result of the efforts of the International Spinal Re-search Trust and the Wings for Life Spinal Cord Research Foundationto bring together researchers with a common goal of developingnon-invasive imaging tools for basic and clinical spinal cord researchand to support advances in treatment and rehabilitation. The goal is tospeed advances and make these imaging tools more widely availableby promoting collaboration between researchers and by identifyingthe most important challenges and needs for spinal cord imaging.

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The current state-of-the-art of spinal cord imaging: Applications

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