Inspired by a patient
Abstract
Objective: Weight-bearing magnetic resonance imaging enables assessment of the cervical spine and craniocervical junction under physiological load, potentially revealing pathology that is occult on conventional supine imaging. This scoping review synthesizes current evidence, maps clinical and emerging applications, and identifies key gaps requiring further investigation.
Methods: A structured search was conducted in PubMed, Scopus, Web of Science, Google Scholar, and Semantic Scholar (July 2025). Eligible studies were reviewed for diagnostic utility, technical considerations, clinical indications, and outcomes. Methodological quality was appraised descriptively in line with Joanna Briggs Institute guidance.
Results: Nine studies, published between 2008 and 2025, met inclusion criteria. Upright and dynamic MRI detected posture-dependent changes including spinal canal narrowing, cord compression, foraminal stenosis, ligamentous buckling, cerebellar tonsillar descent, altered sagittal alignment, and CSF flow differences. Findings were more pronounced in flexion extension and upright postures compared with supine imaging. Normative studies established reference metrics for CCJ motion and prevertebral soft tissue width. Preliminary evidence also highlights applications in connective tissue disorders, Chiari malformation, and upper cervical chiropractic practice, although most studies were feasibility reports with small sample sizes and heterogeneous protocols.
Conclusion: Emerging evidence suggests that WBMRI provides added diagnostic value in selected cervical spine and CCJ conditions by revealing dynamic or load-sensitive pathology not captured on standard supine imaging. While current evidence remains preliminary, standardized protocols, higher-field technologies, and large multicenter outcome-based studies are essential to validate diagnostic thresholds, improve reproducibility, and define the role of WBMRI in routine clinical care.
Health Quality Ontario. Positional Magnetic Resonance Imaging for People With Ehlers-Danlos Syndrome or Suspected Craniovertebral or Cervical Spine Abnormalities: An Evidence-Based Analysis. Ont Health Technol Assess Ser. 2015 Jul 1;15(13):1-24. PMID: 26366238; PMCID: PMC4561548.
Abstract
Background: Ehlers-Danlos syndrome (EDS) is an inherited disorder affecting the connective tissue. EDS can manifest with symptoms attributable to the spine or craniovertebral junction (CVJ). In addition to EDS, numerous congenital, developmental, or acquired disorders can increase ligamentous laxity in the CVJ and cervical spine. Resulting abnormalities can lead to morbidity and serious neurologic complications. Appropriate imaging and diagnosis is needed to determine patient management and need for complex surgery. Some spinal abnormalities cause symptoms or are more pronounced while patients sit, stand, or perform specific movements. Positional magnetic resonance imaging (pMRI) allows imaging of the spine or CVJ with patients in upright, weight-bearing positions and can be combined with dynamic maneuvers, such as flexion, extension, or rotation. Imaging in these positions could allow diagnosticians to better detect spinal or CVJ abnormalities than recumbent MRI or even a combination of other available imaging modalities might allow.
Objectives: To determine the diagnostic impact and clinical utility of pMRI for the assessment of (a) craniovertebral or spinal abnormalities among people with EDS and (b) major craniovertebral or cervical spine abnormalities among symptomatic people.
Data sources: A literature search was performed using Ovid MEDLINE, Ovid MEDLINE In-Process and Other Non-Indexed Citations, Ovid Embase, and EBM Reviews, for studies published from January 1, 1998, to September 28, 2014.
Review methods: Studies comparing pMRI to recumbent MRI or other available imaging modalities for diagnosis and management of spinal or CVJ abnormalities were reviewed. All studies of spinal or CVJ imaging in people with EDS were included as well as studies among people with suspected major CVJ or cervical spine abnormalities (cervical or craniovertebral spine instability, basilar invagination, cranial settling, cervical stenosis, spinal cord compression, Chiari malformation).
Results: No studies were identified that met the inclusion criteria.
Conclusions: We did not identify any evidence that assessed the diagnostic impact or clinical utility of pMRI for (a) craniovertebral or spinal abnormalities among people with EDS or (b) major craniovertebral or cervical spine abnormalities among symptomatic people relative to currently available diagnostic modalities.
Tubbs RS, Kirkpatrick CM, Rizk E, Chern JJ, Oskouian RJ, Oakes WJ. Do the cerebellar tonsils move during flexion and extension of the neck in patients with Chiari I malformation? A radiological study with clinical implications. Childs Nerv Syst. 2016 Mar;32(3):527-30. doi: 10.1007/s00381-016-3014-5. Epub 2016 Jan 12. PMID: 26758883.
