The Additional Role of Diffusion Tensor Imaging in Spinal Cord Pathology: A Comprehensive Case-Based Pictorial Review

Diffusion tensor imaging (DTI) is a cutting-edge magnetic resonance imaging (MRI) technique that enhances the evaluation of spinal cord integrity by analyzing the directional diffusion of water molecules, particularly within white matter tracts. This imaging modality offers vital insights beyond conventional MRI by revealing microstructural changes, often preceding visible anatomical alterations. DTI utilizes parameters such as fractional anisotropy, mean diffusivity, axial diffusivity, and radial diffusivity to quantitatively assess spinal cord pathologies. This comprehensive pictorial review explores DTI's role across a spectrum of spinal disorders, including neoplasms (ependymomas, astrocytomas, metastases), traumatic injuries, cervical spondylotic myelopathy, demyelinating diseases (e.g., neuromyelitis optica spectrum disorder), and rare conditions such as syringomyelia and subacute combined degeneration. DTI proves particularly valuable in differentiating between infiltrative and non-infiltrative tumors, guiding surgical planning, and predicting outcomes in spinal cord injuries. Despite technical limitations such as motion artifacts and the complexity of spinal anatomy, optimized imaging protocols and advanced processing techniques enable meaningful clinical application. Tractography, derived from DTI, provides a detailed visualization of fiber integrity and disruption, aiding in diagnosis and prognostication. Overall, DTI stands out as a powerful adjunct to conventional MRI, significantly improving the diagnostic and therapeutic landscape in spinal cord pathology.