Diffusion-weighted imaging, diffusion-tensor imaging, and fiber tractography of the spinal cord

Diffusion tensor imaging of cerebral white matter: technique, anatomy, and pathologic patterns

Diffusion tensor imaging is a magnetic resonance imaging technique that provides insight into the anatomy and integrity of white matter pathways in the brain. Further processing of these data can help map individual tracts, which can aid in surgical planning. Understanding the basics of this technique can improve characterization of white matter development and disorders.

MRI and MRA of spinal cord arteriovenous shunts

The purpose of this review is to describe the diagnostic criteria for spinal cord arteriovenous shunts (SCAVSs) when using magnetic resonance imaging (MRI) and magnetic resonance angiography (MRA), and to discuss the extent to which the different MRI and MRA sequences and technical parameters provide the information that is required to diagnose these lesions properly. SCAVSs are divided into four groups according to location (paraspinal, epidural, dural, or intradural) and type (fistula or nidus); each type of lesion is described. SCAVSs are responsible for neurological symptoms due to spinal cord or nerve root involvement. MRI is usually the first examination performed when a spinal cord lesion is suspected. Recognition of the image characteristics of vascular lesions is mandatory if useful sequences are to be performed-especially MRA sequences. Because the treatment of SCAVSs relies mainly on endovascular therapies, MRI and MRA help with the planning of the angiographic procedure. We explain the choice of MRA sequences and parameters, the advantages and pitfalls to be aware of in order to obtain the best visualization, and the analysis of each lesion.

MRI in transverse myelitis

Transverse myelitis is an acute inflammatory disease of the spinal cord, characterized by rapid onset of bilateral neurological symptoms. Weakness, sensory disturbance, and autonomic dysfunction evolve over hours or days, most progressing to maximal clinical severity within 10 days of onset. At maximal clinical severity, half will have a paraparesis, and almost all patients have sensory disturbance and bladder dysfunction. Residual disability is divided equally between severe, moderate and minimal or none. The causes of transverse myelitis are diverse; etiologies implicated include demyelinating conditions, collagen vascular disease, and parainfectious causes, however, despite extensive diagnostic work-up many cases are considered idiopathic. Due to heterogeneity in pathogenesis, and the similarity of its clinical presentation with those of various noninflammatory myelopathies, transverse myelitis has frequently been viewed as a diagnostic dilemma. However, as targeted therapies to optimize patient outcome develop, timely identification of the underlying etiology is becoming increasingly important. In this review, we describe the imaging and clinical features of idiopathic and disease-associated transverse myelitis and its major differentials, with discussion of how MR imaging features assist in the identification of various sub-types of transverse myelitis. We will also discuss the potential for advanced MR techniques to contribute to diagnosis and prognostication.

Diffusion tensor imaging to guide surgical planning in intramedullary spinal cord tumors in children

INTRODUCTION

Intramedullary spinal cord neoplasms (ISCN) in children provide diagnostic, treatment and management dilemmas. Resection results in the best chance for disease control, but the greatest risk of neurologic deficit. We hypothesize that diffusion tensor imaging (DTI) and diffusion tensor-fiber tracking (DT-FT) can help characterize margins of pediatric ISCN to aid in surgical planning.

METHODS

This HIPAA compliant retrospective study was performed after Institutional Review Board approval. Patients with ISCN from a single tertiary care pediatric institution were identified, and patients with preoperative DTI were evaluated.

RESULTS

Ten patients (eight males and two females) with ISCN with preoperative DTI were identified. The mean age was 11.1 ± 6.2 years (range, 2-18 years). Eight tumors demonstrated DTI and DT-FT evidence of splayed cord tracts, and two demonstrated evidence of infiltration of cord tracts. The eight patients with splayed tracts underwent resection, with seven achieving gross-total resection and one subtotal resection. The two patients with infiltration of white matter tracts underwent biopsy of their lesion.

CONCLUSIONS

DTI of pediatric ISCN can aid in defining the margins of the tumor and relationship to the intrinsic white matter structures of the spinal cord. Splaying and displacement of fiber tracts appears to predict a discrete margin to the tumor and resectability, whereas infiltration of the white matter tracts suggests biopsy may be more advisable.

Is diffusion anisotropy a biomarker for disease severity and surgical prognosis of cervical spondylotic myelopathy?

