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

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.