Magnetic Resonance Imaging of the Pediatric Spine A. Jay Khanna, MD, Bruce A. Wasserman, MD, and Paul D. Sponseller, MD Abstract Magnetic resonance is an excellent modality for imaging pathologic processes in the pediatric spine. It allows high-resolution views of not only osseous structures (including the vertebral body, spinal canal, and posterior elements) but also soft-tis- sue structures (including the spinal cord, intervertebral disk, and nerve roots). Magnetic resonance imaging (MRI) can show these structures in various planes using different pulse sequences that allow optimal char- acterization of the tissues in and around the pediatric spine. Indica- tions for MRI in children (<18 years) are gradually expanding as technol- ogy improves. Properly interpreting MRI scans in these age groups de- pends on understanding the MRI appearance of the normal pediatric spine anatomy at various stages of development. For entities such as spinal dysraphism, left thoracic curves, and juvenile scoliosis, spe- cific recommendations can help cli- nicians use MRI effectively. MRI Techniques The major factors that influence the MRI appearance of various tissues are the density of protons in the tissue, the chemical environment of the pro- tons, and the magnetic field strength of the scanner. Unlike computed to- mography (CT), which produces im- ages based on the density of various tissues, MRI produces images based on free water content and on other magnetic properties of water, yield- ing superior soft-tissue contrast. Various sequences are produced by manipulating the strength of the ra- diofrequency (RF) pulses, the inter- val between the pulses, the repetition time (TR), and the echo time (TE), that is, the time between applying the RF pulse and measuring the signal emit- ted by the patient. By manipulating these variables, the images can be weighted to emphasize the T1, T2, gradient-recalled echo, or proton den- sity characteristics of a tissue. T1- weighted images allow evaluation of anatomic detail, including that of os- seous structures, disk, and soft tissues. T2-weighted images are used primar- ily to evaluate the spinal cord and to enhance lesion conspicuity.Agradient- recalled echo sequence typically is used when thin axial images are needed, such as for evaluating foraminal nar- rowing in the cervical spine, because its three-dimensional acquisition al- lows for very thin sections. Standard pulse sequences for spi- nal imaging include spin echo T1- weighted images and fast spin echo (FSE) T2-weighted images. The FSE technique allows acquisition of scans without prolonged imaging times. Be- cause cerebrospinal fluid (CSF) is bright on T2-weighted images and the spi- nal cord retains its intermediate sig- nal, the images maximize the contrast between CSF and neural tissue, allow- ing optimal delineation of the spinal cord and nerve roots. T2-weighted im- ages are very sensitive to pathologic changes in tissue, including any pro- Dr. Khanna is Chief Resident, Departmentof Or- thopaedic Surgery, The Johns Hopkins Hospital, Baltimore, MD. Dr. Wasserman is Assistant Pro- fessor, Department of Radiology, The Johns Hop- kins Hospital. Dr. Sponseller is Professor and Vice Chairman, Department of Orthopaedic Surgery, The Johns Hopkins Hospital. Reprint requests: Dr. Sponseller, c/o Elaine P. Henze, Room A672, 4940 Eastern Avenue, Bal- timore, MD 21224-2780. Copyright 2003 by the American Academy of Orthopaedic Surgeons. Magnetic resonance is an excellent modality for imaging the pediatric spine. Its suc- cessful use requires understanding both the basic physics and the sedation protocols necessary for acquiring high-resolution images. Interpreting the images accurately depends on appreciating the differences between the normal anatomy of the pedi- atric and the adult spine. Evaluating the images requires familiarity with the dif- ferential diagnosis of pediatric spine disease, including the most common processes (infections, neoplasms, and trauma) as well as spinal dysraphism. Despite the ac- knowledged usefulness of magnetic resonance imaging of the pediatric spine, con- troversies remain related to its safety in this age group and its limitations in di- agnosing and evaluating scoliosis and tethered cord syndrome. J Am Acad Orthop Surg 2003;11:248-259 248 Journal of the American Academy of Orthopaedic Surgeons cesses in which cells and the extra- cellular matrix have an increase in wa- ter content. This pathologic change is usually shown as an increase in sig- nal intensity on T2-weighted images. The signal from fat may be sup- pressed by a variety of techniques, in- cluding chemical saturation of its sig- nal or application of an inversion pulse, and imaging at a short time of inversion (TI) when there is no