PURPOSE

To explore the value of diffusion-tensor (DT) imaging in addressing the severity of cervical spondylotic myelopathy (CSM) and predicting the outcome of surgical treatment.

MATERIALS AND METHODS

From July 2009 to May 2012, 65 volunteers were recruited for this institutional review board-approved study, and all gave informed consent; 20 volunteers were healthy subjects (age range, 41-62 years), and 45 were patients with CSM (age range, 43-86 years). Anatomic and DT 3.0-T magnetic resonance images were obtained. Surgical decompression was performed in 22 patients with CSM, and patients were followed up for 6 months to 2 years. The clinical severity of myelopathy and postoperative recovery were assessed by using the modified Japanese Orthopaedic Association (mJOA) score. A recovery ratio (comparison of postoperative with preoperative mJOA score) of more than 50% indicated a good clinical outcome of surgery. DT findings, patient age, T2 high signal intensity (HSI), and somatosensory evoked potential (SEP) were analyzed by using a logistic regression model to predict the surgical outcome of patients with CSM.

RESULTS

A significant difference in cervical cord mean fractional anisotropy (FA) was found between healthy subjects and patients with CSM (0.65 ± 0.05 [standard deviation] vs 0.52 ± 0.13, P < .001). FA values were significantly correlated with the severity of neurologic dysfunction indicated by mJOA score (r(2) = 0.327, P = .016). Logistic regression analysis showed that mean FA (P = .030) and FA at the C2 vertebra (P = .035) enabled prediction of good surgical outcome; however, preoperative mJOA (P = .927), T2 HSI (P = .176), SEP amplitude (P = .154), and latency (P = .260) did not.

CONCLUSION

FA is a biomarker for the severity of myelopathy and for subsequent surgical outcome.

Analysis of high-voltage electrical spinal cord injury using diffusion tensor imaging

The aim of this study was to investigate spinal cord injury (SCI) on the basis of diffusion tensor imaging (DTI) in patients with high-voltage electrical injury. We recruited eight high-voltage electrical injury patients and eight healthy subjects matched for age and sex. DTI and central motor conduction time were acquired in both the patient and control groups. We obtained DTI indices according to the spinal cord levels (from C2 to C7) and cross-section locations (anterior, lateral, and posterior). Fractional anisotrophy (FA), mean diffusivity (MD), axial diffusivity (AD), and radial diffusivity (RD) were compared between the two groups; additionally, they were compared in relation to spinal cord level and cross-section location. In the patient group relative to the control group, the FA value decreased and the MD and RD values increased in all of the regions of interest (ROI) with statistical significance (p < 0.05). In the patient group, particularly in the ROIs of the anterior spinal cord compared with the lateral and posterior spinal cords, the FA value decreased with statistical significance (p < 0.05). The DTI indices did not differ by level. DTI revealed the change of diffusion in the spinal cords of patients with high-voltage electrical injury, and corroborated the pathophysiology, myelinopathy and typical anterior spinal cord location of high-voltage electrical SCI already reported in the literature.

Correlation of magnetic resonance diffusion tensor imaging and clinical findings of cervical myelopathy

BACKGROUND CONTEXT

Despite significant advances in the development of diagnostic technology, the diagnosis of cervical myelopathy (CM) still remains based on the clinical findings, which do not provide the means for a sufficiently accurate diagnosis. Furthermore, conventional magnetic resonance imaging (MRI) using T1- and T2-weighted sequences lacks sensitivity to detect and characterize spinal cord lesions. Considering these uncertainties, several investigators have assessed the diagnostic value of diffusion tensor imaging (DTI), an advanced MRI technique that measures the diffusion of water molecules.

PURPOSE

To determine the diagnostic value of DTI in CM in reliably characterizing spinal lesions and in associating them with the clinical findings.

STUDY DESIGN/SETTING

Prospective cohort study.

PATIENT SAMPLE

Fifteen CM patients and five healthy volunteers without a history of neurological disorders or of symptoms as controls.

OUTCOME MEASURES

Symptoms and signs of CM were evaluated by the use of a modified Japanese Orthopedic Score and the other clinical findings. T2-weighed MRI was used to note the number of compressed levels. Diffusion tensor imaging results were measured according to two parameters, fractional anisotropy (FA) and apparent diffusion coefficient (ADC), at anterior, lateral, and posterior regions of interest (ROIs) in each of five cervical vertebrae, C3-C7.

