Dynamic per slice shimming for simultaneous brain and spinal cord fMRI

Reliability of task-based fMRI in the dorsal horn of the human spinal cord

The application of functional magnetic resonance imaging (fMRI) to the human spinal cord is still a relatively small field of research and faces many challenges. Here we aimed to probe the limitations of task-based spinal fMRI at 3T by investigating the reliability of spinal cord blood oxygen level dependent (BOLD) responses to repeated nociceptive stimulation across two consecutive days in 40 healthy volunteers. We assessed the test-retest reliability of subjective ratings, autonomic responses, and spinal cord BOLD responses to short heat pain stimuli (1s duration) using the intraclass correlation coefficient (ICC). At the group level, we observed robust autonomic responses as well as spatially specific spinal cord BOLD responses at the expected location, but no spatial overlap in BOLD response patterns across days. While autonomic indicators of pain processing showed good-to-excellent reliability, both β-estimates and z-scores of task-related BOLD responses showed poor reliability across days in the target region (gray matter of the ipsilateral dorsal horn). When taking into account the sensitivity of gradient-echo echo planar imaging (GE-EPI) to draining vein signals by including the venous plexus in the analysis, we observed BOLD responses with fair reliability across days. Taken together, these results demonstrate that heat pain stimuli as short as one second are able to evoke a robust and spatially specific BOLD response, which is however strongly variable within participants across time, resulting in low reliability in the dorsal horn gray matter. Further improvements in data acquisition and analysis techniques are thus necessary before event-related spinal cord fMRI as used here can be reliably employed in longitudinal designs or clinical settings.

Functional ultrasound imaging of the human spinal cord

Utilizing the first in-human functional ultrasound imaging (fUSI) of the spinal cord, we demonstrate the integration of spinal functional responses to electrical stimulation. We record and characterize the hemodynamic responses of the spinal cord to a neuromodulatory intervention commonly used for treating pain and increasingly used for the restoration of sensorimotor and autonomic function. We found that the hemodynamic response to stimulation reflects a spatiotemporal modulation of the spinal cord circuitry not previously recognized. Our analytical capability offers a mechanism to assess blood flow changes with a new level of spatial and temporal precision in vivo and demonstrates that fUSI can decode the functional state of spinal networks in a single trial, which is of fundamental importance for developing real-time closed-loop neuromodulation systems. This work is a critical step toward developing a vital technique to study spinal cord function and effects of clinical neuromodulation.

Thermal stimulus task fMRI in the cervical spinal cord at 7 Tesla

Although functional magnetic resonance imaging (fMRI) is widely applied in the brain, fMRI of the spinal cord is more technically demanding. Proximity to the vertebral column and lungs results in strong spatial inhomogeneity and temporal fluctuations in B0 . Increasing field strength enables higher spatial resolution and improved sensitivity to blood oxygenation level-dependent (BOLD) signal, but amplifies the effects of B0 inhomogeneity. In this work, we present the first task fMRI in the spinal cord at 7 T. Further, we compare the performance of single-shot and multi-shot 2D echo-planar imaging (EPI) protocols, which differ in sensitivity to spatial and temporal B0 inhomogeneity. The cervical spinal cords of 11 healthy volunteers were scanned at 7 T using single-shot 2D EPI at 0.75 mm in-plane resolution and multi-shot 2D EPI at 0.75 and 0.6 mm in-plane resolutions. All protocols used 3 mm slice thickness. For each protocol, the BOLD response to 13 10-s noxious thermal stimuli applied to the right thumb was acquired in a 10-min fMRI run. Image quality, temporal signal to noise ratio (SNR), and BOLD activation (percent signal change and z-stat) at both individual- and group-level were evaluated between the protocols. Temporal SNR was highest in single-shot and multi-shot 0.75 mm protocols. In group-level analyses, activation clusters appeared in all protocols in the ipsilateral dorsal quadrant at the expected C6 neurological level. In individual-level analyses, activation clusters at the expected level were detected in some, but not all subjects and protocols. Single-shot 0.75 mm generally produced the highest mean z-statistic, while multi-shot 0.60 mm produced the best-localized activation clusters and the least geometric distortion. Larger than expected within-subject segmental variation of BOLD activation along the cord was observed. Group-level sensory task fMRI of the cervical spinal cord is feasible at 7 T with single-shot or multi-shot EPI. The best choice of protocol will likely depend on the relative importance of sensitivity to activation versus spatial localization of activation for a given experiment. PRACTITIONER POINTS: First stimulus task fMRI results in the spinal cord at 7 T. Single-shot 0.75 mm 2D EPI produced the highest mean z-statistic. Multi-shot 0.60 mm 2D EPI provided the best-localized activation and least distortion.

Spinal fMRI demonstrates segmental organisation of functionally connected networks in the cervical spinal cord: A test-retest reliability study

Resting functional magnetic resonance imaging (fMRI) studies have identified intrinsic spinal cord activity, which forms organised motor (ventral) and sensory (dorsal) resting-state networks. However, to facilitate the use of spinal fMRI in, for example, clinical studies, it is crucial to first assess the reliability of the method, particularly given the unique anatomical, physiological, and methodological challenges associated with acquiring the data. Here, we characterise functional connectivity relationships in the cervical cord and assess their between-session test-retest reliability in 23 young healthy volunteers. Resting-state networks were estimated in two ways (1) by estimating seed-to-voxel connectivity maps and (2) by calculating seed-to-seed correlations. Seed regions corresponded to the four grey matter horns (ventral/dorsal and left/right) of C5-C8 segmental levels. Test-retest reliability was assessed using the intraclass correlation coefficient. Spatial overlap of clusters derived from seed-to-voxel analysis between sessions was examined using Dice coefficients. Following seed-to-voxel analysis, we observed distinct unilateral dorsal and ventral organisation of cervical spinal resting-state networks that was largely confined in the rostro-caudal extent to each spinal segmental level, with more sparse connections observed between segments. Additionally, strongest correlations were observed between within-segment ipsilateral dorsal-ventral connections, followed by within-segment dorso-dorsal and ventro-ventral connections. Test-retest reliability of these networks was mixed. Reliability was poor when assessed on a voxelwise level, with more promising indications of reliability when examining the average signal within clusters. Reliability of correlation strength between seeds was highly variable, with the highest reliability achieved in ipsilateral dorsal-ventral and dorso-dorsal/ventro-ventral connectivity. However, the spatial overlap of networks between sessions was excellent. We demonstrate that while test-retest reliability of cervical spinal resting-state networks is mixed, their spatial extent is similar across sessions, suggesting that these networks are characterised by a consistent spatial representation over time.

