Posttraumatic Spinal Cord Injury without Radiographic Abnormality

Abstract

"Spinal Cord Injury without Radiographic Abnormality" (SCIWORA) is a term that denotes objective clinical signs of posttraumatic spinal cord injury without evidence of fracture or malalignment on plain radiographs and computed tomography (CT) of the spine. SCIWORA is most commonly seen in children with a predilection for the cervical spinal cord due to the increased mobility of the cervical spine, the inherent ligamentous laxity, and the large head-to-body ratio during childhood. However, SCIWORA can also be seen in adults and, in rare cases, the thoracolumbar spinal cord can be affected too. Magnetic resonance imaging (MRI) has become a valuable diagnostic tool in patients with SCIWORA because of its superior ability to identify soft tissue lesions such as cord edema, hematomas and transections, and discoligamentous injuries that may not be visualized in plain radiographs and CT. The mainstay of treatment in patients with SCIWORA is nonoperative management including steroid therapy, immobilization, and avoidance of activities that may increase the risk of exacerbation or recurrent injury. Although the role of operative treatment in SCIWORA can be controversial, surgical alternatives such as decompression and fusion should be considered in selected patients with clinical and MRI evidence of persistent spinal cord compression and instability.

Figure 1

American Spinal Injury Association (ASIA) Injury Scale. (Source: with permission from American Spinal Injury Association: International Standards for Neurological Classification of Spinal Cord Injury.)

Figure 2

Autopsy photographs of a 44-year-old man found dead near his bicycle. Cause of dead was not explainable based on external examination and investigation. MDCT scan did not reveal any fractures, dislocations, or other signs of trauma. (a) Autopsy revealed perivertebral hemorrhage (arrows) anterior to C6 and C7. (b) Macroscopic axial autopsy photographs show hemorrhage (arrow) in cervical spinal cord at C5. (Source: with permission from [16].)

Figure 3

A 12-month-old female infant presented with nausea, vomiting, and drowsiness to emergency room after falling from a height of less than 30 cm. She had no neurological deficit at presentation, and cervical spine plain radiographs (a) and CT with 3D reconstruction (b) showed no abnormal findings. (c) Seven days after the injury the patient developed right sided hemiparesis and cervical MRI revealed increased intensity (arrows) in the T2-weighted images at the level of C6. (d) Repeat cervical MRI one month later shows that increased signal intensity has disappeared. The patient continued to improve neurologically until 24 months after the injury and returned to near-normal. (Source: with permission from [17].)

Figure 4

SCIWORA Algorithm. Pure intraneural MRI findings including edema or hemorrhage within the cord parenchyma is not an indication for surgery. Pure extraneural injury including severely injured ligaments or compression even without findings within the cord may be an indication for surgery. Patients with mixed extraintraneural MRI findings have the highest chance to require surgical treatment. Please note that there could be variations in diagnostic work up and treatment based on institutional or surgeons' preferences. ^∗∗∗Main indications for surgical treatment are cord compression and ligamentous instability along with worsening or not-improving neurological findings. (Courtesy of University of Alabama at Birmingham, Department of Orthopaedic Surgery, Birmingham, AL, USA.)