Utility of MR imaging in pediatric spinal cord injury

We evaluated the utility of MR imaging in pediatric patients with acute and subacute spinal cord injuries. MR imaging of 22 pediatric patients with suspected traumatic spinal cord injuries was reviewed. MR findings were correlated with physical examination and compared to available radiographs and CT examinations performed at time of presentation. Twelve patients had abnormalities on MR imaging. Seven had spinal cord contusions; five contusions were hemorrhagic. Five of seven patients with cord contusion had normal radiographs and CT exams. Six patients with normal radiographs and CT examinations had abnormal MR studies revealing cord contusion, ligamentous injury, disc herniation, and epidural hematoma. MR is useful in initial evaluation of pediatric patients with spinal cord injuries and in prognosis of future neurologic function. In the setting of spinal cord symptomatology and negative radiographic studies, MR imaging should be performed. Surgically correctable causes of cord compression demonstrated by MR imaging include disc herniation, epidural hematoma, and retropulsed fracture fragments. The entity of spinal cord injury without radiographic abnormality is a diagnosis of exclusion which should only be made after radiologic investigation with radiographs, high-resolution thin-section CT, and MR imaging.     

MR of physeal fractures of the adolescent knee

The aim of this study was to assess physeal fractures of the pediatric knee identified by MR imaging and to describe the MR findings of such fractures. The authors reviewed 315 consecutive pediatric knee MR examinations done to assess for traumatic injury. The MR images were reviewed for evidence of physeal fracture. Fractures were classified by the Salter-Harris system, and associated findings and injuries were noted. Plain radiographs and medical records were reviewed. Seven distal femoral physeal fractures (Salter II, n = 6; Salter III, n = 1) and two proximal tibia physeal fractures (Salter III, n = 1; complex Salter IV, n = 1) were identified. Magnetic resonance demonstrated widening of a portion of the physis with visualization of a metaphyseal/epiphyseal fracture line. Periosteal elevation was observed in six cases. Four patients had associated ligamentous or meniscal injuries. Plain radiographs were available for review in eight patients. Bone abnormalities suggesting fracture were evident in six of eight patients; however, the fracture was fully delineated in only one patient. The diagnosis or confirmation of fracture by MR changed clinical management in seven of eight patients in whom follow-up was available. Physeal fractures of the pediatric knee are occasionally diagnosed by MR. Magnetic resonance provides improved delineation of non-displaced physeal fractures of the knee, while simultaneously allowing for evaluation of soft tissue structures. Received: 25 October 1999/Accepted: 6 June 2000     

Imaging of spinal injury in abusive head trauma: a retrospective study

Background

Spinal imaging has been a neglected part of abusive head trauma (AHT) imaging. As most of the radiographs and CT spine are negative in AHT in infants, the cervical spine is assumed to be normal. There is increasing evidence in the role of injury to brainstem and cervical cord in the pathogenesis of AHT. In addition, in courts of law, there is fierce debate about AHT, its mimics and other disparate nontraumatic diagnoses explaining the neuroradiological and skeletal findings. However, this discussion ignores the evidence and significance of spinal injury. We sought to study the cervical spine in an AHT cohort to understand the true prevalence of spinal injuries in AHT and contrast it with cohorts of accidental and nontraumatic groups to give the clinicians a robust diagnostic tool in evaluating AHT.

Objective

The purpose of this study is to compare the relative incidence of spinal ligamentous and soft-tissue abnormalities on spinal MRI among three groups of children ages <48 months: 1) those with AHT, 2) those with accidental trauma, and 3) those with nontraumatic conditions.