FASB: an integrated processing pipeline for Functional Analysis of simultaneous Spinal cord-Brain fMRI

Simultaneous functional magnetic resonance imaging (fMRI) of the spinal cord and brain represents a powerful method for examining both ascending sensory and descending motor pathways in humans in vivo . However, its image acquisition protocols, and processing pipeline are less well established. This limitation is mainly due to technical difficulties related to spinal cord fMRI, and problems with the logistics stemming from a large field of view covering both brain and cervical cord. Here, we propose an acquisition protocol optimized for both anatomical and functional images, as well as an optimized integrated image processing pipeline, which consists of a novel approach for automatic modeling and mitigating the negative impact of spinal voxels with low temporal signal to noise ratio (tSNR). We validate our integrated pipeline, named FASB, using simultaneous fMRI data acquired during the performance of a motor task, as well as during resting-state conditions. We demonstrate that FASB outperforms the current spinal fMRI processing methods in three domains, including motion correction, registration to the spinal cord template, and improved detection power of the group-level analysis by removing the effects of participant-specific low tSNR voxels, typically observed at the disk level. Using FASB, we identify significant task-based activations in the expected sensorimotor network associated with a unilateral handgrip force production task across the entire central nervous system, including the contralateral sensorimotor cortex, thalamus, striatum, cerebellum, brainstem, as well as ipsilateral ventral horn at C5-C8 cervical levels. Additionally, our results show significant task-based functional connectivity between the key sensory and motor brain areas and the dorsal and ventral horns of the cervical cord. Overall, our proposed acquisition protocol and processing pipeline provide a robust method for characterizing the activation and functional connectivity of distinct cortical, subcortical, brainstem and spinal cord regions in humans.

Recent developments and future avenues for human corticospinal neuroimaging

Non-invasive neuroimaging serves as a valuable tool for investigating the mechanisms within the central nervous system (CNS) related to somatosensory and motor processing, emotions, memory, cognition, and other functions. Despite the extensive use of brain imaging, spinal cord imaging has received relatively less attention, regardless of its potential to study peripheral communications with the brain and the descending corticospinal systems. To comprehensively understand the neural mechanisms underlying human sensory and motor functions, particularly in pathological conditions, simultaneous examination of neuronal activity in both the brain and spinal cord becomes imperative. Although technically demanding in terms of data acquisition and analysis, a growing but limited number of studies have successfully utilized specialized acquisition protocols for corticospinal imaging. These studies have effectively assessed sensorimotor, autonomic, and interneuronal signaling within the spinal cord, revealing interactions with cortical processes in the brain. In this mini-review, we aim to examine the expanding body of literature that employs cutting-edge corticospinal imaging to investigate the flow of sensorimotor information between the brain and spinal cord. Additionally, we will provide a concise overview of recent advancements in functional magnetic resonance imaging (fMRI) techniques. Furthermore, we will discuss potential future perspectives aimed at enhancing our comprehension of large-scale neuronal networks in the CNS and their disruptions in clinical disorders. This collective knowledge will aid in refining combined corticospinal fMRI methodologies, leading to the development of clinically relevant biomarkers for conditions affecting sensorimotor processing in the CNS.

Association between activity in the ventral premotor cortex and spinal cord activation during force generation-A combined cortico-spinal fMRI study

Force generation is a crucial element of dexterity and a highly relevant skill of the human motor system. How cerebral and spinal components interact and how spinal activation is associated with the activity in the cerebral primary motor and premotor areas is poorly understood. Here, we conducted combined cortico-spinal functional magnetic resonance imaging during a simple visually guided isometric force generation task in 20 healthy young subjects. Activation was localized in the right cervical spinal cord and left primary motor and premotor areas. The main finding is that spinal activation was negatively correlated with ventral premotor cortex activation. Spinal activation was furthermore significantly correlated with primary motor cortex activation, while increasing target forces led to an increase in the amount of activation. These data indicate that human premotor areas such as the ventral premotor cortex might be functionally connected to the lower cervical spinal cord contributing to distal upper limb functions, a finding that extends our understanding of human motor function beyond the animal literature.

Spatial distribution of hand-grasp motor task activity in spinal cord functional magnetic resonance imaging

Upper extremity motor paradigms during spinal cord functional magnetic resonance imaging (fMRI) can provide insight into the functional organization of the cord. Hand-grasping is an important daily function with clinical significance, but previous studies of similar squeezing movements have not reported consistent areas of activity and are limited by sample size and simplistic analysis methods. Here, we study spinal cord fMRI activation using a unimanual isometric hand-grasping task that is calibrated to participant maximum voluntary contraction (MVC). Two task modeling methods were considered: (1) a task regressor derived from an idealized block design (Ideal) and (2) a task regressor based on the recorded force trace normalized to individual MVC (%MVC). Across these two methods, group motor activity was highly lateralized to the hemicord ipsilateral to the side of the task. Activation spanned C5-C8 and was primarily localized to the C7 spinal cord segment. Specific differences in spatial distribution are also observed, such as an increase in C8 and dorsal cord activity when using the %MVC regressor. Furthermore, we explored the impact of data quantity and spatial smoothing on sensitivity to hand-grasp motor task activation. This analysis shows a large increase in number of active voxels associated with the number of fMRI runs, sample size, and spatial smoothing, demonstrating the impact of experimental design choices on motor activation.

