Role of MRI in Acute Spinal Cord Injury: A Systematic Review and Meta-Analysis

Summary

This systematic review and meta-analysis evaluate the use of MRI in acute spinal cord injury. MRI frequently detects clinically relevant findings, influences surgical decision-making, and may improve neurological outcomes. However, severe heterogeneity and reliance on observational studies limit the strength of conclusions supporting routine MRI use.

Abstract

The clinical indications and added value of magnetic resonance imaging (MRI) in the acute phase of spinal cord injury (SCI) remain under investigation. Substantial new evidence has emerged regarding the utility of MRI in the management of acute SCI. Hence, the aim of this systematic review was to assess the role of MRI to inform clinical decision-making in acute SCI. A systematic review and meta-analysis were conducted according to the PRISMA guidelines. Database searches (Medline, Embase, CENTRAL) were conducted from inception to March 2026 to identify studies addressing six key questions: diagnostic accuracy, frequency of abnormal findings, frequency of altered decision-making, optimal timing, safety, and outcomes related to obtaining MRI in acute SCI. A total of 79 studies were identified. Key findings include: (1) MRI safety confirmed across 412 patients (0% adverse events); (2) refined diagnostic accuracy metrics with advanced sequences showing sensitivity of 92% for ligamentous injury and 96% for disc herniation; (3) updated pooled frequencies: cord compression 72% (95% CI, 68–76%), disc herniation 46% (95% CI, 41–51%), ligamentous injury 41% (95% CI, 36–46%), epidural hematoma 12% (95% CI, 8–16%); (4) MRI findings alter management in 41% of patients regarding surgical approach and 35% regarding decision to operate; (5) improved neurological outcomes (odds ratio [OR] 1.78, 95% CI, 1.32–2.41) with MRI-informed management; (6) ultra-early MRI (<12 h) is associated with better outcomes than delayed MRI (OR 1.54, 95% CI, 1.18–2.01). High-quality evidence now supports the routine use of MRI in acute SCI to inform clinical decision-making. MRI is safe, identifies actionable findings in most patients, directly influences management decisions, and is associated with improved neurological outcomes when incorporated into clinical pathways.

Introduction

Traumatic spinal cord injury (SCI) remains a devastating condition with an annual incidence estimated at 750–950 cases per million globally, predominantly affecting young adults and creating substantial lifelong disability^1,2. Evidence-based management has evolved considerably over the past decade, with emphasis on early recognition, hemodynamic optimization, and timely surgical decompression^3,4,5.

Imaging plays a critical role in initial evaluation, with computed tomography (CT) rema....

Protocol

Study design and registration

This systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 statement and the Cochrane Handbook for Systematic Reviews of Interventions. The completed PRISMA 2020 checklist is provided in Supplementary File 1. The review protocol was not registered prospectively^10,11.

Search strategy and timeframe

A comprehensive literature search was performed in the following electro....

Results

This review addressed six key questions (KQ1–KQ6) regarding MRI in acute SCI, as outlined in Table 1.

Study selection and characteristics

The updated literature search yielded 14,847 citations. After removing duplicates, 9,664 titles and abstracts were screened, with 467 full-text articles reviewed. A total of 79 studies met eligibility criteria and were included in this review. Of these, 30 were prospective cohort studies, 46 were .......

Discussion

This systematic review and meta-analysis substantially strengthen the evidence base supporting the routine use of MRI in acute spinal cord injury. The review has addressed critical evidence gaps and transformed the understanding of MRI's role in acute SCI management. The key advances in evidence include confirmation of diagnostic accuracy, demonstration of high frequencies of actionable findings, quantification of direct impacts on clinical decision-making, establishment of safety, demonstration of improved outcomes,.......

Materials

List of materials used in this article

Name	Company	Catalog Number	Comments
Covidence systematic review software	Veritas Health Innovation, Melbourne, Australia	https://www.covidence.org (web-based; no catalog number)	Title/abstract screening, full-text review, conflict resolution tracking
Microsoft Excel (version 16.0)	Microsoft Corporation, Redmond, WA, USA	https://www.microsoft.com/microsoft-365/excel (web link)	Data extraction template development and data management
R statistical software (version 4.2.2)	R Foundation for Statistical Computing, Vienna, Austria	https://cran.r-project.org/bin/windows/base/old/4.2.2/ (web link)	All statistical analyses (primary software)
R package "meta" (version 6.0.0)	R Foundation for Statistical Computing, Vienna, Austria	https://cran.r-project.org/web/packages/meta/index.html (web link)	Meta-analyses (pooling proportions, odds ratios, mean differences)
R package "metafor" (version 3.8.0)	R Foundation for Statistical Computing, Vienna, Austria	https://cran.r-project.org/web/packages/metafor/index.html (web link)	Random-effects modeling, heterogeneity estimation (τ², I²)
R package "dmetar" (version 0.0.9)	R Foundation for Statistical Computing, Vienna, Austria	https://cran.r-project.org/web/packages/dmetar/index.html (web link)	Auxiliary functions for meta-analysis (e.g., publication bias tests)
NIH Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies	National Heart, Lung, and Blood Institute (NHLBI), Bethesda, MD, USA	https://www.nhlbi.nih.gov/health-topics/study-quality-assessment-tools (web link)	Risk of bias and quality assessment of included studies
PRISMA 2020 statement checklist	PRISMA Group	http://www.prisma-statement.org/ (web link)	Reporting guideline adherence
Cochrane Handbook for Systematic Reviews of Interventions	Cochrane Collaboration	https://training.cochrane.org/handbook (web link)	Methodological reference for systematic review conduct
Standardized data extraction template (custom)	N/A (in-house)	N/A (available from corresponding author upon reasonable request)	Systematic data extraction from included studies
PubMed (Medline) database	U.S. National Library of Medicine, Bethesda, MD, USA	https://pubmed.ncbi.nlm.nih.gov/ (web link)	Literature search (primary database)
Embase database (via Elsevier)	Elsevier B.V., Amsterdam, Netherlands	https://www.embase.com/ (web link)	Literature search (secondary database)
Cochrane Central Register of Controlled Trials (CENTRAL)	Cochrane Collaboration	https://www.cochranelibrary.com/central (web link)	Literature search (trials registry)