Materials and methods

This comparative study included 183 children who underwent spine MRI: 67 with AHT, 46 with accidental trauma and a clinical suspicion of spinal injury, and 70 with nontraumatic conditions. Clinical and radiographic findings were collected in all cases and were analyzed retrospectively to identify MRI evidence of traumatic spinal injuries. The incidence of spinal injuries among the three groups was compared. The incidence of spinal ligamentous injuries was calculated for those with and without radiographic evidence of hypoxic-ischemic encephalopathy. All comparisons were performed using Fisher exact test with P?Results Cervical spine ligamentous injuries (predominantly the nuchal, atlanto-occipital and atlanto-axial ligaments) were present in 78% of the AHT group, 46% of the accidental trauma group and 1% of the nontraumatic group; all of these differences were statistically significant. Among the AHT group, ligamentous injuries were statistically correlated with evidence of brain ischemia.

Conclusion

Injury to the cervical spinal posterior ligamentous complex is common in AHT and even more prevalent than in clinically symptomatic traumatic cases. The high correlation between the radiographic findings of occipitocervical ligamentous injuries and hypoxic-ischemic brain injury is consistent with an interpretation that transient upper occipitocervical spinal cord injury in AHT leads to disordered breathing and results in hypoxic-ischemic encephalopathy. We recommend imaging the entire spine in AHT to properly identify and classify these injuries.     

Anatomy and injuries of the pediatric wrist: beyond the basics

Ligamentous injuries of the pediatric wrist, once thought to be relatively uncommon, are increasingly recognized in the context of acute high-energy mechanism trauma and chronic axial loading, including those encountered in both recreational and high-performance competitive sports. Recent advances in MR-based techniques for imaging the pediatric wrist allow for sensitive identification of these often radiographically occult injuries. Detailed knowledge of the intrinsic and supportive extrinsic ligamentous complexes, as well as normal developmental anatomy and congenital variation, are essential to accurately diagnose injuries to these structures. Early identification of ligamentous injury of the pediatric wrist is essential within the conservative treatment culture of modern pediatric orthopedics because treatment of these lesions often necessitates surgery, and outcomes often depend on early and sometimes aggressive intervention. In this article, we review MR arthrogram technique and pediatric wrist anatomy, and correlate appearances on MR and selected ligamentous pathologies of the pediatric wrist.     

Brachytelephalangic chondrodysplasia punctata with severe spinal cord compression: report of four new cases

Brachytelephalangic chondrodysplasia punctata (CDPX1, OMIM: #302950) is a rare congenital skeletal dysplasia caused by arylsulfatase E deficiency (OMIM: #300180). Although the symptoms are usually mild, severe spinal cord compression by dysplastic vertebras may develop. We report four new cases with severe cervical spinal canal narrowing documented by radiography, magnetic resonance imaging (MRI), and autopsy. In all, nine cases of CDPX1 with severe cervical spinal cord compression have now been described. Because these cases account for a large proportion of all reported CDPX1 cases, we believe that an antenatal suspicion of CDPX1 should lead to genetic counseling and to investigations for spinal cord compression. After birth, this complication must be routinely anticipated, and we suggest spinal MRI in all CDPX1 infants. Unless spinal cord compression is confidently ruled out, we recommend that these newborns receive the same care as trauma patients suspected of craniocervical junction disruption. No conflicts of interest occurred for this work.     

Accuracy of MR imaging for detecting epiphyseal extension of osteosarcoma

Background. Too few patients are receiving epiphyseal-sparing limb salvage procedures for osteosarcoma. Objective. To determine how magnetic resonance (MR) imaging can best predict the epiphyseal extension of osteosarcoma. Materials and methods. Forty children underwent complete pretreatment static and dynamic contrast-enhanced MR imaging (DEMRI). Static MR images [T1-weighted and short tau inversion recovery (STIR)] of the epiphyses were read in three ways: (1) for suspicion of any abnormality (tumor or edema), (2) for suspicion of tumor, excluding suspected edema, and (3) validating the second method by using a scale to rate the likelihood of tumor. Presentation imaging was compared to histopathologic findings after chemotherapy and resection. The receiver operating characteristic (ROC) method was used to analyze the scaled ratings of static MR and DEMRI values. Results. At delayed resection, 20 of 40 children with osteosarcoma had confirmed epiphyseal tumor; however, 32 epiphyses were abnormal on STIR and 28 abnormal on T1. Differentiating suspected tumor from edema increased the accuracy to an A_z (area under the ROC curve) of 0.94 for both T1-weighted and STIR static sequences. T1-weighted MR had better specificity and STIR better sensitivity at any given rating. DEMRI was slightly less accurate (Az = 0.90). Conclusion. Static MR imaging most accurately detected epiphyseal extension of osteosarcoma when readers distinguished suspected tumor from edematous or normal tissue. Received: 20 August 1999 Accepted: 13 January 2000     

