This study aimed to explore the relationship between intramedullary injury and midsagittal tissue bridges at the epicenter of sub-acute traumatic cervical spinal cord injury (SCI) and long-term clinical recovery.Imaging and clinical data from 57 traumatic cervical SCI patients at the First Affiliated Hospital of Nanchang University were retrospectively assessed. Midsagittal T2-weighted scans at 1 month post-injury were used to quantify lesion size and tissue bridge width. Correlation analyses were performed to determine the association between tissue bridge width, lesion size, and long-term clinical recovery.At 1 month after SCI, ventral midsagittal tissue bridges (VMTB), dorsal midsagittal tissue bridges (DMTB), and total midsagittal tissue bridges (TMTB) were associated with better AIS grades at 1 year post-injury. Shorter intramedullary lesion length (IMLL) and smaller intramedullary lesion width (IMLW) were linked to better outcomes. TMTB exhibited a stronger correlation with improved AIS grades compared to VMTB, DMTB, IMLL, and IMLW. Moreover, IMLL and IMLW were significantly higher while the DMTB, VMTB, and TMTB widths were significantly lower in patients with a poor prognosis than in those with a good prognosis. ROC analysis showed TMTB had better predictive performance than other measures.The observed association between clinical prognosis and midsagittal tissue bridges underscores the clinical relevance of these structures as neuroimaging biomarkers in patients with sub-acute SCI. Thus, midsagittal tissue bridges may serve as promising and reliable MRI biomarkers during the transition from acute to chronic phase for stratifying, treating, and evaluating patient subgroups in clinical trials.Copyright © 2025. Published by Elsevier Inc.