fat sig- nal present (short TI recovery [STIR]). Chemical suppression typically is used in sequences that result in high fat signal, such as FSE T2-weighted images or postcontrast T1-weighted images. Fat suppression is of little val- ue for noncontrast T1-weighted im- ages because the signal from most pathologic lesions, whether inflam- matory,neoplastic, or infectious,isof- ten low and better visualized because of contrast against the adjacent bright fat signal. Fat suppression on post- contrast T1-weighted images of the vertebral body is useful in adults who have fatty transformation of marrow. Fat-suppressed images may be par- ticularly useful for evaluating liga- mentous injuries or lesions involving the paraspinal tissues. The usefulness of STIR imaging is more limited be- cause the imaging parameters are re- stricted and cannot be optimized to maximize contrast between adjacent tissues of interest. Gradient-recalled echo images ap- pear to be T2-weighted because CSF is relatively bright; however, paren- chymal lesions typically are more con- spicuous on FSE T2-weighted images. The gradient-recalled echo sequence is sensitive to local inhomogeneities of the magnetic field, and signal loss is exaggerated in the presence of such inhomogeneities. Field inhomogene- ities may be caused by metallic im- plants (eg, pedicle screws or paraspi- nal rods), differences in the magnetic susceptibilities of adjacent tissues (eg, air-tissue interfaces), and paramagnetic substances (eg, gadolinium). Blood- breakdown products cause local field distortions resultinginsignalloss,mak- ing this technique very sensitive for the detection of blood. Open MRI systems are being used more frequently, especially for chil- dren. These systems have notably lower field strengths than do closed systems and therefore usually pro- duce studies of inferior overall qual- ity, especially of the spine. However, open MRI systems allow easier access to the sedated or otherwise compro- mised patient. Youngpatients and pa- tients with claustrophobia have ac- cess to parents and the environment, making the procedure less intimidat- ing. However, whenever possible, spinal MRI should be done using closed, 1.5-T systems. Pediatric Sedation Protocols Sedation is often required for success- ful MRI in young children. Many studies have evaluated specific seda- tion protocols. 1,2 The American Acad- emy of Pediatrics (AAP) has pub- lished guidelines for the elective sedation of pediatric patients, 3,4 but compliance with these guidelines is not mandatory. The AAP has stated that careful medical screening and pa- tient selection by knowledgeable medical personnel are needed to ex- clude patients at high risk of life- threatening hypoxia. 4 Also, monitor- ing usingAAPguidelines is necessary for the early detection and manage- ment of life-threatening hypoxia. 3 The AAP recommends that before an ex- amination in which sedation is to be used, children from newborn to age 3 years take nothing by mouth for 4 hours and those aged 3 to 6 years take nothing by mouth for 6 hours. 4 Pediatric sedation practices vary, but a few agents are common to most protocols. Oral chloral hydrate is of- ten recommended for children young- er than 18 months. However, its use is controversial because of its variable absorption, paradoxical effects, and nonstandardized dosing. Older chil- dren usually receive intravenous pen- tobarbital with or without fentanyl. Although studies have reported successful administration of sedatives by trained nurses, 1,2 an anesthesiol- ogist’s expertise can be beneficial for patients with substantial comorbidi- ties, including cardiopulmonary dis- ease, skeletal dysplasias, neuromus- cular disease, and abnormal airway anatomy. Because of the potential risks of anesthesia and sedation in children, there is a trend toward referring those who require sedation to hospitals with pediatric anesthesiologists. An important consideration after sedation for pediatric MRI is the need for strict adherence to established dis- charge criteria, including return to baseline vital signs, level of con- sciousness close to baseline, and abil- ity to maintain a patent airway. 5 Be- cause of the inherent risks of sedation, alternative techniques have been de- vised, including sleep deprivation and rapid, segmental scanning. The latter permits acquisition of high- quality images without the use of se- dation. Normal MRI Anatomy Appreciating normal MRI anatomy (Fig. 1) is essential for understanding and predicting the MRI appearance of pathologic processes. 