Which imaging modalities are most effective in diagnosing conditions that may require neurosurgical intervention?

For diagnosing conditions that may require neurosurgical intervention, MRI is the most effective imaging modality due to its superior soft tissue contrast and ability to delineate neural structures and pathological changes. In suspected spinal metastases or metastatic spinal cord compression, MRI of the spine with sagittal T1, STIR, and T2-weighted sequences, supplemented by axial imaging, is recommended to identify lesions, assess cord compression, and guide treatment planning NICE NG234. For brain tumours, including primary tumours and metastases, standard structural MRI (T2 weighted, FLAIR, DWI, and T1 pre- and post-contrast) is the initial diagnostic test of choice, providing detailed anatomical and pathological information essential for neurosurgical decision-making NICE NG99.

In acute traumatic brain injury, CT imaging of the head is the primary investigation for detecting clinically important injuries requiring neurosurgical input, due to its rapid availability and sensitivity to acute haemorrhage and fractures NICE NG232. MRI is not recommended as the primary imaging in this context but may provide additional prognostic information when clinically indicated NICE NG232.

If MRI is contraindicated in spinal cases, CT scanning is the alternative, with myelography reserved for complex diagnostic scenarios and performed only at specialist centres NICE NG234. Plain X-rays are not recommended for diagnosing spinal metastases, metastatic spinal cord compression, or traumatic brain injury NICE NG234,NICE NG232.

Advanced MRI techniques such as MR perfusion, diffusion tensor imaging, and MR spectroscopy may be considered when standard MRI findings are unclear, particularly in brain tumour follow-up and recurrence assessment, potentially aiding neurosurgical planning NICE NG99.

Overall, the choice of imaging modality depends on the clinical context: MRI is preferred for spinal and brain tumour evaluation, CT is preferred for acute head trauma, and advanced imaging techniques supplement standard MRI when further detail is required NICE NG234,NICE NG232,NICE NG99 Shah & Ross 2016.