Systematic review of ultrasound and MRI prediction of spinal cord anomalies in children with anorectal malformations: what a pediatric urologist writing a protocol needs to know.

Background: Anorectal malformation (ARM) have a high association with spinal cord anomaly (SCA) impacting bladder and bowel function. This study aims to report the diagnostic accuracy of ultrasound (US) and MRI to detect SCA in children with ARM. Method: A systematic review was performed as per PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidance. Search terms used were broadened in three consecutive searches to find papers investigating outcomes from spinal imaging in ARM, with four author search validation. Study quality was assessed as per Quadas 2 score. Meta-analysis comparing US diagnosis to MRI findings was performed using random effects model, including only clinically relevant SCA and considering children who did not develop negative outcomes as a true negative. Results: Eight studies were included, six reporting US outcomes, and two MRI. All studies but one were retrospective studies. Overall, the included studies were applicable, but all suffered risk of bias with incomplete and non-protocolized follow-up. Pooled analysis for MRI compared with surgery found a sensitivity of 97% and a specificity of 94%, with one false positive and one false negative in an 8-month-old baby. When clinically relevant diagnoses were extracted and meta-analysis performed, a sensitivity of 33% and a specificity of 87% were found for infant US diagnosis of SCA. Conclusion: The normal US spine in early infancy does not have diagnostic weight. A positive early scan will allow you to stream into active surveillance. Mandated MRI of infants will depend on the local approach to prophylactic de-tethering surgery.