Spinal Cord Injury Without Radiographic Abnormality Research Articles

Paediatric cervical spine injuries: An audit of 22 acute injuries and literature review

Summary Aim: To describe patterns of injury, radiological evaluation and assessment of paediatric cervical spine injuries at our institution. Methods: We undertook an audit of cervical spine injuries over a 5-year period reviewing injury type, mechanism, radiological evaluation, and National Emergency X-Radiography Utilization Study decision instrument criteria at presentation [Hoffman JR, Wolfson AB, Todd K, Mower WR. Selective cervical spine radiology in blunt trauma: methodology of the National Emergency X-Radiography Utilization Study (NEXUS). Ann Emerg Med 1998;32:461–9]. Result: There were 22 children with cervical spine injuries. Nine children were injured during recreational activities, with seven injuries caused by motor vehicle accidents. There were 12 fractures, five spinal cord injury without radiographic abnormality (SCIWORA), four subluxation/dislocation injuries and one subluxation and fracture. Younger children (age less than 8) suffered injuries in the upper cervical spine. A positive diagnosis in the children with a fracture or subluxation injury was possible on plain films in all but two children. Using the NEXUS criteria, 14 of the 21 patients met at least one criterion on initial assessment. Conclusion: Our injury pattern is similar to that described in previous studies, although recreational activities were the leading mechanism of injury. Plain films were diagnostic in all but two of the fracture or subluxation injuries. The NEXUS decision instrument provides a good assessment of risk but has limitations when assessing young children.

Diagnosis and prognostication of adult spinal cord injury without radiographic abnormality using magnetic resonance imaging: analysis of 40 patients

Background Spinal cord injury without radiographic abnormality (SCIWORA) is not uncommon among middle-aged and elderly people. It is less reported in adults as compared with children. This study was undertaken to find the incidence, magnetic resonance imaging (MRI) changes, and outcome of SCIWORA in adults and to demonstrate the prognostic value of MRI in SCIWORA. Materials and Methods Forty adult patients who sustained SCIWORA for a period of 2 years (January 1999 to December 2000) were admitted to our hospital. Methylprednisolone was given in therapeutic doses, for a period of 24 hours, to those arriving within 6 hours of injury. Magnetic resonance imaging was performed within 72 hours of admission to the hospital. In all patients, sagittal, axial, and coronal T1, spin, and T2 images of MRI were obtained. Clinical status of the patient at the time of admission and discharge was correlated with MRI. Results Four patients (10%), who were in Frankel grade D, with no demonstrable injury on MRI, improved to Frankel grade E at the time of discharge. Two patients (5%) with cord edema and extraneural injury improved to a useful neurological grade (Frankel grades D or E), whereas 13 patients (32.5%) with MRI features of cord contusion and hemorrhage did not achieve useful neurological function. Conclusion Spinal cord injury without radiographic abnormality contributes 12% of cases of spinal cord injury. Magnetic resonance imaging is the investigation of choice, having diagnostic and prognostic value because it demonstrates neural and extraneural injuries and helps to pick up surgically correctable abnormality. Patients with minimal cord changes on MRI have the best outcome followed by those with cord edema. Patients with parenchymatous hemorrhage and contusion on MRI fare badly.