6 Adolescents and Adults The lumbar spine is more fre- quently imaged than the cervical and thoracic area in both children and adults. In adolescents and adults, the lumbar spinal canal appears round proximally and triangular distally. The lumbar facet joints, best visual- ized in the axial plane, are covered with 2 to 4 mm of hyaline cartilage. This cartilage can be well visualized with FSE and gradient-recalled echo pulse sequences. The epidural space and ligaments also should be evalu- ated carefully. Epidural fat is seen as high signal intensity on T1-weighted A. Jay Khanna, MD, et al Vol 11, No 4, July/August 2003 249 images; the ligamentum flavum shows minimally higher T1-weighted signal compared with the other lig- aments. The conus medullaris is usu- ally located at the L1-L2 level. The tra- versing nerve roots pass distally from the conus medullaris and extend an- teriorly and laterally, exiting lateral- ly underneath the pedicle and extend- ing into the neural foramen. The intervertebral disk, consisting of the cartilaginous end plates, anulus fibro- sus, and nucleus pulposus, normally shows increased T2-weighted signal in its central portion. CSF, well im- aged as low T1-weighted and high T2-weighted signal, often can be used to determine the type of pulse se- Figure 1 A, Sagittal T1-weighted MRI scan of a normal lum- bar spine in a 2-year-old boy shows the rectangular shape of the vertebral bodies. The conus medullaris is seen at the L1-L2 level (arrow). B, T2-weighted image shows the long, thin ap- pearance ofthe intervertebral disk. C,Sagittal T1-weighted scan of a normal lumbar spine in a 10-year-old girl. D, T2-weighted scan. Lordosis is normal. The posterior elements are well formed, with a resultant decrease in the canal diameter. E, Sag- ittal T1-weighted scan of a normal lumbar spine in a 16-year- old girl shows dark CSF (thin arrow), the conus medullaris at the L1-L2 level (open arrow), and the basivertebral channel (arrowhead). Note the normal rectangular appearance of the vertebral bodies and the lumbar lordosis compared with the 10-year-old girl. F, Sagittal T2-weighted scan shows bright CSF (thin arrow) and a bright nucleus pulposus (arrowhead). Magnetic Resonance Imaging of the Pediatric Spine 250 Journal of the American Academy of Orthopaedic Surgeons quence that is being used. CSF pul- sations often create artifacts that de- grade the image in the lumbar spine; these artifacts must not be mistaken for a pathologic process. The cervical spine shows a mild lordosis on sagittal images. On axial images, the spinal canal is triangular, with the base located anteriorly. A dark band at the base of the dens is a normal variant that is a remnant of the subdental synchondrosis and should not be mistaken for a fracture. In adults, the facet joints are small and triangular, whereas in children they are large and flat. The spinal cord is elliptical in cross section in the cer- vical spine. There isadifference in sig- nal between the normal gray and white matter of the spinal cord. This signal heterogeneity should not be mistaken for intramedullary pathol- ogy. The intervertebral disks are sim- ilar in appearance to, but smaller than, those seen at the thoracic and lumbar levels. An important anatom- ic feature of the cervical spine is the prominent epidural venous plexus, which is not present in the thoracic or lumbar spine. The thoracic vertebral bodies are relatively constant in size, and the spi- nal canal is almost round. Abundant epidural fat is present posteriorly, but there is less anteriorlythaninthelum- bosacral region. The cord is more round than in the cervical or lumbar regions, and the cord segment lies two to three levels above the corre- sponding vertebral body. The inter- vertebral disks are thinner than the disks in the lumbar spine. The ap- pearance of the CSF is more variable in the thoracic spine than in the lum- bar region because of more prominent CSF pulsations, but on T1-weighted images, it is commonly seen as a re- gion of low signal dorsal to the spi- nal cord. This artifact is often most se- vere at the apex of curves, including the thoracic kyphosis. Certain tech- niques can minimize this artifact, in- cluding gating to the pulse or cardi- ac cycle. Children Differences Between the Pediatric and the Adult Spine The MRI appearance of the grow- ing spine is complex. Substantial changes occur in the vertebral ossi- fication centers and the intervertebral disks, changing the overall appear- ance of the spine markedly, especial- ly between infancy and age 2 years. 