Spinal Cord Injury Without Radiological Abnormality Research Articles

Guidelines for treating spinal cord injury without radiological abnormalities in children

Spinal cord injury without radiological abnormality (SCIWORA) is a rare condition that predominantly affects children. The enigmatic nature of SCIWORA poses significant challenges in terms of diagnosis, treatment, and achieving full recovery. Various factors, such as different injury mechanisms, delayed symptom onset, normal magnetic resonance imaging findings in certain cases, and complex management decisions, contribute to the challenges of dealing with SCIWORA. Attaining a significant outcome and complete recovery through a single-treatment approach is difficult. Therefore, a multifaceted treatment strategy is proposed to yield more favorable results. This paper comprehensively addresses the assessment and management, examination and diagnosis procedures, treatment methods, rehabilitation techniques, and potential complications associated with SCIWORA in children. The paper provides therapeutic guidance for physicians and medical staff, with the aim of enhancing survival rates and improving recovery outcomes. Moreover, it offers suggestions for restoring neurological functions in pediatric patients suffering from SCIWORA.

Ossification of the anterior longitudinal ligament affects the severity and distribution of neurological deficits following spinal cord injury without radiological abnormality

BackgroundThe incidence of spinal cord injury without radiological abnormality (SCIWORA) is increasing among older adults in developed countries. SCIWORA is commonly associated with ossification of the spinal ligament, specifically the ossification of the posterior longitudinal ligament (OPLL) and ossification of the anterior longitudinal ligament (OALL). OALL induces segmental spinal fusion and alters the biomechanical properties of the cervical spine; however, whether OALL modulates the severity of SCIWORA remains unknown. This study aimed to investigate the influence of OALL on the severity and distribution of neurological deficits following SCIWORA. MethodsThis retrospective study included 122 patients with SCIWORA who were admitted to our hospital from April 2008 to March 2022. The neurological function of all the included patients was assessed via the American Spinal Injury Association (ASIA) Impairment Scale (AIS) at admission. Magnetic resonance imaging (MRI) and computed tomography were performed within 48 h of trauma. Central cord syndrome (CCS) was defined as the upper-extremity ASIA motor score being at least 10 points lesser than the lower-extremity motor score. ResultsThe study included 122 patients with a mean age of 65.1 years. Comparing mild (AIS grades C or D) and severe (AIS grades A or B) neurological deficits revealed that the former was independently associated with ground-level falls, OALL, and absence of prevertebral T2 high-intensity area on MRI. Although 39% of patients with SCIWORA exhibited OPLL as an etiology of cervical stenosis, OPLL demonstrated no significant effect on the severity of neurological deficits. CCS occurrence was independently associated with OALL and a larger cross-sectional cord area on MRI. Patients with OALL had significantly higher lower-extremity ASIA motor scores than those without OALL. ConclusionsOALL was significantly associated with mild neurological deficits in the lower extremities and with the occurrence of CCS after SCIWORA.

Clinical diagnosis and treatment of spinal cord injury without evidence of abnormality in children: a review

Spinal cord injury without radiological abnormality (SCIWORA) is a challenging circumstance in all age groups. Symptoms in some children of SCIWORA does not develop at the time of trauma. Different treatment methods (steroid therapy, immobilization, surgery) applied to treat SCIWORA, but with different prognosis. SCIWORA diagnosed when X-rays and computed tomography (CT) normal; however, initial magnetic resonance imaging (MRI) sometimes can be expected. Performing diffusion-weighted imaging (DWI) with early conventional MRI is a gold standard in the diagnosis of SCIWORA. Early MRI and DWI provides a quick diagnosis to facilitate recovery, ensure a superior clinical outcome, and choose a proper treatment method. Although it provides an accurate diagnosis, early immobilization with steroid therapy can present a good prognosis but not in all cases. Durotomy with duraplasty had a good outcome in adult patients, which might be helpful in children. This review explores the current and future methods of diagnosis and treatment of SCIWORA in children.

