Zero Echo Time Magnetic Resonance Imaging of the Spine

Abstract Zero echo time magnetic resonance imaging is an ultrashort echo time technique that enables computed tomography–like visualization of cortical and trabecular bone while preserving the ionizing radiation-free, multiplanar, and soft tissue advantages of conventional magnetic resonance imaging. This narrative review outlines the technical foundations of spinal zero echo time imaging, such as sequence design, key optimization parameters, advanced deep learning–based reconstruction strategies, and common interpretive pitfalls like gas mimicking calcification, metal-related artifacts, and limited spatial resolution. Clinical applications are detailed across traumatic, degenerative, inflammatory, neoplastic, infectious, and developmental spinal conditions, emphasizing how zero echo time complements standard magnetic resonance imaging sequences and often approaches computed tomography in depicting cortical disruption, osteophytes, erosions, sclerosis, and heterotopic ossification. I also highlight emerging roles for zero echo time in pediatric and fetal spine assessment and in magnetic resonance imaging–only surgical planning workflows, where accurate computed tomography–like bone contrast is required but ionizing radiation avoidance is paramount. Collectively, current evidence positions zero echo time as a versatile adjunct that can streamline imaging algorithms, reduce dependence on computed tomography, and support ionizing radiation-sparing magnetic resonance imaging focused pathways for diagnosis, treatment planning, and follow-up in spine disease.