7 In general, the vertebral ossification centers are incompletely ossified ear- ly in childhood, and the disks are thicker and have a higher water con- tent than those in adults. The spinal canal and neural foramina are larger, and there is less curvature. In addi- tion, the overall signal intensity of the vertebral bodies is lower than that of the adult spine on T1-weighted im- ages because of the abundance of red (hematopoietic) marrow relative to yellow (fat) marrow in the pediatric, adolescent, and young adult spine. Full-Term Infant In the newborn, the overall size of the vertebral body is small relative to the spinal canal, and the spinal cord ends at approximately the L2 level. The lumbar spine does not exhibit the usual lordosis and is straight. The ver- tebral bodies show a markedly low signal intensity on T1-weighted im- ages, with a thin, central, hyperin- tense band that likely represents the basivertebral plexus. The spongy bone of the ossification center is el- lipsoid rather than rectangular and often mistaken for disk. The interver- tebral disk is relatively narrow and often contains a thin, bright central band on T2-weighted images that represents the notochordal rem- nants. 6,7 Age 3 Months At age 3 months, the osseous com- ponent of the vertebral body has in- creased and the amount of hyaline cartilage has decreased, giving the vertebral bodies a rectangularappear- ance. The ossification centers begin to gain in signal intensity, starting at the end plates and progressing centrally. The neural foramina have not sub- stantially changed at this age, remain- ing relatively large and ovoid. 6,7 Age 2 Years At age 2 years, the spine has be- gun to show its normal sagittal align- ment, most likely because of weight bearing (Fig. 1,Aand B). The ossified portion of the vertebral body increas- es substantially and begins to assume its adult appearance, with near- complete ossification of the pedicles and the articular processes. The disk space and nucleus pulposus become longer and thinner. The cartilaginous end plate has decreased in size and is often difficult to identify. The neu- ral foramen also begins to take its adult appearance as its inferior por- tion narrows. 7 Age 10 Years At age 10 years, sagittal alignment resembles that of an adult (Fig. 1, C and D). Ossification of the vertebral bodies and posterior elements is near- ly complete, with a resultant decrease in the spinal canal diameter. The ver- tebral bodies also develop concave superior and inferior contours. The nucleus pulposus becomes smaller at this age and spans approximately half the disk space in the sagittal plane. The neural foramina continue to nar- row inferiorly. 6 The Conus Medullaris In early fetal life, the spinal cord extends to the inferior aspect of the bony spinal column. 6 Because the ver- tebral bodies grow more rapidly lon- gitudinally than the spinal cord does, by birth the conus medullaris is re- positioned in the upper lumbar spine. It is important to note the location of the conus medullaris on every pedi- atric spine MRI study (Fig. 1, A and E).Aconus medullaris level below the L2-3 interspace in children older than 5 years is abnormal and indicates pos- sible tethering. 8,9 Saifuddin et al 10 re- A. Jay Khanna, MD, et al Vol 11, No 4, July/August 2003 251 viewed the MRI findings in 504 nor- mal adult spines and found that the average position of the conus med- ullaris was the lower third of L1 (range, middle third of T12 to upper third of L3). Pathologic Processes in the Pediatric Spine Infection Infectious processes involving the pediatric spine include osteomyelitis, diskitis, and epidural and paraspinal abscess. 11-13 In general, the MRI sig- nal characteristics of infection include a region of low T1 and high T2 sig- nal intensity in bone and soft tissue. In identifying vertebral osteomy- elitis, MRI is more sensitive than con- ventional radiographs or CT and more specific than nuclear scintigra- phy. 14,15 Marrow edema can be detect- ed on precontrast, fat-suppressed, FSE T2-weighted images. Postgado- linium enhancement of the disk and adjacent vertebral bodies on postcon- trast, fat-suppressed, T1-weighted images helps confirm the diagnosis. The specificity of MRI for infection is higher in childrenthanadultsbecause one of the primary confounders, de- generative arthritis, is not part of the differential diagnosis. Differentiating osteomyelitis from neoplastic disease is a common dilemma; generally, in- fectious processes are more likely to cross and destroy intervertebral disks than are neoplastic conditions. Diskitis is seen as a disruption of the normally well-defined disk- vertebral borders on T1-weighted im- ages and as an increase in signal of the disk on T2-weighted images. 12 On T2-weighted images, diskitis may obliterate the normally seen horizon- tal cleft within the intervertebral disk. The abnormal signal seen in infec- tious diskitis is associated classically with surrounding soft-tissue inflam- mation and reactive end-plate chang- es. Primary diskitis is more likely to develop in children than adults be- cause of the greater blood supply to the disk. Secondary diskitis after dis- kography or surgery is more likely to develop in adults. Epidural abscessesare rare,butwhen they do develop, it is usually after sur- gery or vertebral osteomyelitis. Epi- dural abscesses are diagnosed based on the MRI findings of a collection in the epidural space and the appropri- ate clinical setting. 