Epidemiology of spinal fractures in children: Cross-sectional study

IntroductionEpidemiological studies of fractures of the spine in children are all old, mostly single-centre, with series spanning periods of 5 to 20 years. HypothesisAs lifestyle is constantly changing, notably with an increase in sports activities and improvements in the prevention of road and household accidents, epidemiology has likely changed. ObjectiveTo update the description of spinal trauma in children and adolescents compared to the existing literature. Material and methodA multicentre cross-sectional study of spinal fracture, dislocation and spinal cord injury without radiological abnormality (SCIWORA) in children was carried out in 15 French university hospital centres, for a period of one year (2016). ResultsOne hundred and sixty-five children were identified: 85 girls, 80 boys; mean age 11 years (range, 10 months–17 years); median, 12 years 6 months. One hundred and fifty-two children (92%) had fracture, 8 (5%) dislocation (including 7 C1-C2 rotary dislocations), and 5 (3%) SCIWORA. Fractures were multiple in 80 cases (49%), contiguous in 73 cases (91%) and non-contiguous in 7 (9%). Locations were cervical in 25 cases (15%), thoracic in 85 (52%), lumbar in 75 and sacral in 4 (2%). Fracture types comprised 234 vertebral compactions (78%), 25 burst fractures (8%), 5 chance fractures (2%), 2 odontoid fractures, and 33 other lesions. Causes comprised fall in 77 cases (47%), sports accidents in 56 (34%), road accidents in 29 (18%), and others in 3. In 52 cases (32%), there was ≥1 associated lesion: appendicular in 35 cases (67%), thoracic or abdominal in 31 (60%), and head in 16 (31%). Twenty-one cases had multiple lesions (40%). Eighteen cases showed neurological involvement (11%) including 5 SCIWORAs. Neurological complications were more frequent before 9 years of age. ConclusionThe epidemiology of spine fractures in children has slightly changed. There are now fewer cervical lesions. Causes are less often road accidents and more often sports accidents. Multi-level lesions remain frequent and the rate of neurological complications is around 10%. Compaction fracture is the most common type.

Adult acute quadriparesis after traumatism: is it Spinal Cord Injury WithOut Radiologic Abnormality (SCIWORA)?

Adult acute quadriparesis after traumatism: is it Spinal Cord Injury WithOut Radiologic Abnormality (SCIWORA)?

Multicenter study of 37 pediatric patients with SCIWORA or other spinal cord injury without associated bone lesion

BackgroundPure traumatic spinal cord injury (without associated bone lesion) are encountered in pediatric accidentology, the most typical being spinal cord injury without radiological abnormality (SCIWORA). The present study reports a multicenter series of under-18-year-olds admitted for traumatic medullary lesion. The objectives were: (1) to describe the causes of pure spinal cord injuries in children in France and their clinical presentation; (2) to identify any prognostic factors; and (3) to describe their medical management in France. Patients and methodA multicenter retrospective study was conducted in 3 pediatric spine pathology reference centers. Files of 37 patients with confirmed spinal cord injury between January 1988 and June 2017 were analyzed: SCIWORA (n=30), myelopathy associated with severe cranial trauma (n=2), and obstetric trauma (n=5). Accident causes, associated lesions, initial Frankel grade, level of clinical spinal cord injury, initial MRI findings, type of treatment and neurology results at last follow-up were collated. The main endpoint was neurologic recovery, defined by improvement of at least 1 Frankel grade. ResultsCauses comprised 17 road accidents, 11 sports accidents, 5 obstetric lesions and 4 falls. Mean follow-up was 502 days. The rate of at least partial neurologic recovery was 20/30 in SCIWORA, 0/5 in obstetric trauma, and 0/4 in case of associated intracranial lesion. In SCIWORA, factors associated with recovery comprised age, accident type, and absence of initial MRI lesion. DiscussionWe report a large series of pediatric spinal cord injury without associated bone lesion. This is a potentially serious pathology, in which prognosis is mainly related to age and trauma mechanism. Level of evidenceIV, case series.

Spinal Injury in Indian Children: Review of 204 Cases.