Occipital condyle fracture and ligament injury: Imaging by CT

The true incidence of fracture of the occipital condyles is unknown. It may be associated with instability at the craniocervical joint. CT is the modality of choice for the demonstration of these fractures, but its use for imaging of the associated ligament injury has not been reported. In order to demonstrate normal anatomy, occipital condyle fracture and ligament injury, and to estimate the incidence of this lesion, 21 children and young adults with high-energy blunt craniocervical injury were examined prospectively. Thin-slice, axial, contiguous, CT was performed from the base of C2 to above the foramen magnum. Bone and soft tissue windows and coronal, sagittal, and curvilinear 2D reconstructions were performed. Five occipital condyle fractures were identified in four patients (19 %), with demonstration of alar ligament injury in two cases and local hematoma in one. In four, artifacts or rotation precluded assessment of ligaments. In all remaining cases normal bone and ligament anatomy was demonstrated. Fracture of the occipital condyles following craniocervical injury is not uncommon in children and young adults. Normal bone and ligament anatomy and pathology can be safely and clearly demonstrated in seriously injured patients and others using this CT technique. Increased awareness of this entity and a low threshold for performing CT should avoid the potentially serious consequences of a missed diagnosis.     

Unilateral hypoxic-ischemic injury in young children from abusive head trauma, lacking craniocervical vascular dissection or cord injury

Background Abusive head trauma (AHT) in young children usually has a severe outcome when associated with hypoxic-ischemic encephalopathy (HIE), which is best characterized by MRI in the acute or subacute phase utilizing diffusion-weighted imaging (DWI). HIE in this setting has been hypothesized to result from stretching of the spinal cord, brainstem, or vasculature. Objective To provide clinical correlation in patients with unilateral HIE and to postulate a mechanism in the setting of suspected AHT. Materials and methods IRB approval was obtained. Over a 5-year period, the medical records and images were reviewed of the 53 children ≤3 years of age who presented with acute head trauma according to the hospital registry. The children were subselected in order to determine how many suffered either HIE or AHT, and to detect those with unilateral HIE. Results In 11 of the 53 children, the etiology of the head trauma was highly suspicious for abuse. In 38 the head trauma was accidental and in 4 the trauma was of unknown etiology and at the time of this report was unresolved legally. Of the 53, 4 suffered HIE confirmed by CT or MRI. In three of these four with HIE the trauma was considered highly suspicious for AHT. Two of these three were the only patients with unilateral HIE, and both (7 months and 14 months of age) presented with early subacute phase HIE seen on DW MRI (range 4–7 days) and are described in detail with clinical correlation. The third child with AHT and HIE had bilateral findings. In the fourth patient the HIE was bilateral and was considered accidental. The work-up for both patients with unilateral HIE included head CT, craniocervical MRI, and craniocervical MR angiography (MRA). In both, there was mostly unilateral, deep white matter restricted diffusion, with subdural hematomas that were small compared to the extent of hypoxic-ischemic insult, and no skull fracture. Craniocervical MRA and axial thin-section fat-saturation images were negative for dissection, brainstem, or cord injury. Legal authorities obtained a confession of inflicted injury in one and a partial confession in the second (which did not fit the extent of injury). Five other children with HIE (based on DWI) were found during this period who had not suffered head trauma; all were bilateral insults. Conclusion HIE associated with AHT might present with largely unilateral white matter injury on DWI following extensive cortical infarction. We propose that unilateral HIE in a young child might be a sign of AHT and might result from cervical vascular compression, whether from kinking during hyperflexion/hyperextension or from direct strangulation.     