Spinal Cord fMRI: A New Window into the Central Nervous System

With the brain, the spinal cord forms the central nervous system. Initially considered a passive relay between the brain and the periphery, the spinal cord is now recognized as being active and plastic. Yet, it remains largely overlooked by the human neuroscience community, in stark contrast with the wealth of research investigating the brain. In this review, we argue that fMRI, traditionally used to image cerebral function, can be extended beyond the brain to help unravel spinal mechanisms involved in human behaviors. To this end, we first outline strategies that have been proposed to tackle the challenges inherent to spinal cord fMRI. Then, we discuss how they have been utilized to provide insights into the functional organization of spinal sensorimotor circuits, highlighting their potential to address fundamental and clinical questions. By summarizing guidelines and applications of spinal cord fMRI, we hope to stimulate and support further research into this promising yet underexplored field.

Thermal Stimulus Task fMRI in the Cervical Spinal Cord at 7 Tesla

PURPOSE

Although functional MRI is widely applied in the brain, fMRI of the spinal cord is more technically demanding. Proximity to the vertebral column and lungs results in strong spatial inhomogeneity and temporal fluctuations in B0. Increasing field strength enables higher spatial resolution and improved sensitivity to BOLD signal, but amplifies the effects of B0 inhomogeneity. In this work, we present the first stimulus task fMRI in the spinal cord at 7 T. Further, we compare the performance of single-shot and multi-shot 2D EPI protocols, as they differ in sensitivity to spatial and temporal B0 inhomogeneity.

METHODS

The cervical spinal cords of 11 healthy volunteers were scanned at 7 T using single-shot 2D EPI at 0.75 mm in-plane resolution and multi-shot 2D EPI at 0.75 and 0.6 mm in-plane resolutions. For each protocol, the BOLD response to thirteen 10-second noxious thermal stimuli applied to the right thumb was acquired in a 10-minute fMRI run. Image quality, temporal SNR, and BOLD activation (percent signal change and z-stat) at both individual- and group-level were evaluated between the protocols.

RESULTS

Temporal SNR was highest in single-shot and multi-shot 0.75 mm protocols. In group-level analyses, activation clusters appeared in all protocols in the ipsilateral dorsal quadrant at the expected C6 neurological level. In individual-level analyses, activation clusters at the expected level were detected in some, but not all subjects and protocols. Single-shot 0.75 mm generally produced the highest mean z-statistic, while multi-shot 0.60 mm produced the best-localized activation clusters and the least geometric distortion. Larger than expected within-subject segmental variation of BOLD activation along the cord was observed.

CONCLUSION

Group-level sensory task fMRI of the cervical spinal cord is feasible at 7 T with single-shot or multi-shot EPI. The best choice of protocol will likely depend on the relative importance of sensitivity to activation versus spatial localization of activation for a given experiment.

The current state of spinal cord functional magnetic resonance imaging and its application in clinical research

Since its development, spinal cord functional magnetic resonance imaging (fMRI) has utilized various methodologies and stimulation protocols to develop a deeper understanding of a healthy human spinal cord that lays a foundation for its use in clinical research and practice. In this review, we conducted a comprehensive literature search on spinal cord fMRI studies and summarized the recent advancements and resulting scientific achievements of spinal cord fMRI in the following three aspects: the current state of spinal cord fMRI methodologies and stimulation protocols, knowledge about the healthy spinal cord's functions obtained via spinal cord fMRI, and fMRI's exemplary usage in spinal cord diseases and injuries. We conclude with a discussion that, while technical challenges exist, novel fMRI technologies for and new knowledge about the healthy human spinal cord have been established. Empowered by these developments, investigations of pathological and injury states within the spinal cord have become the next important direction of spinal cord fMRI. Recent clinical investigations into spinal cord pathologies, for example, fibromyalgia, multiple sclerosis, spinal cord injury, and cervical spondylotic myelopathy, have already provided deep insights into spinal cord impairments and the time course of impairment-caused changes. We expect that future spinal cord fMRI advancement and research development will further enhance our understanding of various spinal cord diseases and provide the foundation for evaluating existing and developing new treatment plans.

Spatial distribution of hand-grasp motor task activity in spinal cord functional magnetic resonance imaging

Upper extremity motor paradigms during spinal cord functional magnetic resonance imaging (fMRI) can provide insight into the functional organization of the cord. Hand-grasping is an important daily function with clinical significance, but previous studies of similar squeezing movements have not reported consistent areas of activity and are limited by sample size and simplistic analysis methods. Here, we study spinal cord fMRI activation using a unimanual isometric hand-grasping task that is calibrated to participant maximum voluntary contraction (MVC). Two task modeling methods were considered: (1) a task regressor derived from an idealized block design (Ideal) and (2) a task regressor based on the recorded force trace normalized to individual MVC (%MVC). Across these two methods, group motor activity was highly lateralized to the hemicord ipsilateral to the side of the task. Activation spanned C5-C8 and was primarily localized to the C7 spinal cord segment. Specific differences in spatial distribution are also observed, such as an increase in C8 and dorsal cord activity when using the %MVC regressor. Furthermore, we explored the impact of data quantity and spatial smoothing on sensitivity to hand-grasp motor task activation. This analysis shows a large increase in number of active voxels associated with the number of fMRI runs, sample size, and spatial smoothing, demonstrating the impact of experimental design choices on motor activation.