Spinal Cord Injury without Radiographic Abnormality in Children, 2 Decades Later

Much new research has emerged since 1982, when the original description of spinal cord injury without radiographic abnormality (SCIWORA) as a self-contained syndrome was reported. This article reviews new and old data on SCIWORA, from the past 2 decades. This article reviews what we have learned since 1982 about the unique biomechanical properties of the juvenile spine, the mechanisms of injuries, the profound influence of age on injury pattern and outcome, the magnetic resonance imaging (MRI) features, and management algorithms of SCIWORA. The increasing use of MRI in SCIWORA has yielded ample evidence of damage in virtually all nonbony supporting tissues of the juvenile vertebral column, including rupture of the anterior and posterior longitudinal ligaments, intervertebral disc disruption, muscular and interspinal ligament tears, tectorial membrane rupture, and shearing of the subepiphyseal growth zone of the vertebral endplates. These findings provide the structural basis for the postulated "occult instability" in the spine of a patient after SCIWORA. MRI also demonstrated five classes of post-SCIWORA cord findings: complete transection, major hemorrhage, minor hemorrhage, edema only, and normal. These "neural" findings are highly predictive of outcome: patients with transection and major hemorrhage had profoundly poor outcome, but 40% with minor hemorrhage improved to mild grades, whereas 75% with "edema only" attained mild grades and 25% became normal. All patients with normal cord signals made complete recovery. The large pool of clinical data from our own and other centers also lends statistical power to uphold most of our original assertions regarding incidence, causes of injury, pathophysiology, age-related changes in the malleability of the spine, vectors of deformation, and the extreme vulnerability of young children to severe cord injury, particularly high cervical cord injury. Thoracic SCIWORA has been identified as an important subset, comprising three subtypes involving high-speed direct impact, distraction from lap belts, and crush injury by slow moving vehicles. Computation of the sensitivities of MRI and somatosensory evoked potentials in detecting SCIWORA shows that both tests were normal in 12 to 15% of children with definite, persistent myelopathy; all of these children were nevertheless braced for 3 months because of their clinical syndrome. Children with transient deficits but abnormal MRI and/or somatosensory evoked potentials were also braced, but the 60% with transient deficits and normal MRI and somatosensory evoked potentials were not braced. This is a change from our original policy in 1982 of bracing all children with persistent or transient deficits, brought on by our new MRI and electrophysiology data. Injury prevention, prompt recognition, use of MRI and electrophysiological verification, and timely bracing of SCIWORA patients remain the chief measures to improve outcome.

Pediatric Spine Fractures

The anatomy and biomechanics of the growing spine produce failure patterns different from those in adults. Spinal injury in the pediatric patient is a concern as prevention of further neurologic damage and deformity and the good potential for recovery make timely identification and appropriate treatment of such injury critical. A retrospective clinical case series was conducted to present data from a large series of pediatric patients with spine injuries from a single regional trauma center. One hundred thirty-seven children with spine injuries were seen over 10 years and were divided into three age groups: 0-9, 10-14, and 15-17 years. Analysis of variance and chi2 were used to analyze differences between groups. There were 36 patients aged 0-9, 49 aged 10-14, and 52 aged 15-17. Spine injury incidence increased with age. Motor vehicular accidents were the most common cause in this series. There were 36% cervical, 34% thoracic, 29% lumbar, 34% multilevel contiguous, and 7% multilevel noncontiguous involvement. Nineteen percent had spinal cord injury. Thirteen of 21 complete neurologic injuries and all 3 incomplete injuries improved. Cord injury was more common in the 0-9 age group. Four of five patients with spinal cord injury without radiographic abnormality (SCIWORA) were in the 0-9 age group and had complete neurologic injuries. Young children with cervical injuries were more likely to die than older children. Fifty-three percent had associated injuries. Eighteen percent underwent decompression, fusion, and instrumentation. Two patients developed scoliosis. The complication rate in surgical patients was higher than in patients treated nonsurgically and in polytrauma patients. This may be related to the severity of the initial injury. Our results suggest age-related patterns of injury that differ from previous work. The incidence of cord injury is 20% with higher frequencies in the young child. Potential for neurologic recovery is good. Young children have a higher risk for death than older children. There was no predominance of cervical injuries in the young child. The incidence of SCIWORA was low. Higher complication rates were seen in polytrauma and surgical patients.

Pediatric spinal cord injury without radiographic abnormality (SCIWORA): the absence of occult instability and lack of indication for bracing.

A retrospective review of medical records and imaging studies of children diagnosed with spinal cord injury without radiographic abnormality (SCIWORA) or SCIWORA-like symptoms at Children's Hospital of Pittsburgh between 1965 and 1999 was undertaken. To evaluate the existence of occult segmental spinal instability and a role for bracing as treatment for SCIWORA, we contrasted the Children's Hospital of Pittsburgh experience with literature reports on SCIWORA. There is a great deal of confusion and conflicting evidence regarding pediatric SCIWORA in the literature. Previous reports from our institution reported unique findings, including the only description of serious, recurrent SCIWORA in the literature. These findings have frequently been cited as the justification for long-term immobilization in all cases of SCIWORA. All records on patients coded as spinal cord injury without fracture or dislocation (ICD-9 code 952.xx) were reviewed. Children 17 years of age or younger with traumatic spinal cord injury and normal plain radiographic findings were included. Penetrating trauma, infection, or metabolic diseases were excluded. A total of 189 patients were diagnosed with SCIWORA at our institution over the 35-year review period. These patients differed from those reported in the literature with respect to a higher incidence, older age, less involved neurologic injury, and more low-energy mechanisms, such as sports and falls. There were no cases of a patient with SCIWORA who deteriorated and developed a permanent neurologic deficit after having either recovered or plateaued from an initial SCIWORA. All recurrent SCIWORA recovered to normal neurologic function. Bracing did not demonstrate any benefit in preventing these minor recurrent SCIWORAs. We identified no cases of serious, recurrent SCIWORA at our institution from 1965 to 1999. A case-by-case evaluation is required for the treatment of spinal cord injury without apparent spinal column injury, and bracing is not uniformly indicated.

