BASICS
Also called spinal cord injury without radiographic evidence of trauma (SCIWORET), spinal cord injury without CT evidence of trauma (SCIWOCTET), or spinal cord injury without neuroimaging abnormality (SCIWONA) ‚
DESCRIPTION
- SCIWORA occurs after trauma; it is an acute spinal cord injury (SCI) and nerve root trauma resulting in transient or permanent sensory, motor, or combined sensorimotor deficits.
- Neural injuries occur without a fracture or misalignment visible on radiographic imaging (x-ray, CT).
- SCIWORA has a broad presentation, from minor neurologic symptoms to complete quadriplegia.
EPIDEMIOLOGY
Incidence
- Variable: reported to be 19 " “34% of pediatric spinal cord injuries (1)
- Occurs in all populations but is primarily observed in pediatric patients (90%) (1)
- Bimodal: affects children <8 years old and adults >60 years old; rarely occurs between 16 and 36 years (2)
- There is no association between Chiari malformation type 1 and SCIWORA.
ETIOLOGY AND PATHOPHYSIOLOGY
- Trauma (3)
- Motor vehicle collision (MVC) (most common cause); either unrestrained passengers, pedestrians, or bicyclists struck by motor vehicles
- Sports-related injury
- Significant fall
- Child abuse
- Mechanism
- Traumatic neural (edema, hematomyelia, cord disruption) and extraneural (disc injury or ligament disruption) injury occurs after (2,4,5) the following:
- Hyperextension
- Hyperflexion
- Longitudinal distraction
- Ischemic damage
- Secondary injury from inflammatory response to tissue damage
- Age: Pediatric patients have a higher incidence of SCIWORA than adults due to anatomic differences and increased mobility and flexibility (1,4,6).
- Horizontally oriented facet joints permit more translational motion in the coronal (AP) plane.
- Anterior wedging of vertebral bodies
- Elasticity of ligaments and joint capsules permits increased intersegmental movement and disc protrusion.
- In patients age <8 years, head size-to-trunk ratio is disproportionately large.
- Weaker nuchal musculature
- Uncovertebral joints are absent.
- Pseudosubluxation of C2 to C3
- Location
- Cervical: upper > lower
- Thoracic: protected and splinted by ribs, preventing forced flexion and extension
- Lumbar: rare, usually fatal (1)
RISK FACTORS
- History of trauma
- Age <8 years
- Male:female
- Adult; 4.5:1 (3,7), Children; 2:1 (3)
- Improper wear of seatbelt
DIAGNOSIS
HISTORY
- MVA
- Sports-related injury
- Fall
- Child abuse
PHYSICAL EXAM
- Assess for sensorimotor deficit.
- Abnormal neurologic findings are not accounted for by known/visible injuries.
- Abnormalities on musculoskeletal exam increases risk of SCI.
DIFFERENTIAL DIAGNOSIS
- End-plate cartilage fracture
- Transverse myelitis
- Intramedulllary hemorrhage
- Anterior spinal artery syndrome
- Disseminated encephalomyelitis
- Atlantoaxial dislocation
- Central cord syndrome
- Brown-Sequard syndrome
DIAGNOSTIC TESTS & INTERPRETATION
- Radiographic screening with CT of the entire spinal column is recommended (5)[C].
- MRI of the region of suspected neurologic injury (5)[C]
- MRI within 24 hours of injury and consider repeat if normal (7)[C]
- Assessment of spinal stability in a SCIWORA patient is recommended with flexion " “extension radiographs in the acute setting and at late follow-up, even in the presence of a magnetic resonance imaging (MRI) negative for extraneural injury (5)[C].
- Neither spinal angiography nor myelography is recommended in the evaluation of patients with SCIWORA (5)[C].
- CT scan can reliably rule out fracture.
Follow-Up Tests & Special Considerations
- Adult considerations: Adults are less prone to SCIWORA due to decreased flexibility and mobility in comparison to pediatric patients, although SCIWORA is possible in the setting of acute trauma or cervical spondylosis.