The confound of hemodynamic response function variability in human resting-state functional MRI studies

Functional magnetic resonance imaging (fMRI) is an indirect measure of neural activity with the hemodynamic response function (HRF) coupling it with unmeasured neural activity. The HRF, modulated by several non-neural factors, is variable across brain regions, individuals and populations. Yet, a majority of human resting-state fMRI connectivity studies continue to assume a non-variable HRF. In this article, with supportive prior evidence, we argue that HRF variability cannot be ignored as it substantially confounds within-subject connectivity estimates and between-subjects connectivity group differences. We also discuss its clinical relevance with connectivity impairments confounded by HRF aberrations in several disorders. We present limited data on HRF differences between women and men, which resulted in a 15.4% median error in functional connectivity estimates in a group-level comparison. We also discuss the implications of HRF variability for fMRI studies in the spinal cord. There is a need for more dialogue within the community on the HRF confound, and we hope that our article is a catalyst in the process.

A second-order and slice-specific linear shimming technique to improve spinal cord fMRI

PURPOSE

To develop a second-order and slice-specific linear shimming technique and investigate its efficiency in the mitigation of signal loss and distortions, and the increase of temporal signal-to-noise ratio (tSNR) within the spinal cord during functional Magnetic Resonance Imaging (fMRI) of the human cervical spinal cord.

METHODS

All scans were performed on a General Electric Discovery MR750 3 T scanner, using a head, neck and spine coil and a neurovascular array. To improve B₀ homogeneity, a field map was acquired, and second-order shims (SOS) were optimized over manually defined regions of interest (ROIs). Signal loss from dephasing by susceptibility-induced gradients was reduced by optimizing slice-specific x-, y- and z-shims to maximize signal within the spinal cord. Spectral-spatial excitation pulses were used in both the slice-specific linear shimming calibration scan and fMRI acquisitions. The shimming technique's efficiency was initially tested on eight healthy volunteers by comparing tSNR between images acquired with the manufacturer's standard linear shimming and with our SOS and xyz-shimming technique. Subsequently, using an increased spatial resolution as needed for fMRI of the spinal cord, tSNR measurements were performed on resting-state fMRI images from 14 healthy participants.

RESULTS

Spinal fMRI images acquired with only the standard linear shimming suffered from severe signal loss below the C5 vertebral level. The developed shimming technique compensated for this loss especially at levels C6 and C7, while tSNR was significantly higher at all vertebral levels with SOS and xyz-shimming than without it.

CONCLUSION

A comprehensive shimming approach which includes the use of spectral-spatial excitation pulses along with both second-order and slice-specific linear shim optimization reduces regional signal loss and increases tSNR along the c-spine (C3-C7), improving the ability to record functional signals from the human spinal cord.

Off-resonance artifact correction for MRI: A review

In magnetic resonance imaging (MRI), inhomogeneity in the main magnetic field used for imaging, referred to as off-resonance, can lead to image artifacts ranging from mild to severe depending on the application. Off-resonance artifacts, such as signal loss, geometric distortions, and blurring, can compromise the clinical and scientific utility of MR images. In this review, we describe sources of off-resonance in MRI, how off-resonance affects images, and strategies to prevent and correct for off-resonance. Given recent advances and the great potential of low-field and/or portable MRI, we also highlight the advantages and challenges of imaging at low field with respect to off-resonance.

Improving T2*-weighted human cortico-spinal acquisitions with a dedicated algorithm for region-wise shimming

Cortico-spinal fMRI acquisitions aim to investigate direct interactions between brain and spinal cord, e.g. during motor output or pain processing, by covering both regions in a single measurement. Due to their large distance and location in the body, a dynamic shim update of constant and linear shim terms is required when using echo-planar imaging (EPI) to achieve reasonable image quality in both target regions. A previously presented approach with region-wise shim settings is based on a standard single-region shim algorithm and suffers from (i) non-optimal shim settings because it combines linear and second-order shim terms optimized for different volumes, and (ii) significant user interactions making it rather cumbersome, time consuming, and error-prone. Here, a dedicated ("CoSpi") shim algorithm for cortico-spinal fMRI is presented that performs joint optimization of static second-order shim terms and one set of linear and constant shim terms for each region in a single run and with minimal user interaction. Field map and T2*-weighted EPI measurements were performed on a clinical 3 T whole-body MR system in water phantoms and five healthy volunteers using the conventional region-wise and CoSpi shim settings as well as "gold standard" shim settings optimized for one of the target regions only. With CoSpi shim settings, (i) overall field inhomogeneity was reduced by about 65% / 75% (brain / spinal cord volume) compared to the conventional region-wise approach and in vivo was within 5% of the values obtained with the single-volume shim settings, (ii) geometric distortions derived from voxel displacement maps were reduced on average by about 35% / 70%, (iii) the temporal SNR determined from an EPI time series that may reflect the impact of through-slice dephasing, was increased by about 17% / 10%, and (iv) the variation of the mean field between slices, a measure targeting the predisposition to insufficient fat saturation and GRAPPA-related ghosting artifacts, was reduced by about 90% / 45%. Thus, the presented algorithm not only speeds up and simplifies the shim procedure considerably, but also provides a better field homogeneity and image quality, which both could help to significantly improve the applicability of cortico-spinal fMRI.

