• Traumatic spinal injury means it resulted from trauma, such as a fall, road-traffic collision, sports injury, or violence.
• Acute spinal injury means it is recent, generally hours to days old.
  So an injury can be an acute traumatic spine injury.

MRI differentiation

Sequence-based approach

1. Sagittal T1
   • Look for fracture anatomy, marrow replacement, epidural fat, and subacute blood.
   • Acute marrow injury is typically T1 dark.
2. Sagittal T2 and STIR/fat-suppressed T2
   • Most useful for acuity.
   • Look for bright edema in bone marrow, cord, ligaments, disc, and paraspinal tissues.
   • A fracture/deformity without STIR edema is usually old, although timing can vary.
3. Axial T2
   • Defines canal compromise, cord compression, root injury, epidural hematoma, and facet injury.
4. GRE/SWI
   • Detects susceptibility from hemorrhage in the spinal cord or epidural space.
5. Post-contrast T1 fat-suppressed images
   • Not routinely needed for straightforward acute trauma.
   • Useful if infection, tumor, inflammatory disease, or uncertain epidural collection is a consideration.

Key acute traumatic MRI patterns

• Cord edema/contusion: T2/STIR bright intramedullary signal with cord expansion.
• Cord hemorrhage: T2/GRE/SWI low-signal focus within the cord, often with surrounding edema. This is generally a more severe injury pattern.
• Posterior ligamentous complex injury: high STIR signal or disruption in interspinous/supraspinous ligaments, ligamentum flavum, facet capsules, and posterior paraspinal muscles. This can indicate instability even when CT has no major fracture.
• Acute compression or burst fracture: vertebral marrow edema, endplate disruption, posterior-wall retropulsion, and possible canal narrowing.
• Fracture-dislocation: translation/rotation with facet disruption and associated disc, ligament, cord, and prevertebral injury.
• Epidural hematoma: extra-axial epidural collection compressing the thecal sac or cord. Signal depends on blood age, so assess morphology and clinical timing rather than one sequence alone.

Important pitfalls

• Degenerative Modic type 1 endplate change can mimic acute fracture edema. It is centered at a degenerative disc/endplate, often with disc height loss and osteophytes, rather than a trauma-related fracture line or posterior soft-tissue injury.
• Cord T2 hyperintensity is not always acute trauma. Chronic cervical spondylotic myelopathy, demyelination, ischemia, infection, and tumor can also cause it. Acute trauma is supported by swelling, hemorrhage, new compression, ligament injury, and matching clinical mechanism.
• MRI does not replace CT for bone detail. CT is better for subtle cortical fractures and posterior-element fractures; MRI adds cord, disc, ligament, hematoma, and marrow assessment. This aligns with the ACR acute spine-trauma guidance, which uses CT first for many high-risk blunt-trauma patients and MRI when cord, nerve-root, or ligament injury is suspected.

High-yield reporting phrase

“Acute traumatic injury is favored when there is marrow edema on STIR, associated paraspinal/prevertebral edema, ligamentous disruption, acute disc injury, epidural hematoma, or cord edema/hemorrhage. Absence of edema with fixed deformity, fatty marrow change, cortication, or cord atrophy favors chronic injury.”