METHODS

On diagnosis of CM by clinical evaluation and findings from T2-weighted MRI, the 15 subjects were assigned to two subgroups based on complaints, symptoms, and signs. The nine subjects who had typical CM symptoms such as motor weakness, gait disturbance, clumsiness of the hands, and unilateral hypesthesia were assigned to the paralysis subgroup. The other six subjects, whose main symptom was pain and who had vague signs of upper motor neuron injury despite a definitive finding of CM by T2-weighted MRI, were assigned to the pain subgroup. Once assignments had been made, subjects underwent DTI done by the use of the same scanner as for T2-weighted MRI. Results of DTI for each subgroup and controls were averaged, and the mean was used for comparisons. Diffusion tensor imaging results from the paralysis subgroup were sorted into affected and unaffected sides according to the presence or the absence of symptoms.

RESULTS

The paralysis subgroup and the pain subgroup had similar findings from T2-weighted MRI on presentation. The paralysis subgroup had statistically significantly decreased FA values in the anterior and lateral ROIs on the affected side and in the anterior ROIs on the unaffected side, compared with controls. The paralysis subgroup also had statistically significantly increased ADC values in the anterior ROIs of the affected side, compared with controls. The pain subgroup showed significantly increased ADC values in anterior, lateral, and posterior ROIs.

CONCLUSIONS

Use of DTI to quantitatively compare compression in the cervical spinal cords of CM subjects and healthy controls explained individual differences in the clinical findings in the subjects. These findings even applied to CM subjects whose compressed spinal cords looked similar on conventional T2-weighted MRI. Therefore, DTI provided more accurate and reliable information than did conventional T2-weighted MRI about the relationship between spinal cord structure and clinical presentation of CM. Based on our DTI findings, we hypothesized that different clinical findings in CM are attributable to the stage of progression and the severity of pathologic change at presentation. We anticipate that the use of DTI to quantify the extent of myelopathological changes in CM could be more reliable than any other existing diagnostic tools and might provide invaluable information about selecting the optimal treatment for CM and predicting surgical outcomes and prognosis.

[Spinal cord diffusion tensor tractography as a diagnostic tool in difficult cases of spinal cord intramedullary tumours]

Diffusion tensor-based spinal cord tractography is a technically complicated but rapidly evolving diagnostic method. The difficulties result from the volume of the spinal cord, the constant pulsing of the cerebrospinal fluid and respiratory movements. The method is being used more and more frequently to examine long spinal tracts in patients with intramedullary tumours. The method can be especially useful for ambiguous cases investigation. The presented case with coincidental intramedullary tumour and severe cervical spondylosis has been described by the authors to show their own experience with spinal cord tractography as a useful tool in determining an effective treatment method.

Diffusion tensor imaging of the spinal cord: a review

Diffusion tensor imaging (DTI) is a magnetic resonance technique capable of measuring the magnitude and direction of water molecule diffusion in various tissues. The use of DTI is being expanded to evaluate a variety of spinal cord disorders both for prognostication and to guide therapy. The purpose of this article is to review the literature on spinal cord DTI in both animal models and humans in different neurosurgical conditions. DTI of the spinal cord shows promise in traumatic spinal cord injury, cervical spondylotic myelopathy, and intramedullary tumors. However, scanning protocols and image processing need to be refined and standardized.

Application of diffusion tensor imaging (DTI) in pathological changes of the spinal cord

We review the current knowledge concerning clinical applications of the advanced technique of magnetic resonance imaging (MRI): diffusion tensor imaging (DTI) of the spinal cord. Due to technical difficulties, DTI has rarely been used in spinal cord diseases. However, in our opinion it is potentially a very useful method in diagnosis of the different pathological processes of the spinal cord and spinal canal. We discuss the physical principles and technical aspects of DTI, as well as current and future applications. DTI seems to be a very promising method for assessment of spinal cord trauma, spinal canal tumors, degenerative myelopathy, as well as demyelinating and infectious diseases of the spinal cord. DTI enables both qualitative and quantitative (by measuring of the fractional anisotropy and apparent diffusion coefficient parameters) assessment of the spinal cord. The particular applications are illustrated by the examples provided in this article.