SCIWORA in Childhood

Mower, William R. MD, PhD; Hendey, Greg W. MD; Hoffman, Jerome R. MD, MA; Wolfson, Allan B. MD Author Information

SCIWORA in Childhood

SCIWORA in Childhood

Spinal Cord Injury without Radiographic Abnormality: Results of the National Emergency X-Radiography Utilization Study in Blunt Cervical Trauma

The purpose of this study was to better define the incidence and characteristics of patients with spinal cord injury without radiographic abnormality (SCIWORA), using the database of the National Emergency X-Radiography Utilization Study (NEXUS). This was a prospective, observational study of blunt trauma patients in 21 U.S. medical centers undergoing plain cervical radiography. SCIWORA was defined as spinal cord injury demonstrated by magnetic resonance imaging, when a complete, technically adequate plain radiographic series revealed no injury. Of the 34,069 patients entered, there were 818 (2.4%) with cervical spine injury, including 27 (0.08%) patients with SCIWORA. Over 3,000 children were enrolled, including 30 with cervical spine injury, but none had SCIWORA. The most common magnetic resonance imaging findings among SCIWORA patients were central disc herniation, spinal stenosis, and cord edema or contusion. Central cord syndrome was described in 10 cases. In the large NEXUS cohort, SCIWORA was an uncommon disorder, and occurred only in adults.

Magnetic resonance imaging correlation in pediatric spinal cord injury without radiographic abnormality.

The authors conducted a study to determine correlations between clinical syndromes and early magnetic resonance (MR) imaging-documented findings in children with spinal cord injury without radiographic abnormality (SCIWORA). The authors retrospectively reviewed the records obtained in 20 patients who presented with SCIWORA to the Children's Hospital of Buffalo between 1992 and 1999. Initial neurological syndromes, subsequent hospital course and outcome, and early MR imaging findings obtained using conventional sequences on a 1.5-tesla unit were recorded. Neurological syndromes on presentation were complete (Frankel Grade A) in two patients (10%), severe partial (Frankel Grade C) in one patient (5%), and mild partial (Frankel Grade D) in 17 patients (85%). Partial neurological deficits resolved in 14 (78%) of 18 patients within 72 hours and lasted more than 72 hours in four patients (22%). Magnetic resonance imaging was performed in both patients presenting with complete injuries and in 17 of 18 patients presenting with partial neurological deficits. The studies were obtained within 24 hours in 17 patients (85%). Neuroimaging revealed spinal cord swelling at the cervical level in one of the children with complete injury and cord edema with associated hemorrhage at cervical and thoracic levels in the other. Neural and extraneural elements were shown to be normal in all 17 patients with partial injuries who underwent MR imaging, including in the four patients with partial motor deficits lasting more than 72 hours. In this series, the predominant neurological presentation of SCIWORA was a mild, partial syndrome that resolved within 72 hours. Magnetic resonance imaging revealed abnormal features only in those patients with complete neurological deficits. These findings suggest that in the acute setting conventional MR imaging sequences may lack the sensitivity to demonstrate neural and extraneural abnormalities associated with partial or temporary neurological deficits of SCIWORA, even when those deficits persist beyond 72 hours.

Spinal Cord Injury Without Radiographic Abnormality (SCIWORA) in Children

SCIWORA is a syndrome occurring when the spinal cord sustains neural damage during a traumatic event without positive radiographic findings. Anatomic characteristics of the pediatric spine place children at risk for this injury. The injury occurs through extreme flexion, hyperextension, longitudinal distraction or ischemic damage to the spinal cord. Diagnosis is based on MRI findings. Timely diagnosis and stabilization is key to optimizing the child's recovery. Nursing care and evaluation of these children goes beyond the ABCs of resuscitation focusing on astute neurological examination.