Impact of autocalibration method on accelerated EPI of the cervical spinal cord at 7 T

PURPOSE

The spinal cord contains sensorimotor neural circuits of scientific and clinical interest. However, spinal cord functional MRI (fMRI) is significantly more technically demanding than brain fMRI, due primarily to its proximity to the lungs. Accelerated echo-planar imaging (EPI) at 7 T is particularly vulnerable to k-space phase inconsistencies induced by motion or B0 fluctuation, during either autocalibration signal (ACS) or time-series acquisition. For 7 T brain fMRI, sensitivity to motion and B0 fluctuation can be reduced using a re-ordered segmented EPI ACS based on the fast low-angle excitation echo-planar technique (FLEET). However, respiration-induced B0 fluctuations (exceeding 100 Hz at C7) are greater, and fewer k-space lines per slice are required for cervical spinal cord fMRI at 7 T, necessitating a separate evaluation of ACS methods.

METHODS

We compared 24-line single-shot EPI with 48-line two-shot segmented EPI, two-shot FLEET, and gradient echo (GRE)-based ACS acquisition methods, performed under various physiological conditions, in terms of temporal signal-to-noise ratio and prevalence of artifacts in generalized autocalibrating partially parallel acquisition (GRAPPA)-accelerated EPI of the cervical spinal cord at 7 T.

RESULTS

Segmented EPI and FLEET ACS produce images with nearly identical patterns of severe image artifacts. GRE and single-shot EPI ACS consistently produce images free from significant artifacts, and temporal signal-to-noise ratio is significantly greater for GRE ACS, particularly in lower slices where through-slice dephasing is most severe.

CONCLUSIONS

GRE and single-shot EPI-ACS acquisition methods, which are robust to respiration-induced phase errors between k-space segments, produce images with fewer and less severe artifacts than either FLEET or conventionally segmented EPI for accelerated EPI of the cervical spinal cord at 7 T.

Advanced spinal cord MRI in multiple sclerosis: Current techniques and future directions

Spinal cord magnetic resonance imaging (MRI) has a central role in multiple sclerosis (MS) clinical practice for diagnosis and disease monitoring. Advanced MRI sequences capable of visualizing and quantifying tissue macro- and microstructure and reflecting different pathological disease processes have been used in MS research; however, the spinal cord remains under-explored, partly due to technical obstacles inherent to imaging this structure. We propose that the study of the spinal cord merits equal ambition in overcoming technical challenges, and that there is much information to be exploited to make valuable contributions to our understanding of MS. We present a narrative review on the latest progress in advanced spinal cord MRI in MS, covering in the first part structural, functional, metabolic and vascular imaging methods. We focus on recent studies of MS and those making significant technical steps, noting the challenges that remain to be addressed and what stands to be gained from such advances. Throughout we also refer to other works that presend more in-depth review on specific themes. In the second part, we present several topics that, in our view, hold particular potential. The need for better imaging of gray matter is discussed. We stress the importance of developing imaging beyond the cervical spinal cord, and explore the use of ultra-high field MRI. Finally, some recommendations are given for future research, from study design to newer developments in analysis, and the need for harmonization of sequences and methods within the field. This review is aimed at researchers and clinicians with an interest in gaining an overview of the current state of advanced MRI research in this field and what is primed to be the future of spinal cord imaging in MS research.

Optimized multi-echo gradient-echo magnetic resonance imaging for gray and white matter segmentation in the lumbosacral cord at 3 T

Atrophy in the spinal cord (SC), gray (GM) and white matter (WM) is typically measured in-vivo by image segmentation on multi-echo gradient-echo magnetic resonance images. The aim of this study was to establish an acquisition and analysis protocol for optimal SC and GM segmentation in the lumbosacral cord at 3 T. Ten healthy volunteers underwent imaging of the lumbosacral cord using a 3D spoiled multi-echo gradient-echo sequence (Siemens FLASH, with 5 echoes and 8 repetitions) on a Siemens Prisma 3 T scanner. Optimal numbers of successive echoes and signal averages were investigated comparing signal-to-noise (SNR) and contrast-to-noise ratio (CNR) values as well as qualitative ratings for segmentability by experts. The combination of 5 successive echoes yielded the highest CNR between WM and cerebrospinal fluid and the highest rating for SC segmentability. The combination of 3 and 4 successive echoes yielded the highest CNR between GM and WM and the highest rating for GM segmentability in the lumbosacral enlargement and conus medullaris, respectively. For segmenting the SC and GM in the same image, we suggest combining 3 successive echoes. For SC or GM segmentation only, we recommend combining 5 or 3 successive echoes, respectively. Six signal averages yielded good contrast for reliable SC and GM segmentation in all subjects. Clinical applications could benefit from these recommendations as they allow for accurate SC and GM segmentation in the lumbosacral cord.

Automated slice-specific z-shimming for functional magnetic resonance imaging of the human spinal cord

Functional magnetic resonance imaging (fMRI) of the human spinal cord faces many challenges, such as signal loss due to local magnetic field inhomogeneities. This issue can be addressed with slice-specific z-shimming, which compensates for the dephasing effect of the inhomogeneities using a slice-specific gradient pulse. Here, we aim to address outstanding issues regarding this technique by evaluating its effects on several aspects that are directly relevant for spinal fMRI and by developing two automated procedures in order to improve upon the time-consuming and subjective nature of manual selection of z-shims: one procedure finds the z-shim that maximizes signal intensity in each slice of an EPI reference-scan and the other finds the through-slice field inhomogeneity for each EPI-slice in field map data and calculates the required compensation gradient moment. We demonstrate that the beneficial effects of z-shimming are apparent across different echo times, hold true for both the dorsal and ventral horn, and are also apparent in the temporal signal-to-noise ratio (tSNR) of EPI time-series data. Both of our automated approaches were faster than the manual approach, lead to significant improvements in gray matter tSNR compared to no z-shimming and resulted in beneficial effects that were stable across time. While the field-map-based approach performed slightly worse than the manual approach, the EPI-based approach performed as well as the manual one and was furthermore validated on an external corticospinal data-set (N > 100). Together, automated z-shimming may improve the data quality of future spinal fMRI studies and lead to increased reproducibility in longitudinal studies.