- A normal MRI does not rule out SCIWORA (1,2,7).
- MRI abnormalities correlate closely with neurologic injury and prognosis (3)[C].
- MRI may be able to demonstrate neural and extra-neural injuries: cartilaginous end-plate fracture, edema, herniation, and interspinous ligamentous injury (1,2)
Diagnostic Procedures/Other
- Diagnosis is based on clinical findings of neurologic dysfunction or MRI abnormality.
- Consider diffusion-weighted MRI and somatosensory-evoked potentials (SSEPs) in cases of suspected SCIWORA with normal MRI (5,8)[C].
TREATMENT
GENERAL MEASURES
- Immobilize unconscious patients until plain x-ray and CT radiographs are obtained.
- Immobilize until neurologic and pain assessment can be made.
- Transient findings, such as numbness, and a history of trauma should be treated with immobilization following SCI protocol.
- Supportive care and serial neurologic and musculoskeletal exams
- Blood pressure support (5)[C]
- Corticosteroid use is controversial and is not considered standard practice for pediatric cases (6)[C].
ADDITIONAL THERAPIES
- Rigid external immobilization of the spinal segment for 12 weeks (day and night) (1)
- Immobilization for 12 weeks even after the return of normal neurologic function to minimize SCIWORA recurrence (1,2,5)[C]
- Avoidance of "high-risk " ť activities for up to 6 months following SCIWORA (2,5)[C]
- Initially, treatment is nonoperative. Surgery may be required for spinal cord compression or spine instability secondary to extraneural injury (1,2).
- Surgery for adults is often warranted as disc and ligamentum flavum pathology is common (2)[C].
- Early discontinuation of external immobilization is recommended for patients who become asymptomatic, and spinal stability is confirmed with flexion and extension radiographs (5)[C].
INPATIENT CONSIDERATIONS
Admission Criteria/Initial Stabilization
- Unexplained neurologic findings (2)[C]
- Neurologic injury found via MRI (2)[C]
- Suspected ligamentous lesion (2)[C]
- Trauma and spinal injury protocol
- Rigid immobilization
- Consultation with a spine surgeon
Discharge Criteria
- Neurologic exam without any deficits
- Resolution of transient neurologic symptoms
ONGOING CARE
- SCIWORA can present with no initial symptoms after trauma followed by subsequent neurologic deterioration.
- Reassess neurologic function within 24 to 48 hours if patient presents with no initial symptoms after a traumatic event, as there may be a latency period and secondary injury.
- Clinical symptoms may take as long as 10 days to develop (3).
- Follow-up MRI before discharge
PROGNOSIS
- Initial clinical instability, injury severity, MRI findings, neurologic features, injury location, patient age, and persistence of symptoms have a direct correlation with prognosis.
- Favorable
- Initial mild to moderate injury
- Normal or mild edema on initial MRI (1)
- Resolution of changes as evidenced by follow-up MRI
- Unfavorable
- Initial severe neural injury
- MRI findings of spinal cord transection and significant hemorrhage
- Intramedullary hemorrhage seen on MRI is predictive of complete cord injury (1).