Abstract
Background: In the past, diagnosis of the Chiari I malformation has primarily been made on midsagittal MRI. We hypothesized that based on the frequent presentation of opisthotonos in patients with hindbrain hernia (primarily Chiari II malformation but sometimes Chiari I malformation) that the hyperextension might be a compensatory technique used by such patients to bring the cerebellar tonsils up out of the cervical spine.
Patients and methods: This prospective study reviewed imaging of patients with Chiari I malformation who underwent flexion/extension MRI for evaluation of their hindbrain herniation. Age-matched controls were used for comparison.
Results: In general, there was elevation of the cerebellar tonsils with extension and increased descent with flexion of the cervical spine. In 72 % of patients, flexion of the neck resulted in descent of the cerebellar tonsils. In 64 % of patients, extension of the neck resulted in ascent of the cerebellar tonsils. In the 14 patients with an associated syrinx, 71 % were found to have caudal movement of the cerebellar tonsils with neck flexion, and only 43 % were observed to have any movement of the cerebellar tonsils in neck extension compared to patients without a syrinx where ascent of the tonsils was seen in only nine during neck extension. Two patients were observed to have the reverse finding of ascent of the cerebellar tonsils with neck flexion and descent of the cerebellar tonsils with neck extension. Five patients had no movement of the cerebellar tonsils in either flexion or extension of the neck, and one of these had a small syrinx.
Conclusions: Although minimal and not in all patients, we observed elevation of the herniated cerebellar tonsils with extension of the cervical spine in patients with Chiari I malformation. This finding provides evidence as to why some patients with hindbrain herniation present with opisthotonos and supports earlier findings that CSF flow is reduced at the craniocervical junction in flexion in patients with Chiari I malformation.
Tam SKP, Chia J, Brodbelt A, Foroughi M. Assessment of patients with a Chiari malformation type I. Brain Spine. 2021 Dec 3;2:100850. doi: 10.1016/j.bas.2021.100850. PMID: 36248113; PMCID: PMC9560699.
Abstract
Introduction
The prevalence of Chiari malformation type I (CM-I) has been estimated as up to 1% of the general population. The majority of patients are asymptomatic and usually do not need treatment. Symptomatic patients, and some asymptomatic patients with associated conditions, may benefit from further assessment and treatment.
Research question
The aim of this review was to describe the clinical and radiological assessment of patients presenting with a CM-I.
Material and methods
A literature search was performed using the PubMed and Embase databases focused on clinical assessment and imaging techniques used to diagnose CM-I.
Results
Following a complete clinical evaluation in patients with symptomatic CM-I and/or radiologically significant CM-I (tonsillar impaction, resulting tonsillar asymmetry and loss of CSF spaces), MRI of the brain and whole spine enables an assessment of the CM-I and potential associated or causative conditions. These include hydrocephalus, syringomyelia, spinal dysraphism, and tethered cord. Flow and Cine MRI can provide information on CSF dynamics at the craniocervical junction, and help in surgical decision-making. Hypermobility or instability at the upper cervical and craniocervical junction is less common and can be measured with CT imaging and flexion/extension or upright MRI.
Discussion and conclusion
The majority of CM-I detected are incidental findings on MRI imaging of brain or spine, and do not require intervention. Once a radiological diagnosis and concern has been raised, clinical assessment by an appropriate specialist is required. A MRI brain and cervical spine is indicated in all radiologically labelled CM-I. In symptomatic patients or cases of radiologically significant CM-I, MRI of the brain and entire spine is indicated. Further investigations should be tailored to individuals’ needs.
David Chu, Michael Boitano, Dan Culver, Raymond Damadian, Mary Gianni, Rob Viel, Jan Votruba, Robert Wolf. First Upright Study of CSF Flow in Chiari I Malformation with Cine Phase-Contrast MRI. https://archive.ismrm.org/2009/0940.html
Cerebrospinal fluid (CSF) flow abnormalities are generally known to correlate better with symptomatology than the degree of tonsillar herniation in Chiari I malformation (CMI) patients. However, all MRI studies of CSF flow in CMI patients have been restricted to the recumbent position. We present the first study of CSF flow and spinal cord pulsation in the upright posture in a CMI patient. Upright imaging revealed major CSF flow abnormalities that were absent in the supine posture.
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