Cervical spine injuries in children: A review of 103 patients treated consecutively at a level 1 pediatric trauma center

Purpose: Cervical spine (C-spine) injuries occur infrequently in children but may be associated with significant disability and mortality. The purpose of this study was to review the experience of a level 1 pediatric trauma center to determine the epidemiology, risk factors, mechanisms, levels, types of injury, comorbid factors, and outcomes associated with these potentially devastating injuries. Methods: A retrospective analysis of 103 consecutive C-spine injuries treated at a level 1 pediatric trauma center over a 9½-year period (January 1991 through August 2000) was performed. Results: The mean age was 10.3 ± 5.2 years, and the male-to-female ratio was 1.6:1. The most common mechanism of injury was motor vehicle related (52%), followed by sporting injuries (27%). Football injuries accounted for 29% of all sports-related injuries. Sixty-eight percent of all children sustained injuries to C1 to C4; 25% to C5 to C7; and 7% to both. Spinal cord injury without radiographic abnormality (SCIWORA) occurred in 38%. Five patients had complete cord lesions involving the lower C-spine (C4 to C7); 4 of these were motor vehicle related, and all 4 patients died. Isolated C-spine injuries occurred in 43%, whereas 38% had associated closed head injuries (CHI). The overall mortality rate was 18.5%, most commonly motor vehicle related (95%), occurring in younger children (mean and median age 5 years) and associated with upper C-spine injuries (74%) and CHI (89%). C1 dislocations occurred in younger children (mean age, 6.6 years), most often as a result of motor vehicle-related trauma (especially pedestrians) and were associated with the highest injury severity score (ISS), longest length of stay (LOS), most CHIs, and the highest mortality rate (50%). C-spine fractures with or without SCI occurred most commonly as a result of falls and dives. Sporting injuries occurred almost exclusively in adolescent boys (mean age, 13.8 years) and were isolated injuries associated with a relatively low ISS and shorter LOS. Interestingly, 75% of sporting injuries showed SCIWORA, and all infants suffering from child abuse had SCIWORA. Conclusions: Mechanisms of injury are age related, with younger children sustaining C-spine injuries as a result of motor vehicle-related trauma and older adolescents commonly injured during sporting activities. C-spine injuries in children most commonly involve the upper C-spine, but complete lesions of the cord are associated more frequently with lower C-spine injuries. The type of C-spine injury is related to the mechanism of injury: SCIWORA is associated with sporting activities and child abuse, C-spine dislocations most commonly result from motor vehicle-related trauma (especially among pedestrians), and C-spine fractures occur most commonly as a result of falls and dives. Predictors of mortality include younger age, motor vehicle-related mechanism, C1 dislocations, high ISS greater than 25, and associated CHI. A high index of suspicion for SCIWORA is essential when evaluating adolescents with neck trauma associated with sporting injuries or victims of child abuse. J Pediatr Surg 36:1107-1114. Copyright © 2001 by W.B. Saunders Company.

Improving the imaging diagnosis of cervical spine injury in the very elderly: implications of the epidemiology of injury

Purpose: To enumerate host and vector factors that affect each phase of cervical spine injury (CSI) among the elderly, and to attribute specific pathoanatomic characteristics of CSI to host and/or vector factors. Methods: Structured review of English literature references selected from MEDLINE keyword search using PUBMED and OVID search engines. Only articles addressing the role of “aging” or being “elderly” (using a variety of definitions) in CSI were included. The following information was abstracted: journal; year of publication; authors' specialty or departmental affiliation; study design; inclusion and exclusion criteria; year(s) of data collection; number of CSI vs. controls; summary findings, including rate estimates, obvious study weaknesses. Results: Seven of 13 articles were medical-record-based case series, most derived from institutional trauma registries. Four were population-based surveys. One was an assessment of Medicare claims data for all-cause trauma and one a review paper. Blunt-force CSI was most commonly related to domestic falls, then to vehicular-pedestrian collisions and finally to vehicular crashes. More than two-thirds of fractures involved CO-C3, especially in individuals with cervical spondylosis and/or osteoporosis. In 15 to 40 % of CO-C3 fractures there is a delay in diagnosis. An adult forme fruste of SCIWORA (spinal cord injury without radiographic abnormality) was a relatively common cause of central and anterior cord syndromes in the absence of observable fractures or dislocations. Conclusions: The epidemiology of CSI in elderly patients should inform triage and imaging decisions. Since most CSI diagnostic errors involve the upper cervical spine, additional attention to the radiographic anatomy of the craniocervical junction and diligent search for abnormalities in this region are warranted.