11 Gadolinium- enhanced T1-weighted images often show a peripheral rim of enhancement that represents the abscess wall. Paraspinal abscesses occur adja- cent to the spinal column, most com- monly in the paraspinal musculature. They may be secondary to a primary infection in the spine or may arise spontaneously in the paraspinal mus- culature. These abscesses may be seen as retropharyngeal abscesses in the cervical spine, paraspinous or retro- mediastinal abscesses in the thoracic spine, or psoas abscesses in the lum- bar spine. The MRI characteristics of paraspinal abscesses include a well- defined wall and peripheral enhance- ment on postgadolinium, T1- weighted images. Trauma MRI can be used to evaluate the pediatric spinal trauma victim who has an abnormal neurologic exami- nation or is unresponsive. The patient is first evaluated with conventional radiographs, which may be normal, even in a child with a neural deficit. Although CT allows for better eval- uation of osseous detail and displaced fractures, MRI provides improved evaluation of nondisplaced fractures because of its ability to detect marrow-signal abnormalities. Spinal cord injury without radio- graphic abnormality (SCIWORA) is a well-defined entity seen in the pe- diatric age group. 16,17 The character- istic hypermobility and ligamentous laxity of the pediatric bony cervical and thoracic spine predispose children to this type of injury. 16 The elasticity of the bony pediatric spine and the relatively large size of the head allow the musculoskeletal structures to de- form beyond physiologic limits, which results in cord trauma followed by spontaneous reduction of the spine. 16 As with other types of spinal cord injuries, the most important predic- tor of outcome is the severity of neu- rologic injury. A patient with a com- plete neurologicdeficitafterSCIWORA has a poor prognosis for recovery of neurologic function. The role of MRI in SCIWORA syndrome is to define the location and the degree of neural injury, rule out occult fractures and subluxation that may require surgi- cal intervention, and evaluate for the presence of ligamentous injury. T2- weighted images typically show in- creased signal in the cord, vertebral body, or ligaments. The increased T2 signal in the cord is compatible with edema and can range from a partial, reversible contusion to complete transection of the cord. Two other traumatic entities can oc- cur in children, usually as the result of participation in sports. The first is acute disk herniation. This is often a fracture with a hingelike displacement of fibrocartilage and slipping of the entire disk with vertebral end-plate fracture rather than extrusion of a disk fragment from the nucleus, as is seen in adults. 18 Such avulsion fractures are often occult on conventional radio- graphs and are better detected with CT and MRI. 18 Axial MRI scans dem- onstrate the fracture fragment as an area of low signal intensity protrud- ing into the spinal canal, and sagittal images demonstrate a low signal in- tensity region in the shape of a Y or 7 on all pulse sequences. 18 The second entity is a spondylo- lysis as a cause of back pain in young athletes. MRI, however, is not the op- timal method for evaluating spondy- lolysis. CT offers increased spatial res- olution and the ability to accurately define the osseous defect, whereas ra- dionuclide imaging can demonstrate increased radiotracer activity in the region of the defect. Magnetic Resonance Imaging of the Pediatric Spine 252 Journal of the American Academy of Orthopaedic Surgeons Neoplasms MRI is the modality of choice for evaluating neoplasms in and around the pediatric spine. 19 An effective and commonly used approach is to clas- sify the lesion as extradural, intra- dural-extramedullary (Fig. 2), or in- tradural-intramedullary (Fig. 3). With this anatomic classification system, the primary role of the MRI exami- nation is to define the location of the suspected neoplasm, which is best achieved with axial and sagittal T1- and T2-weighted images. Once the lesion has been classified, the T2- weighted images can be used to char- acterize the lesion further. Specifical- ly, the degree of surrounding edema and tissue infiltration and the pres- ence or absence of a cystic component can be determined. Next, postgado- linium enhancement images should be compared with unenhanced T1- weighted images. The final step in ob- taining a diagnosis is to correlate the imaging findings with the patient’s age and other criteria to narrow the differential diagnosis. Spinal Dysraphism Spinal dysraphism is a general term used to describe a wide range of anomalies resulting from incomplete fusion of the midline mesenchyma, bone, and neural elements. The os- seous abnormalities consist of defects within the neural arch with partial or complete absence of the spinous pro- cesses, laminae, or other components of the posterior elements. MRI has been shown to be the best modality for evaluating spinal dysraphism. 