Tracking changes following spinal cord injury: insights from neuroimaging

Traumatic spinal cord injury is often disabling and recovery of function is limited. As a consequence of damage, both spinal cord and brain undergo anatomical and functional changes. Besides clinical measures of recovery, biomarkers that can detect early anatomical and functional changes might be useful in determining clinical outcome—during the course of rehabilitation and recovery—as well as furnishing a tool to evaluate novel treatment interventions and their mechanisms of action. Recent evidence suggests an interesting three-way relationship between neurological deficit and changes in the spinal cord and of the brain and that, importantly, noninvasive magnetic resonance imaging techniques, both structural and functional, provide a sensitive tool to lay out these interactions. This review describes recent findings from multimodal imaging studies of remote anatomical changes (i.e., beyond the lesion site), cortical reorganization, and their relationship to clinical disability. These developments in this field may improve our understanding of effects on the nervous system that are attributable to the injury itself and will allow their distinction from changes that result from rehabilitation (i.e., functional retraining) and from interventions affecting the nervous system directly (i.e., neuroprotection or regeneration).

Imaging of the spine at 3 tesla

Magnetic resonance (MR) imaging at 3 T has proved superior to 1.5 T in the brain for detecting numerous pathologic entities including hemosiderin, tiny metastases, subtle demyelinating plaques, active demyelinating plaques, and some epileptogenic foci, as well as small aneurysms with MR angiography. 3 T is superior to most advanced imaging techniques including diffusion, diffusion tensor imaging, perfusion, spectroscopy and functional MR imaging. The increased signal/noise ratio at 3 T permits higher spatial resolution. Initially spine imaging at 3 T proved more difficult with less successful results. During the past 7 years, technological advances in magnet and surface coil design as well as improved radio frequency transmitters and pulse sequence design in combination with the large body of knowledge accrued by radiologists and physicists during a nine year experience with clinical imaging of the spine with the doubled B0, has resulted in 3 T MRI of the spine achieving a reputation similar to that for brain imaging.

Advanced diffusion-weighted magnetic resonance imaging techniques of the human spinal cord

Unlike those of the brain, advances in diffusion-weighted imaging (DWI) of the human spinal cord have been challenged by the more complicated and inhomogeneous anatomy of the spine, the differences in magnetic susceptibility between adjacent air and fluid-filled structures and the surrounding soft tissues, and the inherent limitations of the initially used echo-planar imaging techniques used to image the spine. Interval advances in DWI techniques for imaging the human spinal cord, with the specific aims of improving the diagnostic quality of the images, and the simultaneous reduction in unwanted artifacts have resulted in higher-quality images that are now able to more accurately portray the complicated underlying anatomy and depict pathologic abnormality with improved sensitivity and specificity. Diffusion tensor imaging (DTI) has benefited from the advances in DWI techniques, as DWI images form the foundation for all tractography and DTI. This review provides a synopsis of the many recent advances in DWI of the human spinal cord, as well as some of the more common clinical uses for these techniques, including DTI and tractography.

Diffusion tensor imaging in the assessment of ossification of the posterior longitudinal ligament: a report on preliminary results in 3 cases and review of the literature

Cervical spondylotic myelopathy due to ossification of the posterior longitudinal ligament (OPLL) is a common neurosurgical disease that carries high morbidity. OPLL and other degenerative processes cause narrowing of the central canal, with subsequent spinal cord injury. Repeated minor trauma and vascular aberrations have been purported to underlie cervical spondylotic myelopathy, although the exact pathophysiological mechanism is unclear. Regardless, detection of early axonal damage may allow more timely surgical intervention and prediction of functional outcome. Diffusion tensor (DT) imaging of the cervical spine is a novel technique with improved sensitivity compared with conventional anatomical MR imaging that is currently available on most clinical scanners. This review describes the theoretical basis, application, and analysis of DT imaging as it pertains to neurosurgery. Particular emphasis is placed on OPLL.

Diffusion tensor imaging and fiber tractography in cervical compressive myelopathy: preliminary results

OBJECTIVE

To assess diffusion tensor imaging (DTI) parameters in cervical compressive myelopathy (CCM) patients compared to normal volunteers, to relate them with myelopathy severity, and to relate tractography patterns with postoperative neurologic improvement.