Study design:Retrospective study.Objective:The purpose of the study was to analyze the epidemiological parameters and associated factors after spinal cord injury (SCI) in children, in the last 14 years admitted at a tertiary care center (Indian Spinal Injury Centre [ISIC], New Delhi, India).Method:The demographic and injury-related data was analyzed descriptively. The incidence, type, and level of injury were compared across the age groups using a χ2 test. Wherever appropriate, Fisher exact test was used.Results:There were 1660 pediatric trauma cases admitted at ISIC from 2002 to 2015, where 204 cases presented with spine injuries. The average age of children sustaining spine injury was 15.69 years (3-18 years of range). There were 15 patients in the age group 0 to 9 years, 27 patients in the age group 10 to 14 years, and 162 patients in the age group 15 to 18 years. This difference in spine injury incidence among the age groups was statistically significant. Fall from height was a common mode of injury. In our sample, boys were 3 times more likely to be injured than girls. Burst fractures were common among the type of injuries.Conclusion:Our study confirms the predominance of cervical spine injury and the high incidence of multilevel contiguous with a lesser percentage of noncontiguous multilevel spinal involvement. SCIWORA (spinal cord injury without radiological abnormality) incidences were in a similar context to the literature available. There was a very low incidence of death. Neurological improvement was seen in 8 operated cases and 4 conservatively treated cases.

Spinal Cord Injury without Radiological Abnormality in Adults: Clinical and Radiological Discordance.

Patients with spinal cord injury without radiological abnormality (SCIWORA) show varying clinical prognostic courses independent of radiological findings. The fact that patients cannot be evaluated using a specific terminologic standard has led to the emergence of the real SCIWORA definition. In this study, clinical progressions of 11 patients diagnosed with SCIWORA were analyzed, and terminologic differences were discussed. The clinical findings of 11 adults with a diagnosis of SCIWORA at the time of diagnosis and in the long term were analyzed according to the ASIA classification scheme. The presence of a correlation between radiological findings from the early and late periods and the clinical findings was investigated. High-dose methylprednisolone treatment was administered to all newly diagnosed patients in the early period, and the clinical response was observed. Clinical, prognostic, and radiological comparisons with SCIWORA cases reported in the literature were conducted. Seven patients received a diagnosis of cervical SCIWORA, and 4 patients had thoracal SCIWORA. Neurologic findings at the time of diagnosis and in the early and late periods vary independent of radiological findings. In the cases where significant neurologic recovery was not observed within the first 3 days, significant recovery also was not seen in the later period. In the cases where neurologic recovery was seen, improvements in sphincter function and sensory and motor deficits were observed. In patients diagnosed with SCIWORA, early neurologic response is the determining factor for prognosis. Clinical findings and prognosis demonstrate no correlation with radiological findings.

A case of real spinal cord injury without radiologic abnormality in a pediatric patient with spinal cord concussion.

Real spinal cord injury without radiologic abnormality (SCIWORA) is a rare clinical entity. The patient was a 13-year-old girl whose body was overturned anteriorly after crashing her bicycle into a curb. Following the accident, in which her neck and upper back hit the ground, she could not move due to paralysis. On arrival, she had paresis of the bilateral upper extremities and experienced a painful sensation when her upper extremities were touched. Cervical roentgenography and whole-body computed tomography revealed no traumatic lesions in either the intracranium or the cervical bone. Urgent spinal magnetic resonance imaging (MRI) showed no significant spinal cord lesions or spinal canal stenosis. She was put on complete bed rest with a cervical collar. On the 2nd hospital day (24 h after the accident), her motor weakness had almost completely subsided, and she felt only mild dysesthesia in both forearms. Roentgenography revealed no instability. Her motor weakness completely recovered on the third day after accident and she was diagnosed with spinal cord concussion. The present case study, in which MRI was performed, showed that an immediate improvement was obtained in a patient who experienced real SCIWORA. The importance of not only spinal cord lesions, but also perispinal soft tissue injury on MRI has been emphasized for predicting patient outcomes. Accordingly, immediate MRI is essential for evaluating patients with signs and symptoms of spinal cord injury, even when plain neck roentgenography and cervical CT are negative.