Cervical neurofibromas in children with NF-1

Background. Children with neurofibromatosis type 1 (NF1) are at increased risk of developing plexiform neurofibroma throughout the body, including the cervical soft tissues. However, the incidence of cervical soft tissue tumors and the value of screening MR for children with NF1 are not known. Purpose. The purposes of this study were to determine the incidence and clinical significance of cervical tumors seen on MR imaging in children with NF1. Materials and methods. A retrospective review of the brain and orbit MR with cervical images obtained on 95 children who meet the NIH consensus criteria for NF1 and who are followed at our neurofibromatosis clinic was carried out. Results. Cervical tumors were found on MR imaging in 21 of 95 (22 %) children. Of 21 children with cervical tumors, 14 children were determined to be surgical candidates. In nine children, MR imaging altered the clinical management by demonstrating tumors for which surgery was indicated, but the tumors were not suspected prior to MR imaging. Conclusion. Cervical tumors are commonly seen in children with NF1. MR imaging may demonstrate a significant number of tumors that require surgery, but were not suspected prior to MR imaging. Received: 1 July 1998 Accepted: 14 October 1998     

Usefulness of MRI detection of cervical spine and brain injuries in the evaluation of abusive head trauma

Background

In the evaluation of children younger than 3 years with intracranial hemorrhage it can be difficult to determine whether the cause of hemorrhage was traumatic, and if so, whether abusive head trauma (AHT) is a possibility. Cervical spine MRI is not a routine part of the nationally recommended imaging workup for children with suspected abusive head trauma. There is increasing evidence that spinal injuries are found at autopsy or MRI in abused children. However the prevalence of cervical spine injuries in children evaluated for abusive head trauma is unknown. We sought to determine both the incidence and the spectrum of cervical spine and brain injuries in children being evaluated for possible abusive head trauma. We also examined the relationship between cervical and brain MRI findings and selected study outcome categories.

Materials and methods

This study is a 3-year retrospective review of children evaluated for abusive head trauma. Inclusion criteria were: children with head trauma seen at our institution between 2008 and 2010, age younger than 36 months, availability of diagnostic-quality brain and cervical spine MRI, and child abuse team involvement because abusive head trauma was a possibility. A child abuse pediatrician and pediatric radiologists, all with board certification, were involved in data collection, image interpretation and data analysis. Statistical analysis was performed using Stata v12.1.

Results

The study included 74 children (43 boys, 31 girls) with a mean age of 164 days (range, 20–679 days). Study outcomes were categorized as: n?=?26 children with accidental head trauma, n?=?38 with abusive head trauma (n?=?18 presumptive AHT, n?=?20 suspicious for AHT), and n?=?10 with undefined head trauma. We found cervical spine injuries in 27/74 (36%) children. Most cervical spine injuries were ligamentous injuries. One child had intrathecal spinal blood and two had spinal cord edema; all three of these children had ligamentous injury. MRI signs of cervical injury did not show a statistically significant relationship with a study outcome of abusive head trauma or help discriminate between accidental and abusive head trauma. Of the 30 children with supratentorial brain injury, 16 (53%) had a bilateral hypoxic–ischemic pattern. There was a statistically significant relationship between bilateral hypoxic–ischemic brain injury pattern and abusive head trauma (P?<?0.05). In addition, the majority (81%) of children with bilateral hypoxic–ischemic brain injuries had cervical injuries.

Conclusion

Although detection of cervical spine injuries by MRI does not discriminate between accidental and abusive head trauma, it can help to distinguish a traumatic from non-traumatic intracranial subdural hemorrhage. Cervical MRI should be considered in children with acute intracranial bleeds and otherwise non-contributory history, physical examination and ophthalmological findings. There is a statistically significant relationship between diffuse hypoxic–ischemic brain injury patterns and abusive head trauma. The high incidence of cervical injuries in children with hypoxic–ischemic injuries suggests a causal relationship. Overall, increased utilization of brain and spine MRI in children being evaluated for abusive head trauma can be helpful.     

