The Utility of Magnetic Resonance Imaging of the Spinal Cord in Paediatric Transverse Myelitis: A Systematic Review

Background Spinal cord magnetic resonance imaging (MRI) is central to the diagnosis of paediatric acute transverse myelitis (ATM), yet its true diagnostic yield, concordance with cerebrospinal fluid (CSF) inflammation, and prognostic value remain unclear. Objective To quantify the diagnostic yield of spinal cord MRI in paediatric ATM, evaluate agreement with CSF inflammatory markers, and explore associations between MRI features and clinical outcomes. Methods A systematic review was conducted in accordance with PRISMA guidelines and prospectively registered (CRD42024504846). MEDLINE, EMBASE, CINAHL, PsycINFO and CENTRAL were searched from 2006 to October 2025. Observational studies including ≥5 children (≤18 years) with monophasic ATM who underwent spinal cord MRI were eligible. The primary outcome was the proportion of clinically diagnosed ATM cases demonstrating inflammatory spinal cord lesions on MRI. Secondary outcomes included MRI–CSF concordance and associations between imaging findings and long-term outcomes. Risk of bias was assessed using QUADAS-2. Results Twelve studies comprising 330 children were included. The pooled diagnostic yield of spinal cord MRI was 97.6% (95% CI 92.2 to 100.0%), with substantial heterogeneity (I²=71.8%) and a wide 95% prediction interval of 71.2 to 99.6%, indicating that a future paediatric cohort could plausibly report a yield anywhere within that range. Longitudinally extensive transverse myelitis and gadolinium enhancement were the most frequently reported features. Paired MRI–CSF data were available for 61 patients; discordance was observed in 36%, most commonly MRI-positive with normal CSF. Follow-up data (n=237) showed 64% achieved good recovery, whereas 30% had severe residual deficits; persistent bladder dysfunction occurred in 31%. Baseline MRI positivity did not reliably predict outcome. Conclusions Spinal cord MRI demonstrates a high diagnostic yield in imaged children with clinically diagnosed ATM, but imaging was a condition of cohort entry in most included studies and the pooled estimate is strongly influenced by study design. MRI should be interpreted alongside CSF findings, and baseline imaging alone does not reliably stratify prognosis. Standardised prospective studies are required to refine the diagnostic and prognostic role of MRI in paediatric inflammatory myelopathies.