Evaluation of pediatric cervical spine injuries

To compare historical features, clinical examination findings, and radiographic results among pediatric patients with cervical spine injury (CSI), a retrospective review of patients who were diagnosed with CSI was undertaken. Two main groups were identified: radiographically evident cervical spine injury (RESCI), and spinal cord injury without radiographic abnormality (SCIWORA). Demographic, historical, clinical, and radiographic information was obtained from patients' charts and analyzed to determine factors associated with CSI and to determine the efficacy of the various radiographic views. Seventy-two children, ages from 1 month to 15 years (median age, 9 yrs), were included in the study. Sports-related injuries were the most common. Forty patients had RESCI and 32 had SCIWORA. Forty-nine (80%) of all the patients had abnormal findings on neck examination, and six (16%) of the RECSI group had abnormal neurological findings. Lateral radiographs had a sensitivity for CSI of 79%; a three-view radiographic series had a sensitivity of 94%. All patients with CSI who were clinically asymptomatic had both a high-risk injury mechanism and a distracting injury. CSI should be suspected in any child with abnormal findings on neck or neurological examination. A minimum of three radiographic cervical spine views should be obtained in the evaluation of CSI in children. Even in the face of a three-view series, CSI should be suspected in patients with an abnormal neck or neurological exam, high-risk mechanism of injury, or distracting injury.

Major Cervical Spine Injuries in Children and Adolescents

A population-based study of pediatric cervical spine trauma in the Auckland region over 7 years starting in March 1989 identified 32 patients younger than 15 years of age who sustained a fracture, dislocation, or major ligamentous injury including SCIWORA (spinal cord injury without radiographic abnormality). Thirty-one percent had associated injuries and 53% had abnormal neurologic findings on presentation. Children younger than 10 years of age with cervical spine trauma more commonly sustained the injury in a motor vehicle accident and had a preponderance of injuries of the upper cervical spine. Children 10 years of age or older were more often injured during sport or recreational activity and the injuries followed a more typically adult pattern. Treatment included closed reduction in two patients and posterior open reduction and stabilization in eight patients (25%) with one of these also requiring decompression. All patients treated surgically had a very satisfactory outcome.

Spinal injuries in the pediatric age group: a review of 82 cases of spinal cord and vertebral column injuries.

A review of 82 children with spinal cord and/or vertebral column injury treated in our department between 1968 and 1993 showed that 67% of the patients were boys and the average age was 11.4 years. The cause, vertebral level, and type of injury, and the severity of neurological injury varied with the age of the patient. The cause of pediatric injuries differed from that of adult injuries in that falls were the most common causative factor (56%) followed by vehicular accidents (23%). The most frequent level of spinal injury was in the cervical region (57%, 47 patients) followed by the lumbar region (16.5%, 13 patients). In our series, 18% of the patients had complete injury and the overall mortality rate was 3.6%. Eleven children (13%) had spinal cord injury without radiographic abnormality (SCIWORA), whereas 39 (47%) had evidence of neurological injury. Although the spinal injury patterns differed between children and adolescents, the outcome was found to be predominantly affected by the type of neurological injury (P < 0.05). Children with complete myelopathy uniformly remained with severe neurological dysfunction; children with incomplete myelopathy recovered nearly normal neurological function. Finally, the authors conclude that most spinal injuries can be successfully managed with nonoperative therapy. The literature is reviewed as to the treatment and outcome of pediatric spinal injuries.

SCIWORA (spinal cord injury without radiographic abnormality) in infants and children.