MR findings of complicated multifetal gestations

This paper presents a review of various complications of multifetal gestations identified on MR imaging and highlights findings of those complications unique to monochorionic twinning. The goal is to illustrate the potential of MR as a useful application in these clinical circumstances. A total of 32 women with multifetal gestations and suspected complication detected initially by US underwent T2-weighted MR imaging. Additional T1-weighted images were obtained when intracranial hemorrhage was suspected. MR and US findings were compared in all cases. Of 32 cases, six demonstrated fetal complications specific to monochorionic twinning; the findings consisted of conjoined twins (n=2), twin-twin transfusion syndrome (n=1), co-twin demise with embolic disease (n=2), and twin-reversed arterial perfusion. (TRAP) syndrome (n=1). MR imaging confirmed US findings in all cases and was particularly helpful in delineating the extent of intracranial complications of monochorionic twins. The technique also showed improved anatomical detail in cases of conjoined twins. MR imaging provided additional information in cases of complicated monochorionic twinning, making it a useful complementary technique when combined with initial sonographic assessment.     

Traumatic diaphragmatic injuries in infants and children: imaging findings

Objectives. Traumatic diaphragmatic injuries (DI) in infants and children are uncommon and are often associated with multiple severe injuries. Delayed presentation can be life threatening due to organ herniation and strangulation. We present the imaging findings in a relatively large population of children who experienced this rare injury.¶Methods. Medical records of all patients admitted to our Trauma Service from 1977 to 1998 with DI were retrospectively reviewed recording imaging, clinical and surgical or autopsy findings.¶Results. Of sixteen patients with DI (7 females, 9 males; age 3 weeks to 15 years), 14 suffered from blunt trauma secondary to high-energy impact, and 2 from penetrating injuries. Unilateral DI occurred equally on each side, with one bilateral injury. Associated injuries, present in 81 %, included severe head injuries, visceral, mesenteric and vascular injuries and multiple fractures. Six patients died from multiple organ failure (3), head injury (2), and shock (1). Findings in the initial chest X-ray suggested the diagnosis in 13 (81 %) of 16 injuries, and CT demonstrated irregularity and thickening of the diaphragm in 4 out of 7.¶Conclusions. Plain film findings suggested the diagnosis in most; CT and MR were useful adjuncts. High index of suspicion and awareness of the mechanism of injury can lead to prompt diagnosis, early repair, and decreased morbidity and mortality.     

Magnetic resonance imaging of knee injuries in children

The purpose of this study was to evaluate the significance of meniscal appearances and determine the frequency of abnormalities seen on magnetic resonance (MR) imaging in children with knee injuries. We reviewed 78 consecutive MR imaging studies of 74 children aged 5–16 years with unfused epiphyses. Menisci were evaluated using conventional grading techniques. We used ² to compare the frequencies of medial and lateral meniscus and anterior cruciate ligament (ACL) tears with each other and with published data for children. Similarly, we compared the proportions of tears of these structures with published data. Arthroscopy results from 26 children were used to calculate sensitivity and specificity of MR imaging for meniscal tears, which were 100 % (8/8) and 89 % (16/18), respectively. The majority of studies (82 %) had grade I or II signal intensity in one or both menisci. Arthroscopy results available in 33 % of this group revealed normal menisci. Tears of the medial and lateral menisci were significantly more common than of the ACL. Injuries of the ACL were seen significantly less frequently than previously reported. Grade I or II meniscal signal intensity in children with knee injuries is consistent with a normal meniscus. Tears of the menisci are more common than ACL tears. MR imaging in this context appears reliable.     