Demographic and injury characteristics of spinal cord injury in 275 children

Objective To study the demographic and injury characteristics of pediatric spinal cord injury(SCI) in children less than 14 years old in order to provide the guide for its prevention and treatment. Methods A retrospective study was performed and a total of 275 cases of children (less than 14 years old) with SCI were identified in China Rehabilitation Research Center(CRRC) from January 1989 to December 2014.The clinical information including gender, age, causes of injury, date of injury and injury condition were analyzed. Results Among 275 cases(male 111 cases, female 164 cases), 48.0% of the cases were 4.0-7.0 years old (132/275 cases), including 93 female cases (70.5%, 93/132 cases). Transport activities(74 cases, 26.9%), non traumatic causes(72 cases, 26.2%), sports and leisure activities (70 cases, 25.5%) were the main causes of SCI.Significant difference was observed in a number of patients in sports between 2003-2014 group (28.0%, 65/232 cases) and 1987-2002 group(11.6%, 5/43 cases)(χ2=5.135, P=0.023). The largest gender gap among kids was doing sports (7 male cases, 63 female cases), and the chief reason for children aged 4.0 to 7.0 years was also sports (48.2%, 55/114 cases). Patients suffered with SCI without radiologic abnormality (SCIWORA), in greater number (69.5%, 141/203 cases), and 121 (85.8%, 121/141 cases) patients were thoracic cord injury without radiologic abnormality(TCIWORA). Sports was the main cause of injury (64.1%, 50/78 cases) for 4.0 to 7.0 years old children (64.5%, 78/121cases) who were the greatest number of patients with TCIWORA.The earliest case of sports occurred in 1995, which happened nationwide each year since 2001.Spine hyperextension (90.0%, 63/70 cases) was the most common in sports, which caused 62 patients with SCIWORA (98.4%, 62/63 cases) including 47 children with complete thoracic cord injury (75.8%, 47/62 cases), and it often occurred in summer and autumn. Conclusions Sports injury was the most common cause of SCI children in CRRC nearly 12 years.The incidence of this damage was growing up and the girl(4-7 years old) because of spine hyperextension in sports(bend down in dancing practice) was the largest proportion of children with SCI.This severe damage which often resulted in complete thoracic cord injury should arouse more attention in clinic.The main crowd protection was the children who exercised back bend.This results provided important clues to develop related etiologic study and pointed out that it was needed to collect more information to investigate its injury mechanism. Key words: Spinal cord injury; Spinal cord injury without radiologic abnormality; Retrospective analysis; Child

Treatment of Atypical Central Cord Injury Without Fracture or Dislocation.

In general, spinal cord injury without radiological abnormality (SCIWORA) with spondylosis is considered to be a central cord injury. This article describes the clinical features and surgical outcomes of atypical central cord injury in patients with spondylotic SCIWORA (ACCISS). Fifty-two patients were enrolled in the study from January 2006 to December 2011. Diagnoses were made from imaging (computed tomography, magnetic resonance imaging) and clinical findings. The neurologic status of patients was assessed using the American Spinal Injury Association (ASIA) score and Japanese Orthopaedic Association (JOA) score. Patients were divided into 3 groups with regard to the timing of surgery after injury: those undergoing early surgery (less than 24 hours after injury), those undergoing late surgery (more than 24 hours after injury but during initial admission to the hospital and within 3 weeks from injury), and those undergoing delayed surgery (during second admission to the hospital, within 3 months but later than 3 weeks from injury). Seventeen patients underwent early surgery, 22 underwent late surgery, and 13 underwent delayed surgery. Mean follow-up was 15 months (range, 5-33 months). Patients in all groups showed very good recovery after surgical treatment, with the recovery rate of ASIA and JOA scores being 68.6% and 60.2%, respectively. No significant difference in recovery rate was found between the groups with regard to the timing of surgery. This retrospective study supports the notion that surgical decompression is effective in the treatment of patients with ACCISS. Timing of surgery (less than 3 months) was not significantly associated with neurologic recovery.

Spinal Cord Injury Without Radiological Abnormality (SCIWORA): Is It Still a Notable Definition?