We review the biomechanics of the pediatric cervical spine and the clinical findings that pertain to SCIWORA (spinal cord injury without radiographic abnormality) in order to provide a more thorough understanding of this pediatric phenomenon of closed spinal trauma with significant neurologic sequelae but without bony injury. The unique hypermobility and ligamentous laxity of the pediatric bony cervical and thoracic spine predispose to a SCIWORA-type injury. In SCIWORA, the unusually elastic biomechanics of the pediatric bony spine allow deformation of the musculoskeletal structures beyond physiologic extremes, permitting direct cord trauma followed by spontaneous reduction of the bony spine. Potential mechanisms of the SCIWORA include hyperextension/flexion, longitudinal distraction, and ischemic injury of the spinal cord.

Magnetic resonance imaging in the evaluation of spinal cord injury without radiographic abnormality in children.

Seven children aged birth to 17 years with spinal cord injury without radiographic abnormality (SCIWORA) were studied with magnetic resonance imaging (MRI) between 3 hours and 16 days after the injury. There were six cervical cord injuries and one thoracic cord injury. The MRI findings were divided into two groups: extraneural and neural. The extraneural findings included one case of anterior longitudinal ligament disruption and anterior C6-C7 disc herniation associated with hyperextension; one case of posterior longitudinal ligament disruption and C2-C3 disc herniation associated with lateral flexion; and one case of C6-C7 disc abnormality consistent with increased water content occurring with hyperflexion. These ligament and disc injuries did not correlate with late instability. The neural MRI findings included one case of cord transection with rostral cord stump hemorrhage and one case of hemorrhage involving the majority of the cord's transverse diameter, both associated with permanent complete cord injuries; one case of hemorrhage involving a minor portion of the cord and of the brain stem's transverse diameter associated with a severe partial cord injury but subsequent incomplete improvement; one case of edema without hemorrhage associated with Brown-Séquard syndrome and subsequent incomplete improvement; and three cases of normal cord signal and outline. Two of the latter patients had mild cord injuries that recovered completely. In the third, a child with complete T12 sensorimotor paralysis at presentation, the normal MRI findings predicted the subsequent complete recovery. No extraaxial compressive lesion was demonstrated in these seven children.(ABSTRACT TRUNCATED AT 250 WORDS)

Pediatric Spinal Cord Injury Without Radiographic Abnormalities

Spinal cord injury without radiographic abnormality (SCIWORA) occurs primarily in the pediatric population but is less common than other forms of spinal injury among children. Between 1972 and 1990, 159 pediatric patients were admitted to the Barrow Neurological Institute with acute traumatic spinal cord or vertebral column injuries. Of these, 26 children (16%) sustained SCIWORA. The mechanism of injury, its severity, and the prognosis for recovery were related to the patient's age. In young children, SCIWORA accounted for 32% of all spinal injuries and tended to be severe; 70% were complete injuries. In older children, SCIWORA accounted for only 12% of the spinal injuries, was rarely associated with a complete injury, and had an excellent prognosis for complete recovery of neurologic function. As with other types of spinal cord injuries, the severity of neurological injury was the most important predictor of outcome. Patients with complete neurological deficits from SCIWORA had a poor prognosis for recovery of neurological function.

Transient Neurologic Deficits Associated with Thoracic and Lumbar Spine Trauma Without Fracture or Dislocation

Two categories of persistent posttraumatic neurologic deficits of the spinal cord without evidence of a spinal fracture or dislocation have been described previously. Spinal cord injury without radiographic abnormality (SCI-WORA) is seen in children. In the elderly, hyperextension injuries causing neurologic deficits without bony injury have also been described. The purpose of this report is to review mechanisms by which transient neurologic deficits occur in the absence of bony disruption. The authors describe four cases in which transient neurologic deficits occurred after blunt trauma to the thoracic or lumbar spine. Their experience indicates that, when neurologic deficits after trauma occur without fracture or dislocation, there is often an underlying structural susceptibility of the axial skeleton.

The pediatric cervical spine: Developmental anatomy and clinical aspects

The radiographic interpretation of the pediatric cervical spine can be a perplexing problem for the emergency physician. Given the wide range of variances in the ossification centers, the unfused synchondroses, and the relative hypermobility of the pediatric cervical spine, radiographs may be easily misread if one is not thoroughly familiar with the developmental anatomy and variants. This paper discusses those developmental aspects of the pediatric cervical spine that impact on emergency radiographic interpretation. Frequently encountered pediatric cervical spine fracture/dislocations are reviewed with an analysis of age-related distributions. Finally, the syndrome of Spinal Cord Injury Without Radiographic Abnormality (SCIWORA) is discussed.