20,21 A classification system has been proposed for evaluating a patient with a suspected spinal dysraphism (Table 1). 21 The differential diagnosis can be narrowed to one of three types: spinal dysraphism with a back mass either covered or not covered with skin, or with no back mass. The final diagnosis then can be made based on the lesion’s MRI characteristics. Myelomeningocele is the most common form of spinal dysraphism (Fig. 4). It usually presents in the lum- bosacral region (although it can be seen at higher levels) as a back mass not covered with skin. The mass may or may not be covered by lepto- meninges containing a variable amount of neural tissue. The sac her- niates through a defect in the poste- rior elements of the spine. The spinal cord usually contains a dorsal cleft, Figure 2 A schwannoma in an 8-year-old boy. A, Sagittal T1-weighted MRI scan shows an intradural-extramedullary mass impressing on the anterior cervical cord at the C5 level (ar- row). B, Axial T2-weighted image shows the lesion herniating through the right C5-C6 neu- ral foramen (arrows). Figure 3 An astrocytoma in a 6-year-old boy. A, Sagittal T1-weighted MRI scan shows an intradural-intramedullary lesion within the spi- nal cord at the T3-T5 levels (arrow). B, Sagittal T2-weighted image shows the partially cystic nature of the lesion. C, Axial T2-weighted image confirms that the lesion (arrow) is within the center of the spinal cord. A. Jay Khanna, MD, et al Vol 11, No 4, July/August 2003 253 is splayed open, and is often tethered within the sac. 21 Progressive scolio- sis is seen in 66% of patients with my- elomeningocele, Arnold-Chiari type II malformation in 90% to 99%, di- astematomyelia in 30% to 40%, and syringohydromyelia in 40% to 80%. 22 Scarring can occur at the sur- gical site after sac closure, so it is im- portant to monitor these patients for signs and symptoms of tethered cord syndrome. Of the entities presenting with a skin-covered back mass in the pres- ence of spinal dysraphism, lipomen- ingocele is the most common. 6,21 The lipomeningocele consists of lipoma- tous tissue that is continuous with the subcutaneous tissue of the back and also insinuates through the dysraph- ic defect and dura and into the spi- nal canal. The spinal cord often con- tains a dorsal defect at the level of the lipomatous tissue and may be teth- ered at this level. The essential MRI feature of this lesion is that the li- pomatous tissue follows the signal characteristics of subcutaneous fat on all pulse sequences, including fat- suppressed pulse sequences. Occult spinal dysraphism pre- sentswithouta backmass.Diastema- tomyelia is characterized by a sagit- tal splitting into two segments of the spinal cord, conus medullaris, or filum terminale, often in the thoracic or lumbar spine. The dural tube and arachnoid are undivided in approx- imately half these patients; clinical findings are rare, and surgery is not indicated. In the remaining patients, the dural tube and arachnoid are completely or partially split at the level of the spinal cord cleft, which results in tethering of the cord and subsequentclinicalsymptoms. Coro- nal T1- and T2-weighted images best define the sagittal split in the cord; the findings should be con- firmed on axial images. Another entity often seen in pa- tients with spinal dysraphism is sy- ringohydromyelia, or a syrinx (Fig. 5). Asyrinx is a longitudinal cavity with- in the spinal cord that may or may not communicate with the central ca- nal. Attempts to explain the etiology include developmental, traumatic, in- flammatory, ischemic, and pressure- related causes. Sagittal MRI scans show a linear, low T1 and high T2 sig- Table 1 Classification of Spinal Dysraphism Category Types Back mass not covered with skin Myelomeningocele Myelocele Back mass covered with skin Lipomyelomeningocele Myelocystocele Simple posterior meningocele No back mass (occult) Diastematomyelia Dorsal dermal sinus Intradural lipoma Tight filum terminale Anterior sacral meningocele Lateral thoracic meningocele Hydromyelia Split notochord syndrome Caudal regression syndrome (Adapted with permission from Byrd SE, Darling CF, McLone DG, Tomita T: MR im- aging of the pediatric spine. Magn Reson Imaging Clin North Am 