SUBJECTS AND METHODS

Twenty patients suffering from CCM were prospectively enrolled (M:F = 13:7, mean age, 49.6 years; range 22-67 years) from September 2009 to March 2010. Sensitivity encoding (SENSE) single-shot echo-planar imaging (EPI) was used for the sagittal DTI. Twenty sex- and age-matched normal volunteers underwent the same scanning procedure. Fractional anisotropy (FA) and apparent diffusion coefficient (ADC) values in the spinal cord were compared between the patients and normal volunteers and were related to myelopathy severity based on Japanese Orthopedic Association (JOA) scores. Tractography patterns were related to myelopathy severity and postoperative improvement.

RESULTS

There were significant differences between patients and normal volunteers in terms of FA (0.498 ± 0.114 vs. 0.604 ± 0.057; p = 0.001) and ADC (1.442 ± 0.389 vs. 1.169 ± 0.098; p = 0.001). DTI parameters and tractography patterns were not related to myelopathy severity. In ten patients in the neurologically worse group, postoperative neurologic improvement was seen in four of five patients with intact fiber tracts, but only one of five patients with interrupted fiber tracts exhibited neurologic improvement.

CONCLUSION

DTI parameters in CCM patients were significantly different from those in normal volunteers but were not significantly related to myelopathy severity. The patterns of tractography appear to correlate with postoperative neurologic improvement.

Orientation entropy analysis of diffusion tensor in healthy and myelopathic spinal cord

The majority of nerve fibers in the spinal cord run longitudinally, playing an important role in connecting the brain to the peripheral nerves. There is a growing interest in applying diffusion tensor imaging (DTI) to the evaluation of spinal cord microarchitecture. The current study sought to compare the organization of longitudinal nerve fibers between healthy and myelopathic spinal cords using entropy-based analysis of principal eigenvector mapping. A total of 22 subjects were recruited, including 14 healthy subjects, seven cervical myelopathy (CM) patients with single-level compression, and one patient suffering from multi-level compression. Diffusion tensor magnetic resonance (MR) images of the cervical spinal cord were obtained using a pulsed gradient, spin-echo echo-planar imaging (SE-EPI) sequence with a 3T MR system. Regions of interest (ROIs) were drawn manually to cover the spinal cord, and Shannon entropy was calculated in principal eigenvector maps. The results revealed no significant differences in orientation entropy values along the whole length of cervical spinal cord in healthy subjects (C2-3: 0.73±0.05; C3-4: 0.71±0.07; C4-5: 0.72±0.048; C5-6: 0.71±0.07; C6-7: 0.72±0.07). In contrast, orientation entropy values in myelopathic cord were significantly higher at the compression site (0.91±0.03), and the adjacent levels (above: 0.85±0.03; below: 0.83±0.05). This study provides a novel approach to analyze the orientation information in diffusion MR images of healthy and diseased spinal cord. These results indicate that orientation entropy can be applied to determine the contribution of each compression level to the overall disorganization of principal nerve tracts of myelopathic spinal cord in cases with multi-level compression.

Reduced field-of-view diffusion imaging of the human spinal cord: comparison with conventional single-shot echo-planar imaging

BACKGROUND AND PURPOSE

DWI of the spinal cord is challenging because of its small size and artifacts associated with the most commonly used clinical imaging method, SS-EPI. We evaluated the performance of rFOV spinal cord DWI and compared it with the routine fFOV SS-EPI in a clinical population.

MATERIALS AND METHODS

Thirty-six clinical patients underwent 1.5T MR imaging examination that included rFOV SS-EPI DWI of the cervical spinal cord as well as 2 comparison diffusion sequences: fFOV SS-EPI DWI normalized for either image readout time (low-resolution fFOV) or spatial resolution (high-resolution fFOV). ADC maps were created and compared between the methods by using single-factor analysis of variance. Two neuroradiologists blinded to sequence type rated the 3 DWI methods, based on susceptibility artifacts, perceived spatial resolution, signal intensity-to-noise ratio, anatomic detail, and clinical utility.

RESULTS

ADC values for the rFOV and both fFOV sequences were not statistically different (rFOV: 1.01 ± 0.18 × 10(-3) mm(2)/s; low-resolution fFOV: 1.12 ± 0.22 × 10(-3) mm(2)/s; high-resolution fFOV: 1.10 ± 0.21 × 10(-3) mm(2)/s; F = 2.747, P > .05). The neuroradiologist reviewers rated the rFOV diffusion images superior in terms of all assessed measures (P < 0.0001). Particular improvements were noted in patients with metal hardware, degenerative disease, or both.

