Weighing the Risk Profile of Cervical Spine MRI in Evaluating Pediatric Cervical Spine Injuries

Abstract

Objective: Screening for cervical spine injury (CSI) after blunt trauma is common, but there remains varied practice patterns and clinical uncertainty regarding adequate radiographic evaluation. An oft-cited downside of MRI is the added risk compared to CT in the pediatric population; however, these specific risks have not yet been reported. This study examines the risks of cervical spine MRI in pediatric trauma patients in the context of what value MRI adds. Methods: Retrospective observational study of all pediatric blunt trauma patients who were evaluated with a cervical spine MRI over a four-year period at a level 1 pediatric trauma center. Clinical and radiographic data were abstracted, as well as anesthesia requirements and MRI-related major adverse events. CT and MRI results were compared for their ability to detect clinically unstable injuries—those requiring halo or surgery. Results: There was one major adverse event related to MRI among the 269 patients who underwent cervical spine MRI—a rate of 0.37%. While 55% of children had an airway and anesthesia for MRI, only 57% of these airways were newly placed for the MRI. None of the 85 patients newly intubated for MRI developed aspiration pneumonitis or ventilator-associated pneumonia, and no patients had a significant neurologic event while at MRI. Another area of the body was imaged concurrently with the cervical spine MRI in 64% of patients and 83% of MRIs were performed within 48 hours. CT and MRI were both 100% sensitive for injuries requiring halo or operative intervention. Eighty-three patients had an MRI performed after a negative CT, 11% (9/83) of these patients had a clinically stable injury detected on subsequent MRI, and none of these patients presented for delayed cervical spine complications. Conclusions: Overall, the safety profile of MRI in this setting is excellent and less than one-third of patients need new airway and anesthesia solely for MRI. In this clinical scenario, MRIs can happen relatively quickly and many patients require another body part to be imaged concurrently anyway. MRI and CT were both 100% sensitive for clinically unstable injuries. In the appropriate patients, MRI remains a safe and radiation-free alternative to CT.

Clinical outcome following magnetic resonance imaging as first-line imaging in low-impact pediatric spine trauma: a single-center retrospective observational study

“…No MRI- or anesthesia-related adverse effects were reported in this study population, consistent with previously published observations of an excellent safety profile of MRI [ 7 ]. Our study shows that in a selected pediatric population, spinal MRI can usually be obtained without sedation or anesthesia for children aged 5 years or older (Supplementary Material 3).…”

“…Another study by Henry et al [ 17 ] showed that STIR MRI had good sensitivity in pediatric cervical spine injuries and may be of clinical use in the clearance of the pediatric cervical spine. In a recent study by Lee et al [ 7 ], MRI was found to be 100% sensitive to unstable cervical injuries.…”

“…Although the role of MRI as a secondary modality after negative CT has been studied, the clinical feasibility and diagnostic reliability of first-line emergency MRI in pediatric spine trauma are poorly known. Lee et al [ 7 ] recently published a retrospective analysis of 269 pediatric trauma patients undergoing cervical MRI in an emergency setting. They found that MRI is safe and 100% sensitive to unstable injuries and concluded that MRI should be considered an alternative to CT in pediatric spinal trauma.…”

Outcomes of Follow-up Imaging After Pediatric Spinal Trauma Confirmed With Magnetic Resonance Imaging

“…MRI is superior in visualizing the ligaments and comparable to CT in detecting bony injuries 9,10 . A recent retrospective analysis found MRI safe and 100% sensitive for unstable injuries in the pediatric population with suspected cervical spine trauma 11 . The most significant drawbacks of the MRI include the need for anesthesia in younger or restless children, higher cost per examination, and longer scanning time compared with CT or conventional radiographs.…”

“… 9 , 10 A recent retrospective analysis found MRI safe and 100% sensitive for unstable injuries in the pediatric population with suspected cervical spine trauma. 11 The most significant drawbacks of the MRI include the need for anesthesia in younger or restless children, higher cost per examination, and longer scanning time compared with CT or conventional radiographs. Despite the higher sensitivity in ligamentous injuries, MRI does not necessarily yield additional value in the treatment of pediatric spinal trauma, 12 – 14 but its major advantage over CT is the lack of ionizing radiation.…”