1996;4:797-833.) Figure 4 A myelomeningocele in a 6-year-old girl. A, Sagittal T1-weighted MRI scan shows a low-back mass contiguous with the contents of the spinal canal (arrows). B, T2-weighted image shows that the mass is filled with high-signal-intensity fluid, compatible with CSF (ar- rows). C, Axial T1-weighted image confirms that the mass communicates with the spinal canal through a defect in the posterior elements (arrows). Magnetic Resonance Imaging of the Pediatric Spine 254 Journal of the American Academy of Orthopaedic Surgeons nal intensity within the parenchyma of the spinal cord. Gibbs artifact, or truncation arti- fact, can mimic a syrinx on sagittal images (Fig. 6). Gibbs artifact is seen on sagittal T1- and T2-weighted im- ages as a linear region of altered sig- nal intensity in the center of the spi- nal cord. Thus, it is important to evaluate serial axial T1- and T2- weighted images to confirm findings. Gibbs artifact results from not using a sufficiently high spatial frequency for sampling data. It can be corrected by using a higher-resolution matrix. Chiari Malformations Chiari malformations are seen fre- quently in patients with spinal dys- raphism. Chiari type I malformations consist of cerebellar tonsillar ectopia, in which the cerebellar tonsils extend below the level of the foramen mag- num. The common measurement for the degree of herniation of the ton- sils below the foramen magnum is 5 mm. Mikulis et al 23 reported a vari- Figure 5 A large syrinx involving the entire spine in a 2-year-old boy. A, Sagittal T1-weighted MRI scan shows the syrinx to be largest at the level of the lower thoracic spine (arrows). Axial T1-weighted (B) and T2-weighted (C) images confirm that the syrinx is located within the center of the spinal cord. Figure 6 A 5-year-old girl had a history of neck and arm pain. A, Sagittal T2-weighted MRI scan shows a long linear region of high signal intensity within the center of the cer- vical spinal cord (arrow). This finding can easily be mistaken for a syrinx. B, Sagittal T1-weighted image also suggests low signal intensity in the same region but fails to show a syrinx, demonstrating normal cord anatomy. C, Axial T2-weighted image also demonstrates normal anatomy. These find- ings are compatible with a Gibbs artifact. A. Jay Khanna, MD, et al Vol 11, No 4, July/August 2003 255 ation by age in the upper limit of nor- mal: 6 mm in the first decade of life, 5 mm in the second and third de- cades, and 3 mm by the ninth decade. In Chiari I malformations, the brain- stem is spared and the fourth ventri- cle remains in its normal location. Chiari I malformations are associat- ed with syringohydromyelia, cranio- vertebral junction anomalies, and basilar invagination. Chiari II malfor- mations are more advanced and con- sist of downward displacement of the brainstem and inferior cerebellum into the cervical spinal canal, with a de- crease in size of the posterior fossa. Tethered Cord Syndrome Tethered cord syndrome is seen in a substantial number of patients with spinal dysraphism, especially those who have undergone surgical closure of the defect. 24,25 During fetal life, the spinal cord extends to the sacrococ- cygeal level.Becauseofthe rapid growth of the vertebral column after birth, the cord ascends to the L1-L2 level in the newborn. During the formation of a spinal dysraphic defect such as my- elomeningocele, the open neural el- ements often attach to the peripheral ectoderm, resulting in spinal cord teth- ering. After surgical closure of the sac, there is a tendency for the spinal cord to become adherent at the repair site. As the child grows, this adherence may tether the cord and prevent cephalad cord migration, with eventual symp- toms. Thus, in patients with spinal dys- raphic and related conditions, includ- ing myelomeningoceles, myeloceles, lipomeningoceles, and diastematomy- elia, tethered cord should be ruled out as the potential cause of any deteri- oration in neurologic function. MRI has been proposed as the ini- tial, and possibly only, imaging study for a patient with a suspected teth- ered spinal cord. 9 Sagittal images should be evaluated to determine the level of the conus medullaris (Fig. 7). A conus level below the L2-L3 inter- space in children older than 5 years is abnormal and an indication of pos- sible tethering. 8,9 In addition, the teth- ered cord is often displaced posteri- orly in the spinal canal. Other findings include lipoma or scar tissue within the epidural space and increased thick- ness of the filum terminale. 