Simultaneous brain, brainstem and spinal cord pharmacological-fMRI reveals involvement of an endogenous opioid network in attentional analgesia

Pain perception is decreased by shifting attentional focus away from a threatening event. This attentional analgesia engages parallel descending control pathways from anterior cingulate (ACC) to locus coeruleus, and ACC to periaqueductal grey (PAG) – rostral ventromedial medulla (RVM), indicating possible roles for noradrenergic or opioidergic neuromodulators. To determine which pathway modulates nociceptive activity in humans, we used simultaneous whole brain-spinal cord pharmacological-fMRI (N = 39) across three sessions. Noxious thermal forearm stimulation generated somatotopic-activation of dorsal horn (DH) whose activity correlated with pain report and mirrored attentional pain modulation. Activity in an adjacent cluster reported the interaction between task and noxious stimulus. Effective connectivity analysis revealed that ACC interacts with PAG and RVM to modulate spinal cord activity. Blocking endogenous opioids with Naltrexone impairs attentional analgesia and disrupts RVM-spinal and ACC-PAG connectivity. Noradrenergic augmentation with Reboxetine did not alter attentional analgesia. Cognitive pain modulation involves opioidergic ACC-PAG-RVM descending control which suppresses spinal nociceptive activity.

Investigating the human spinal sensorimotor pathways through functional magnetic resonance imaging

Most of our knowledge about the human spinal ascending (sensory) and descending (motor) pathways comes from non-invasive electrophysiological investigations. However, recent methodological advances in acquisition and analyses of functional magnetic resonance imaging (fMRI) data from the spinal cord, either alone or in combination with the brain, have allowed us to gain further insights into the organization of this structure. In the current review, we conducted a systematic search to produced somatotopic maps of the spinal fMRI activity observed through different somatosensory, motor and resting-state paradigms. By cross-referencing these human neuroimaging findings with knowledge acquired through neurophysiological recordings, our review demonstrates that spinal fMRI is a powerful tool for exploring, in vivo, the human spinal cord pathways. We report strong cross-validation between task-related and resting-state fMRI in accordance with well-known hemicord, postero-anterior and rostro-caudal organization of these pathways. We also highlight the specific advantages of using spinal fMRI in clinical settings to characterize better spinal-related impairments, predict disease progression, and guide the implementation of therapeutic interventions.

Non-Invasive Functional Evaluation of the Human Spinal Cord by Assessing the Peri-Spinal Neurovascular Network With Near Infrared Spectroscopy

Current medical care lacks an effective functional evaluation for the spinal cord. Magnetic resonance imaging and computed tomography mainly provide structural information of the spinal cord, while spinal somatosensory evoked potentials are limited by a low signal to noise ratio. We developed a non-invasive approach based on near-infrared spectroscopy in dual-wavelength (760 and 850 nm for deoxy- or oxyhemoglobin respectively) to record the neurovascular response (NVR) of the peri-spinal vascular network at the 7th cervical and 10th thoracic vertebral levels of the spinal cord, triggered by unilateral median nerve electrical stimulation (square pulse, 5-10 mA, 5 ms, 1 pulse every 4 minutes) at the wrist. Amplitude, rise-time, and duration of NVR were characterized in 20 healthy participants. A single, painless stimulus was able to elicit a high signal-to-noise ratio and multi-segmental NVR (mainly from Oxyhemoglobin) with a fast rise time of 6.18 [4.4-10.4] seconds (median [Percentile 25-75]) followed by a slow decay phase for about 30 seconds toward the baseline. Cervical NVR was earlier and larger than thoracic and no left/right asymmetry was detected. Stimulus intensity/NVR amplitude fitted to a 2nd order function. The characterization and feasibility of the peri-spinal NVR strongly support the potential clinical applications for a functional assessment of spinal cord lesions.

An optimized MP2RAGE sequence for studying both brain and cervical spinal cord in a single acquisition at 3T

Magnetization Prepared 2 Rapid Acquisition Gradient Echo (MP2RAGE) is a T₁ mapping technique that has been used broadly on brain and recently on cervical spinal cord (cSC). The growing interest for combined investigation of brain and SC in numerous pathologies of the central nervous system such as multiple sclerosis (MS), amyotrophic lateral sclerosis (ALS) and traumatic injuries, now brings about the need for optimization with regards to this specific investigation. This implies large spatial coverage with high spatial resolution and short acquisition time, high CNR and low B₁⁺ sensitivity, as well as high reproducibility and robust post-processing tools for T₁ quantification in different regions of brain and SC. In this work, a dedicated protocol (referred to as Pr-BSC) has been optimized for simultaneous brain and cSC T₁ MP2RAGE acquisition at 3T. After computer simulation optimization, the protocol was applied for in vivo validation experiments and compared to previously published state of the art protocols focusing on either the brain (Pr-B) or the cSC (Pr-SC). Reproducibility and in-ROI standard deviations were assessed on healthy volunteers in the perspective of future clinical use. The mean T₁ values, obtained by the Pr-BSC, in brain white, gray and deep gray matters were: (mean ± in-ROI SD) 792 ± 27 ms, 1339 ± 139 ms and 1136 ± 88 ms, respectively. In cSC, T₁ values for white matter corticospinal, posterior sensory, lateral sensory and rubro/reticulospinal tracts were 902 ± 41 ms, 920 ± 35 ms, 903 ± 46 ms, 891 ± 41 ms, respectively, and 954 ± 32 ms for anterior and intermediate gray matter. The Pr-BSC protocol showed excellent agreement with previously proposed Pr-B on brain and Pr-SC on cSC, with very high inter-scan reproducibility (coefficients of variation of 0.52 ± 0.36% and 1.12 ± 0.62% on brain and cSC, respectively). This optimized protocol covering both brain and cSC with a sub-millimetric isotropic spatial resolution in one acquisition of less than 8 min, opens up great perspectives for clinical applications focusing on degenerative tissue such as encountered in MS and ALS.