A comparison between scintigraphy and computed abdominal tomography in blunt liver and spleen injuries in children

Fifty consecutive paediatric patients with objective clinical signs of blunt abdominal trauma underwent both computed abdominal tomography (CT) and liver-spleen scintigraphy (LSS). All were managed non-operatively with no morbidity or mortality. Five splenic and 13 liver injuries were visualised on CT while LSS revealed 9 splenic and 29 liver injuries. Where injury to either organ was detected by both modalities, there was good correlation anatomically and also as to the extent of injury. LSS demonstrated injuries not shown on CT, which appeared to detect only more extensive injuries. We conclude that scintigraphy may be the more sensitive and therefore more appropriate method when blunt injury to the liver and spleen alone is clinically suspected. Abdominal CT remains the early investigation of choice in patients with clinical evidence of haemoperitoneum associated with shock or multiple injuries, particularly when injury to the kidneys as well as to the liver and spleen is suspected or when a concomitant brain scan is indicated. Offprint requests to: D. H. Bass     

Magnetic resonance imaging features of complex Chiari malformation variant of Chiari 1 malformation

Background

Complex Chiari malformation is a subgroup of Chiari 1 malformation with distinct imaging features. Children with complex Chiari malformation are reported to have a more severe clinical phenotype and sometimes require more extensive surgical treatment than those with uncomplicated Chiari 1 malformation.

Objective

We describe reported MR imaging features of complex Chiari malformation and evaluate the utility of craniometric parameters and qualitative anatomical observations for distinguishing complex Chiari malformation from uncomplicated Chiari 1 malformation.

Materials and methods

We conducted a retrospective search of the institutional imaging database using the keywords “Chiari” and “Chiari 1” to identify children imaged during the 2006–2011 time period. Children with Chiari 2 malformation were excluded after imaging review. We used the first available diagnostic brain or cervical spine MR study for data measurement. Standard measurements and observations were made of obex level (mm), cerebellar tonsillar descent (mm), perpendicular distance to basion-C2 line (pB-C2, mm), craniocervical angle (degrees), clivus length, and presence or absence of syringohydromyelia, basilar invagination and congenital craniovertebral junction osseous anomalies. After imaging review, we accessed the institutional health care clinical database to determine whether each subject clinically met criteria for Chiari 1 malformation or complex Chiari malformation.

Results

Obex level and craniocervical angle measurements showed statistically significant differences between the populations with complex Chiari malformation and uncomplicated Chiari 1 malformation. Cerebellar tonsillar descent and perpendicular distance to basion-C2 line measurements trended toward but did not meet statistical significance. Odontoid retroflexion, craniovertebral junction osseous anomalies, and syringohydromyelia were all observed proportionally more often in children with complex Chiari malformation than in those with Chiari 1 malformation.

Conclusion

Characteristic imaging features of complex Chiari malformation, especially obex level, permit its distinction from the more common uncomplicated Chiari 1 malformation.     

Blunt Abdominal Trauma in the Pediatric Patient

Timely diagnosis and a rational approach to operative versus nonoperative management of intra-abdominal injuries in children are critical to providing optimal pediatric trauma care. Suspicion of IAI is based on the mechanism of injury and findings on examination. Subsequent evaluation and management of IAI is influenced by the patient's hemodynamic status and the presence of extra-abdominal injuries. The hemodynamically unstable patient with suspected IAI requires emergent laparotomy. The hemodynamically stable patient is evaluated using laboratory and imaging studies, most importantly, CT of the abdomen. Stable patients with hepatic or splenic injuries are almost always managed nonoperatively, whereas small bowel, colon, and pancreatic injuries with main duct disruption require laparotomy.     

Skeletal injuries associated with sexual abuse

Background: Sexual abuse is often associated with physical abuse, the most common injuries being bruising and other soft-tissue injuries, but fractures occur in 5% of sexually abused children. The fractures described to date have formed part of the spectrum of injuries in these children and have not been specifically related to the abusive act. Objective: To describe concurrent sexual abuse and fractures. Materials and methods: Three children with pelvic or femoral shaft injuries in association with sexual abuse. Results: A 3-year-old girl with extensive soft-tissue injuries to the arms, legs and perineum also sustained fractures of both pubic rami and the sacral side of the right sacro-iliac joint. A 5-month-old girl with an introital tear was shown to have an undisplaced left femoral shaft fracture. A 5-year-old girl presented with an acute abdomen and pneumoperitoneum due to a ruptured rectum following sexual abuse. She had old healed fractures of both pubic rami with disruption of the symphysis pubis. Conclusions: Although the finding of a perineal injury in a young child may be significant enough for the diagnosis of abuse, additional skeletal injuries revealed by radiography will assist in confirmation of that diagnosis and may be more common than hitherto suspected.Presented as a poster at the 40th annual congress of ESPR, Genoa, Italy, June 2003     