The developing Magnetic Resonance Imaging technologies have led to significant changes in the radiological diagnostic criteria of the Spinal Cord Injury without Radiological Abnormality (SCIWORA). Moreover, some authors even introduced alternative definitions for this specific disease recently. The aims of this study were to report an adolescent case with pure SCIWORA and to clarify its definition in the literature. A 16 year-old adolescent patient with thoracolumbar SCIWORA together with a pelvic fracture after a vehicle accident was presented in this case report. In neurological examination, both extremities were graded as Frankel type A. The X-ray and Magnetic Resonance Imaging revealed the right ischium-superior pubic ramus fracture and only edema of the spinal cord at T12, L1 and L2 vertebral levels, subsequently. A high dose of methyl-prednisolone was administered. Pelvic fracture was promptly fixed with an external fixator. After a follow-up period of two years, the neurological status of the patient showed progression to Frankel B. The patient continues to his life with wheelchair. In conclusion, an adolescent case with SCIWORA that fulfills all its original criteria was reported and a review of the literature was discussed in this study. In order to describe this special pathology, SCIWORA seems still to be the best ideal term.

ABSTRACT 819

Background and aims: Spinal cord injury without radiological abnormality (SCIWORA) often occurs in the skeletally immature cervical and thoracic spine. In this report we discribe a girl who had prolonged weaning because of SCIWORA. Methods: Case Report: 2 year-old girl was hit by a car while running a road. Cervikal X-ray and CT scan of the brain and CT scan of the chest was normal. She was unable to move her limb and leg. She had abdominal breathing, defecation, and urinary incontinence. MRI of the cervical spine showed atropic spinal cord from C5 toT1. The smallest anterior posterior diameter was 10 mm. The patient needed ventilator support for 2 weeks and she had extubation failure one time. After high dose steroid therapy and proper rehabilitation program for 2 weeks extubation accomplished. Results: Discussion: Pediatric spinal injuries are uncommon. SCIWORA occurs most often in pediatric population and accounts for up to 2/3 of severe cervical injuries in children of< 8 years of age. Spinal cord injury in children frequently occurs without fracture or dislocation. The mechanism of neural injury probably related to intersegmental displacements of the spinal cord when subjected to flexion, extension, and distraction forces. The physician attending to a multiply injured child must be aware that children, may have a spinal cord injury.

Conus Medullaris Spinal Cord Injury (SCI) without Radiologic Abnormality (SCIWORA) in a Young Cheerleader: A Case Report

Conus Medullaris Spinal Cord Injury (SCI) without Radiologic Abnormality (SCIWORA) in a Young Cheerleader: A Case Report

Early magnetic resonance imaging in spinal cord injury without radiological abnormality in adults

The purpose of this study was to describe the clinical and imaging characteristics of patients experiencing blunt spinal trauma without radiological abnormalities but transient or persistent neurological deficits. This retrospective study analyzed plain radiographs, computed tomographic scans, and magnetic resonance images of patients with spinal cord injury without radiological abnormality (SCIWORA) who were admitted to a Level I trauma center. Neurologic status, Frankel grade, and short-term patient outcome were assessed. Of 1,604 patients experiencing blunt spinal trauma, 21 (12 men and 9 women) with a mean age of 35.5 years (range, 16.2-70.9 years) presented with a clinicoradiographic mismatch. Magnetic resonance imaging (MRI) was available in 15 patients. In seven patients (46.6%), MRI revealed either neural (n = 2, 13.3%) or extraneural (n = 5, 33.3%) spinal abnormalities. Importantly, in eight patients (53.3%), no spinal abnormalities were visible on MRI. Furthermore, subgroup analysis revealed no prognostic value regarding the presence or absence of detectable spinal injuries. Spinal abnormalities were not detected on MRI in a substantial proportion of patients presenting with SCIWORA. The prognostic value of MRI findings in SCIWORA needs to be validated by future studies. Epidemiological study, level V.