9 Although MRI can determine whether a spinal cord is anatomically tethered, these findings should be correlated with the patient’s symptoms and serial phys- ical examinations before surgical re- lease is considered. Controversies in MRI of the Pediatric Spine MRI of the pediatric spine remains controversial in several conditions, in- cluding scoliosis and tethered cord syndrome, as well as with spinal in- strumentation. Safety is also a concern. Scoliosis The use of MRI imaging in scoli- osis is primarily to detect intraspinal abnormalities, which are more fre- quently associated with uncommon curve patterns such as left thoracic curves, an abnormal neurologic ex- amination, or young age at pre- sentation. 26-30 Recently, Do et al 26 con- cluded that MRI is not indicated before spine arthrodesis in a patient with an adolescent idiopathic scoli- osis curve pattern and a normal phys- ical and neurologic examination. One area of particular controversy is back pain in the presence of scolio- sis. In a retrospective study of 2,442 Figure 7 A14-year-old boy had ahistory of lipomeningocele.After surgical resection, bowel and bladder dysfunction and new lower-extremity paresthesias developed. A, Sagittal T2- weighted image shows the conus medullaris extending to approximately the L4 level and the filum terminale extending to the S1 level (arrow), compatible with tethered cord syn- drome. B, Axial T2-weighted image at the L4 level shows the cord located posteriorly within the thecal sac (arrow). C, Axial T2-weighted image at the L5 level shows the placode (thin arrow) with a right-side nerve root (thick arrow) coursing anteriorly and laterally. Magnetic Resonance Imaging of the Pediatric Spine 256 Journal of the American Academy of Orthopaedic Surgeons patients, Ramirez et al 31 found that a left thoracic curve or abnormal result on neurologic examination best pre- dicted an underlying pathologic con- dition. They found a significant asso- ciation between back painandageolder than 15 years (P < 0.001), skeletal ma- turity (P < 0.001), postmenarcheal sta- tus (P < 0.001), and history of injury (P<0.018).Theauthors concluded that it is unnecessary to perform extensive diagnostic studies on every patientwith scoliosis and back pain. MRI should be reserved for patients with infan- tile or juvenile scoliosis, left thoracic curves, or abnormal neurologic find- ings. Because coronal views are espe- cially useful in evaluating patients with scoliosis, they should be a part of the routine imaging protocol. Tethered Cord Syndrome The rate of MRI in tethered cord syndrome remains controversial. When MRI demonstrates a tethered cord, a choice between surgical and nonsurgical treatment must be made. Although anatomic tethering of the cord is detected easily on MRI, indi- cations for surgery depend on the clinical history and results of serial physical examinations. Imaging in the Presence of Implants MRI of the spine in the presence of instrumentation is generally safe but is limited by the image artifacts the implants produce. The pulse se- quence used for imaging titanium produces less degradation from arti- fact because it is less ferromagnetic than stainless steel (Fig. 8). 32,33 Thus, titanium may be the better choice of implant in a patient who may require follow-up with MRI. However, with appropriate imaging techniques, clin- ically useful information can be ob- tained safely in the presence of both types of implants. 34 Specialized pulse sequences such as the metal artifact reduction sequence (MARS) can help reduce the degree of tissue-obscuring artifact produced by spinal hardware and improve image quality compared with conventional T1-weighted spin- echo pulse sequences. 35 MRI Safety MRI may be contraindicated in pa- tients with ferromagnetic implants, materials, or devices because of the risk of implant dislodgement, heat- ing, and induction of current. 36 Shel- lock et al 36 reviewed and compiled the results of more than 80 studies and described the ferromagnetic qualities of 338 objects, including 30 ortho- paedic implants, materials, and devic- es. They found that most orthopaedic implants are made from nonferro- magnetic materials and therefore are safe for MRI procedures. Another concern is that of safety within the MRI suite. Areas surrounding and Figure 8 A 6-year-old boy had a history of high-grade astrocytoma. A, Anteroposterior radiograph6 weeks after resection, multilevellaminectomy, and posterior spinalarthrodesis from T4 to L3 with titaniumpedicle screws, hooks, and rods. B, Midline sagittal postgadolinium T1-weightedMRIscan allows visualization of thecanal con- tents with minimal artifact from the pedicle screws (arrows). C, Parasag- ittal postgadolinium T1-weighted im- age shows a rod (thick arrow) and pedicle screw (thin arrow). Neither obscures theMRI scan. D,Axial post- gadolinium T1-weighted image also shows thepedicle screws (arrows) and a patent spinal canal. A. Jay Khanna, MD, et al Vol 11, No 4, July/August 2003 257