- Follow-up MRI findings of persistent SCI
- Higher cervical injuries
- Patients age <8 years (1)
- Concominant traumatic brain injury (concussion)
COMPLICATIONS
Iatrogenic, delayed, and recurrent SCIWORA have been reported; therefore, careful handling of trauma patients and close follow up is warranted. ‚
REFERENCES
11 Launay ‚ F, Leet ‚ AI, Sponseller ‚ PD. Pediatric spinal cord injury without radiographic abnormality: a meta-analysis. Clin Orthop Relat Res. 2005;(433):166 " “170.22 Kasimatis ‚ GB, Panagiotopoulos ‚ E, Megas ‚ P, et al. The adult spinal cord injury without radiographic abnormalities syndrome: magnetic resonance imaging and clinical findings in adults with spinal cord injuries having normal radiographs and computed tomography studies. J Trauma. 2008;65(1):86 " “93.33 Boese ‚ CK, Oppermann ‚ J, Siewe ‚ J, et al. Spinal cord injury without radiologic abnormality in children: a systematic review and meta-analysis. J Trauma Acute Care Surg. 2015;78(4):874 " “882.44 Trigylidas ‚ T, Yuh ‚ SJ, Vassilyadi ‚ M, et al. Spinal cord injuries without radiographic abnormality at two pediatric trauma centers in Ontario. Pediatr Neurosurg. 2010;46(4):283 " “289.55 Rozzelle ‚ CJ, Aarabi ‚ B, Dhall ‚ SS, et al. Spinal cord injury without radiographic abnormality (SCIWORA). Neurosurgery. 2013;72(Suppl 2):227 " “233.66 Easter ‚ JS, Barkin ‚ R, Rosen ‚ CL, et al. Cervical spine injuries in children, part II: management and special considerations. J Emerg Med. 2011;41(3):252 " “256.77 Boese ‚ CK, Lechler ‚ P. Spinal cord injury without radiologic abnormalities in adults: a systematic review. J Trauma Acute Care Surg. 2013;75(2):320 " “330.88 Shen ‚ H, Tang ‚ Y, Huang ‚ L, et al. Application of diffusion-weighted MRI in thoracic spinal cord injury without radiographic abnormality. Int Orthop. 2007;31(3):375 " “383.
ADDITIONAL READING
- Parikh ‚ RN, Muranjan ‚ M, Karande ‚ S, et al. Atlas shrugged: cervical myelopathy caused by congenital atlantoaxial dislocation aggravated by child labor. Pediatr Neurol. 2014;50(4):380 " “383.
- Piatt ‚ JHJr, Campbell ‚ JW. Spinal cord injury without radiographic abnormality and the Chiari malformation: controlled observations. Pediatr Neurosurg. 2012;48(6):360 " “363.
- Shah ‚ LM, Zollinger ‚ LV. Congenital craniocervical anomalies pose a vulnerability to spinal cord injury without radiographic abnormality (SCIWORA). Emerg Radiol. 2011;18(4):353 " “356.
CODES
ICD10
- S14.109A Unsp injury at unsp level of cervical spinal cord, init
- S14.2XXA Injury of nerve root of cervical spine, initial encounter
- S14.102A Unsp injury at C2 level of cervical spinal cord, init encntr
- S14.103A Unsp injury at C3 level of cervical spinal cord, init encntr
- S14.104A Unsp injury at C4 level of cervical spinal cord, init encntr
- S14.105A Unsp injury at C5 level of cervical spinal cord, init encntr
- S14.101A Unsp injury at C1 level of cervical spinal cord, init encntr
- S14.108A Unsp injury at C8 level of cervical spinal cord, init encntr
- S14.106A Unsp injury at C6 level of cervical spinal cord, init encntr
- S14.107A Unsp injury at C7 level of cervical spinal cord, init encntr
ICD9
- 952.9 Unspecified site of spinal cord injury without evidence of spinal bone injury
- 953.9 Injury to unspecified site of nerve roots and spinal plexus
- 952.00 C1-C4 level with unspecified spinal cord injury
- 952.05 C5-C7 level with unspecified spinal cord injury
SNOMED
- 90584004 Spinal cord injury (disorder)
- 405754008 cervical spinal cord injury (disorder)
- 129137006 Nerve root injury
- 24392008 injury at C1-C4 level with spinal cord injury AND without bone injury (disorder)
- 11807002 injury at C5-C7 level with spinal cord injury AND without bone injury (disorder)
CLINICAL PEARLS
- If a patient presents with a history of trauma and neurologic symptoms but has negative x-ray and CT findings, consider SCIWORA.
- Spinal cord appearance on MRI provides prognostic information (3)[C].
- Treat SCIWORA with early immobilization, continue for 12 weeks, and avoid high-risk activities for an additional 12 weeks (2)[C].
- Immobilization for 12 weeks is superior to 8 weeks (1)[C].
- Consider serial scans or short-interval follow-up MRI to assess for delayed presentation of pathology (3)[C].