Cortico-spinal imaging to study pain

Functional magnetic resonance imaging of the brain has helped to reveal mechanisms of pain perception in health and disease. Recently, imaging approaches have been developed that allow recording neural activity simultaneously in the brain and in the spinal cord. These approaches offer the possibility to examine pain perception in the entire central pain system and in addition, to investigate cortico-spinal interactions during pain processing. Although cortico-spinal imaging is a promising technique, it bears challenges concerning data acquisition and data analysis strategies. In this review, we discuss studies that applied simultaneous imaging of the brain and spinal cord to explore central pain processing. Furthermore, we describe different MR-related acquisition techniques, summarize advantages and disadvantages of approaches that have been implemented so far and present software that has been specifically developed for the analysis of spinal fMRI data to address challenges of spinal data analysis.

B0 field homogeneity recommendations, specifications, and measurement units for MRI in radiation therapy

PURPOSE

The purpose is: (a) Relate magnetic resonance imaging (MRI) quality recommendations for radiation therapy (RT) to B₀ field homogeneity; (b) Evaluate manufacturer specifications of B₀ homogeneity for 34 commercial whole-body MRI systems based on the MRI quality recommendations and RT application; (c) Measure field homogeneity in five commercial MRI systems and one commercial MRI-Linac used in RT and compare the results with their B₀ homogeneity specifications.

METHODS

Magnetic resonance imaging quality recommendations for spatial integrity, image blurring, fat saturation, and null banding in RT were developed based on the literature. Guaranteed (maximum) and typical B₀ field homogeneity specifications for various diameter spherical volumes (DSVs) were provided by GE, Philips, Siemens, and Canon. For each system, the DSV that conforms to each MRI quality recommendation and anatomical RT application was estimated based on the manufacturer specifications. B₀ field homogeneity was measured on six MRI systems including Philips (1.5 T), Siemens (1.5 and 3 T), and ViewRay MRI (0.35 T) systems using 24 and 35 cm DSV spherical phantoms. Two measurement techniques were used: (a) MRI using phase contrast field mapping to measure peak-to-peak (pk-pk), volume root mean square (VRMS), and standard deviation (SD); and (b) Magnetic resonance (MR) spectroscopy by acquiring a volumetric free induction decay (FID) to measure full width at half maximum (FWHM). The measurements were used to assess: (a) conformance with the manufacturer specifications; and (b) the relationship between the various field homogeneity measurement units. Measurements were made with and without gradient shimming (gradshim) or second-order active shimming. Multiple comparisons, analysis of variance (ANOVA), and Pearson correlations were performed to assess the dependence of pk-pk, VRMS, SD, and FWHM measurements of field homogeneity on shim volume, level of shim, and MRI system.

RESULTS

For a 40 cm DSV, the B₀ homogeneity specifications ranged from 0.35 to 5 ppm (median = 0.75 ppm) VRMS for 1.5 T systems and 0.2 to 1.4 ppm (median = 0.5 ppm) VRMS for 3 T systems. The usable DSVs ranged from 16 to 49 cm (median = 35 cm) based on the image quality recommendations and the manufacturer specifications. There was general compliance between the six measured field homogeneities and manufacturer specifications although signal dephasing was observed in two systems at < 35 cm DSV. The relationships between pk-pk, VRMS, SD, and FWHM varied based on MRI system, shim volume, and quality of shim. However, VRMS and SD measurements were highly correlated.

CONCLUSIONS

The delineation of the diseased lesion from organs at risk is the main priority for RT. Therefore, field homogeneity performance for RT must minimize image blurring and image artifacts (null bands and signal dephasing) while optimizing spatial integrity and fat saturation. Based on the specifications and recommendations for field homogeneity, some MRI systems are not well suited to meet the strict demands of RT particularly for the large imaging volumes used in body MRI. VRMS and SD measurements of B₀ field homogeneity tend to be more stable and sensitive to field inhomogeneities in RT applications than pk-pk and FWHM.

Discovery and validation of biomarkers to aid the development of safe and effective pain therapeutics: challenges and opportunities

Pain medication plays an important role in the treatment of acute and chronic pain conditions, but some drugs, opioids in particular, have been overprescribed or prescribed without adequate safeguards, leading to an alarming rise in medication-related overdose deaths. The NIH Helping to End Addiction Long-term (HEAL) Initiative is a trans-agency effort to provide scientific solutions to stem the opioid crisis. One component of the initiative is to support biomarker discovery and rigorous validation in collaboration with industry leaders to accelerate high-quality clinical research into neurotherapeutics and pain. The use of objective biomarkers and clinical trial end points throughout the drug discovery and development process is crucial to help define pathophysiological subsets of pain, evaluate target engagement of new drugs and predict the analgesic efficacy of new drugs. In 2018, the NIH-led Discovery and Validation of Biomarkers to Develop Non-Addictive Therapeutics for Pain workshop convened scientific leaders from academia, industry, government and patient advocacy groups to discuss progress, challenges, gaps and ideas to facilitate the development of biomarkers and end points for pain. The outcomes of this workshop are outlined in this Consensus Statement.