Thoraco‐lumbar Spinal Cord Injury without Radiological Abnormality in an Adult

Introduction Spinal cord injury without radiological abnormality (SCIWORA) has been reported previously in both pediatric and adult patients, the cervical spine being the most commonly affected site. The thoracic spine is a biomechanically stable structure supported by costotransverse articulations and the rib cage, which increases axial loading capacity by three to four times. Furthermore, advancing rigidity of the aging spine in adult patients makes thoracic SCIWORA a rare scenario. Although there are a few reports of upper thoracic SCIWORA in adults, we were unable to find any published reports of thoraco-lumbar SCIWORA in an adult.

Double-level spinal cord injury without vertebral fracture or dislocation: a case report

Spinal cord injuries without evidence of vertebral fracture or dislocation on plain radiographs and computed tomography are referred to as SCIWORA (Spinal Cord Injury without Radiological Abnormality). This entity is seen more often in children due to the specific anatomical and functional properties of the pediatric spine. The aim of this study was to present a rare case in which SCIWORA occurred at two levels simultaneously with complete anatomic transection and to emphasize the importance of SCIWORA in forensic medicine. A three-year-old boy was admitted to the emergency department with paraplegia after being hit by a car. Computed tomography and plain radiographs failed to reveal any bone fracture or dislocation. However, magnetic resonance imaging showed loss of continuity with near-complete and complete anatomic transection of the spinal cord at the T3-4 and T6-7 levels. According to the literature, only two cases of double-level SCIWORA have been reported previously. However, this is the first case of double-level SCIWORA with complete anatomic transection. The mechanism of injury in the case reported here remains obscure regarding the forensic reconstruction of the event.

Spinal Injuries in Children

About 5% of spinal injuries occur in children – however the consequences to the society are devastating, all the more so because the cervical spine is more commonly affected. Anatomical differences with adults along with the inherent elasticity of the pediatric spine, makes these injuries a biomechanically separate entity. Hence clinical manifestations are unique, one of which is the Spinal Cord Injury Without Radiological Abnormality. With the advent of high quality MRI and CT scan along with digital X-ray, it is now possible to exactly delineate the anatomical location, geometrical configuration, and the pathological extent of the injury. This has improved the management strategies of these unfortunate children and the role of surgical stabilization in unstable injuries can be more sharply defined. However these patients should be followed up diligently because of the recognized long term complications of spinal deformity and syringomyelia.

Cervical spine clearance in paediatric trauma: are we clear?

In adult poly-trauma, cervical spine injuries may be cleared radiologically if normal. However, in children, clinical evaluation has been part of the cervical spine clearance irrespective of radiological clearance due...

Use of the Finite Element Method to Study the Mechanism of Spinal Cord Injury Without Radiological Abnormality in the Cervical Spine

Three-dimensional C3-C5 and C3-C4 finite element (FE) models were used to analyze biomechanical responses under compression and extension moments. To validate our models against other published FE models and experimental studies and improve our understanding of the mechanism of spinal cord injury without radiologic abnormality (SCIWORA) in cervical spine. The underlying mechanism for SCIWORA remains unclear. We hypothesized that the incidence of SCIWORA was associated with facet joint morphology and bony pincers mechanism. FE models were constructed using data from computed tomography scans of the cervical spine of a healthy young man. The C3-C5 FE models consisted of bony vertebra, articulating facets, and intervertebral disc. Facet surfaces were oriented at 30 degrees , 45 degrees , and 60 degrees from the transverse plane. These models were constrained in all degrees of freedom at the C5 inferior vertebral body and a uniform axial displacement of 1 mm was applied to the superior nodes of C3. Three model versions changed to C3-C4 models with ligaments. The C4 inferior-most bony nodes were constrained, whereas the top of the C3 superior-most bony nodes were left unconstrained. These models were subjected to an axial compression load of 73.6 N with extension moments (1.8 Nm) applied to the upper bony section C3 vertebra. The predicted responses were compared with published results. The response under axial compression was validated and corresponded closely with published results. Under sagittal moment, the C3-C4 FE model with 60 degrees facet was the most flexible in extension (4.22 degrees ). Total translation was highest for the model with 60 degrees facet. The load displacement response of C3-C5 FE models was in agreement with published data. We confirmed that the C3-C4 FE model with 60 degrees facet was the most susceptible to SCIWORA and that the bony pincers mechanism was dependent on facet joint inclination.