Is MRI Needed for Pediatric C-Spine Clearance?

January 22, 2020

Spoon Feed
If the CT c-spine shows no abnormality in children, MRI does not appear to add value in detecting occult unstable injuries or need for intervention.

Why does this matter?
The Consensus Algorithm for Pediatric C-spine Clearance recommends CT in children with GCS of 8 or less. If they remain altered over the next 72 hours, MRI is recommended for c-spine collar clearance, even if the CT is normal. We know adults who are altered and have normal CT are safe for collar clearance. This practice is advocated for by both WEST and EAST. Even intoxicated patients may have their collar cleared with a normal CT. Is a follow up MRI needed in children if CT is completely normal?

Normal CT = no unstable injury
This was a retrospective review of 221 children with c-spine trauma who underwent both CT and MRI over a 15 year period at a single center. In 160 out of 221 children with no abnormality on CT, none had radiographic evidence of instability on MRI (defined as “disruption of two or more contiguous spinal columns”). In the 21 out of 221 children with stable appearing injuries on CT, 4 children (4/21, 19%) were actually unstable on MRI; two of these patients underwent intervention. Of the 40 out of 221 patients with unstable injury on CT, all were also confirmed on MRI. Here is my take home. If the CT is normal, you are done. An MRI is not needed. If a CT shows an unstable injury, then unless MRI helps with surgical planning, intervention can be based on the CT. If a CT shows a stable injury, you probably want to be sure and back it up with MRI. See flow diagram.