Assessing the spatial distribution of cervical spinal cord activity during tactile stimulation of the upper extremity in humans with functional magnetic resonance imaging

Dermatomal maps are a mainstay of clinical practice and provide information on the spatial distribution of the cutaneous innervation of spinal nerves. Dermatomal deficits can help isolate the level of spinal nerve root involvement in spinal conditions and guide clinicians in diagnosis and treatment. Dermatomal maps, however, have limitations, and the spatial distribution of spinal cord sensory activity in humans remains to be quantitatively assessed. Here we used spinal cord functional MRI to map and quantitatively compare the spatial distribution of sensory spinal cord activity during tactile stimulation of the left and right lateral shoulders (i.e. C5 dermatome) and dorsal third digits of the hands (i.e., C7 dermatome) in healthy humans (n = 24, age = 36.8 ± 11.8 years). Based on the central sites for processing of innocuous tactile sensory information, we hypothesized that the activity would be localized more to the ipsilateral dorsal spinal cord with the lateral shoulder stimulation activity being localized more superiorly than the dorsal third digit. The findings demonstrate lateralization of the activity with the left- and right-sided stimuli having more activation in the ipsilateral hemicord. Contradictory to our hypotheses, the activity for both stimulation sites was spread across the dorsal and ventral hemicords and did not demonstrate a clear superior-inferior localization. Instead, the activity for both stimuli had a broader than expected distribution, extending across the C5, C6, and C7 spinal cord segments. We highlight the complexity of the human spinal cord neuroanatomy and several sources of variability that may explain the observed patterns of activity. While the findings were not completely consistent with our a priori hypotheses, this study provides a foundation for continued work and is an important step towards developing normative quantitative spinal cord measures of sensory function, which may become useful objective MRI-based biomarkers of neurological injury and improve the management of spinal disorders.

Evidence for decreased Neurologic Pain Signature activation following thoracic spinal manipulation in healthy volunteers and participants with neck pain

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The use of brain-based models of pain were explored in two clinical studies.

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Neurologic pain signature activation decreased following spinal manipulation.

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Spinal manipulation altered the processing of pain-related brain activity.

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We provide evidence for a centrally mediated therapeutic action of spinal manipulation.

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Brain-based models have potential as objective clinical biomarkers of pain.

Background Context

Spinal manipulation (SM) is a common treatment for neck and back pain, theorized to mechanically affect the spine leading to therapeutic mechanical changes. The link between specific mechanical effects and clinical improvement is not well supported. SM's therapeutic action may instead be partially mediated within the central nervous system.

Purpose

To introduce brain-based models of pain for spinal pain and manual therapy research, characterize the distributed central mechanisms of SM, and advance the preliminary validation of brain-based models as potential clinical biomarkers of pain.

Study Design

Secondary analysis of two functional magnetic resonance imaging studies investigating the effect of thoracic SM on pain-related brain activity: A non-controlled, non-blinded study in healthy volunteers (Study 1, n = 10, 5 females, and mean age = 31.2 ± 10.0 years) and a randomized controlled study in participants with acute to subacute neck pain (Study 2, n = 24, 16 females, mean age = 38.0 ± 15.1 years).

Methods

Functional magnetic resonance imaging was performed during noxious mechanical stimulation of the right index finger cuticle pre- and post-intervention. The effect of SM on pain-related activity was studied within brain regions defined by the Neurologic Pain Signature (NPS) that are predictive of physical pain.

Results

In Study 1, evoked mechanical pain (p < 0.001) and NPS activation (p = 0.010) decreased following SM, and the changes in evoked pain and NPS activation were correlated (r_RM² = 0.418, p = 0.016). Activation within the NPS subregions of the dorsal anterior cingulate cortex (dACC, p = 0.012) and right secondary somatosensory cortex/operculum (rS2_Op, p = 0.045) also decreased following SM, and evoked pain was correlated with dACC activity (r_RM² = 0.477, p = 0.019). In Study 2, neck pain (p = 0.046) and NPS (p = 0.033) activation decreased following verum but not sham SM. Associations between evoked pain, neck pain, and NPS activation, were not significant and less clear, possibly due to inadequate power, methodological limitations, or other confounding factors.

Conclusions

The findings provide preliminary evidence that SM may alter the processing of pain-related brain activity within specific pain-related brain regions and support the use of brain-based models as clinical biomarkers of pain.

Measurement of T2* in the human spinal cord at 3T

PURPOSE

To measure the transverse relaxation time T₂* in healthy human cervical spinal cord gray matter (GM) and white matter (WM) at 3T.

METHODS

Thirty healthy volunteers were recruited. Axial images were acquired using an averaged multi-echo gradient-echo (mFFE) T₂*-weighted sequence with 5 echoes. We used the signal equation for an mFFE sequence with constant dephasing gradients after each echo to jointly estimate the spin density and T₂* for each voxel.

RESULTS

No global difference in T₂* was observed between all GM (41.3 ± 5.6 ms) and all WM (39.8 ± 5.4 ms). No significant differences were observed between left (43.2 ± 6.8 ms) and right (43.4 ± 5.5 ms) ventral GM, left (38.3 ± 6.1 ms) and right (38.6 ± 6.5 ms) dorsal GM, and left (39.4 ± 5.8 ms) and right (40.3 ± 5.8 ms) lateral WM. However, significant regional differences were observed between ventral (43.4 ± 5.7 ms) and dorsal (38.4 ± 6.0 ms) GM (p < 0.05), as well as between ventral (42.9 ± 6.5 ms) and dorsal (37.9 ± 6.2 ms) WM (p < 0.05). In analyses across slices, inferior T₂* was longer than superior T₂* in GM (44.7 ms vs. 40.1 ms; p < 0.01) and in WM (41.8 ms vs. 35.9 ms; p < 0.01).

CONCLUSIONS

Significant differences in T₂* are observed between ventral and dorsal GM, ventral and dorsal WM, and superior and inferior GM and WM. There is no evidence for bilateral asymmetry in T₂* in the healthy cord. These values of T₂* in the spinal cord are notably lower than most reported values of T₂* in the cortex.