Leptomeningeal metastases in pediatrics: magnetic resonance image manifestations and correlation with cerebral spinal fluid cytology

Background: Detection of leptomeningeal metastases is fundamental to a complete evaluation of central nervous system (CNS) or non‐CNS tumor with suspected involvement of the neuroaxis. Our purpose was to assess the appearances of different magnetic resonance (MR) sequences in the diagnosis of leptomeningeal metastases and correlate those positive findings with the cerebral spinal fluid (CSF) cytology results. Methods: The authors reviewed the medical records and MR image manifestations of leptomeningeal metastases from 18 children who had positive MR findings and retrospectively correlated them with CSF cytologic results. There was a uniform MR protocol and the patients were examined with the same sequences. Results: The abnormalities included pial‐arachnoid disease (n= 16), disease coating the nerves (n= 12), hydrocephalus (n= 3) and subependymal metastases (n= 2). Enhanced T1 images were better than unenhanced fluid attenuated inversion recovery (FLAIR) and T2 to delineate cranial and spinal leptomeningeal metastases. In our sample, seven out of 18 cases were cytologically negative on a single lumbar puncture. Conclusions: Contrast‐enhanced MR imaging can be invaluable, detecting the false‐negative lumbar punctures. FLAIR and diffusion images can be helpful in diagnosing leptomeningeal metastases of non‐enhancing primary tumors. Prognosis was more related to the primary tumor type than to the leptomeningeal enhancement MR pattern.     

Spinal cord injuries in older children: is there a role for high-dose methylprednisolone?

We present a retrospective case series of 15 children (aged 8-16 years) with blunt traumatic spinal cord injury who were treated with methylprednisolone as per the National Acute Spinal Cord Injury Study protocol. Of all patients, 12 (80%) were male. Causes were sports injuries (n = 9), motor vehicle crashes (n = 2), and falls (n = 4). Most injuries were nonskeletal (n = 14), and all patients had incomplete injury of the spinal cord. The most common location of tenderness was cervical (n = 7). Of the 15 patients, methylprednisolone was initiated within 3 hours in 13 patients and between 3 and 8 hours in 2 patients. All patients received the medication for 23 hours as per the National Acute Spinal Cord Injury Study protocol. Of the 15 patients, 13 recovered completely by 24 hours and were discharged with a diagnosis of spinal cord concussion. One patient had compression fracture of T5 and T3-T5 spinal contusion but no long-term neurological deficit. One patient was discharged with diagnosis of C1-C3 spinal cord contusion (by magnetic resonance imaging) and had partial recovery at 2 years after injury. All patients with a diagnosis of cord concussion had normal plain films of the spine and computed tomographic and magnetic resonance imaging findings. None of the patients had any associated major traumatic injuries to other organ systems. The high-dose steroid therapy did not result in any serious bacterial infections.     

Rickets on MR images

Background. The pathologic changes at the physis in patients with rickets have been well demonstrated histologically. Radiographs can depict only the associated osseous abnormalities. Patients and methods. We report two children in whom MR imaging demonstrated rachitic changes in the physeal cartilage beyond the well-recognized bony features. Results. The striking appearance of the physes and the physes of the secondary ossification centers confirm that MR imaging can successfully evaluate the cartilaginous structures of the developing skeleton. Conclusion. Though MR imaging is clearly unnecessary for the diagnosis of rickets, it is important that the typical features are not misinterpreted as other pathology. Received: 11 June 1998 Accepted: 8 February 1999