CONCLUSIONS

rFOV DWI of the spinal cord overcomes many of the problems associated with conventional fFOV SS-EPI and is feasible in a clinical population. From a clinical standpoint, images were deemed superior to those created by using standard fFOV methods.

The role of DTI in early detection of cervical spondylotic myelopathy: a preliminary study with 3-T MRI

INTRODUCTION

The radiological diagnosis of cervical spondylotic myelopathy (CSM) has to be made as soon as possible, since surgery performed in earlier stages during the course of CSM was reported to be more successful when compared with later stages. We hypothesized that diffusion tensor imaging (DTI) may detect CSM in earlier stages, before the appearance of signal increase in T2-weighted sequences.

METHODS

A total of 16 patients with neurological signs and symptoms of CSM but without hyperintensity in spinal cord on T2-weighted sequences enrolled in the study. The magnetic resonance (MR) examinations were performed on a 3-T MR imaging system. Apparent diffusion coefficient (ADC) and fractional anisotropy (FA) maps were generated on axial plane. The ADC and FA measurements in each individual were made at the level of most severe cervical canal stenosis and at a nonstenotic level. Student's t test was used to compare FA and ADC values of the spinal cord in stenotic and nonstenotic segments. We also investigated if there was a correlation between DTI parametrics and duration of clinical symptoms by using Pearson correlation analysis.

RESULTS

All patients showed changes in DTI parametrics at stenotic segments. While FA values of the spinal cord at the stenotic level showed a statistically significant reduction, there was a statistically significant increase in the measured ADC values (p < 0.001). There was no statistical correlation between the duration of symptoms and DTI parametrics.

CONCLUSION

Our preliminary findings indicate that DTI may show abnormalities in the spinal cord before the development of T2 hyperintensity on conventional sequences in patients with CSM.

Spinal cord infarction from an unstable aortic plaque

A 78 year-old woman presented with acute onset low back pain with radiation into the right T12-L2 dermatomes, progressive flaccid paraparesis, urinary incontinence and bilateral lower extremity paresthesias. Examination revealed flaccid paraparesis, and a T12 sensory level to pin with intact vibration and proprioception. Magnetic resonance imaging (MRI) (Figure 1) of the spinal cord demonstrated T2 hyperintensity and restricted diffusion from T12 to the conus medullaris. Computed tomogram (CT) aortogram (Figure 2) highlighted an ulcerated plaque and thrombus at the approximate level of the artery of Adamkiewicz. These findings were consistent with a spinal cord infarct of the cord from T12-L2. The patient was treated with Clopidogrel and IV heparin (x two days) and was transferred for spinal cord rehabilitation.

Entropy-based analysis for diffusion anisotropy mapping of healthy and myelopathic spinal cord

The present study utilized diffusion MR imaging and fractional anisotropy (FA) mapping to delineate the microstructure of spinal cord. The concept of Shannon entropy was introduced to analyze the complex microstructure of healthy and injured spinal cords based on FA map. A total of 30 volunteers were recruited in this study with informed consent, including 13 healthy adult subjects (group A, 25±3 years), 12 healthy elderly subjects (group B, 53±7 years) and 5 cervical spondylotic myelopathy (CSM) patients (group C, 53±15 years). Diffusion MRI images of cervical spinal cord were taken using pulsed gradient spin-echo-echo-planar imaging (SE-EPI) sequence with a 3T MR system. The region of interest was defined to cover the spinal cord in FA maps. The Shannon entropy of FA values of voxels in the cord was calculated as well as the average FA values. The significant differences were determined among three groups using one-way ANOVA and post-hoc test. As compared with adult and elderly healthy subjects, the entropy of whole spinal cord was significantly lower in CSM patients (group A: 6.07±0.18; B: 6.01±0.23; C: 5.32±0.44; p<0.05). Whereas there were no significant difference in FA values among groups (group A: 0.62±0.08; B: 0.64±0.09; C: 0.64±0.12). In CSM patients, there was a loss of architectural structural complexity in the cervical spinal cord tissue as noted by the lower Shannon entropy value. It indicated the potential application of entropy-based analysis for the diagnosis of the severity of chronic compressive spinal cord injuries, i.e. CSM.