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Clinical Brief
SCIWORA-Spinal Cord Injury Without Radiological
Abnormality

Veena Kalra, Sheffali Gulati, Mahesh Kamate and Ajay Garg1
Department of Pediatrics and 1Department of Neuroradiology, All India Institute of Medical Sciences, New Delhi
ABSTRACT
Following trauma, the commonly used radiological investigations, plain radiographs and computed tomography (CT) studies
do not rule out injury to the spinal cord. This is especially true for children, as an entity known by the acronym SCIWORA (spinal
cord injury without radiological abnormality) exists and the changes may be picked up only on magnetic resonance imaging
(MRI). Early treatment (within 6 hours) with high dose methylprednisolone improves the outcome. Spinal trauma being common
it is possible that the burden of neurological handicap following this can be reduced by increasing awareness and early
treatment with steroids. In the community, pediatricians are often the first medical contact after spinal trauma and awareness
of the lacune of conventional imaging techniques is important especially if clinical symptoms pertaining to the spine are present.
The community pediatrician is hereby made aware of the need to investigate spinal trauma with a MRI for possible SCIWORA
situation as it generates a possibility for therapeutic intervention to alter the outcome positively.
[Indian J Pediatr 2006; 73 (9) : 829-831]
Key words : Spinal cord; Trauma; MRI
Spinal cord injury without radiological abnormality was no deformity of legs or spine. Next day when the (SCIWORA) is defined as the occurrence of acute child woke up, the parents noted that the child was not traumatic myelopathy despite normal plain radiographs moving his legs and was not able to sit without support. and normal computed tomography (CT) studies. Though There was no history of fever or vomiting, no history of common in children compared to adults, overall incidence any paucity of movement or weakness in upper limbs or is less. As both the radiograph and CT scan be normal and any history suggestive of cranial nerve involvement. early treatment with high dose methylprednisolone There was no breathing difficulty or bowel incontinence. improves the outcome, pediatrician who comes across On general examination, there was pallor. There was no such a patient should be aware of such condition, its evidence of any fracture of limb bones, lacerations or treatment and outcome. We report here a case of a two deformity or tenderness over the spine. Neurological and a half year old child with SCIWORA who presented examination revealed a conscious child with normal to us late, 3 days after trauma with complete flaccid cranial nerves and upper limbs. There was gross hypotonia in the lower limbs, 0/5 power and areflexia. Abdominal reflex, cremasteric, anal reflex were absent. Bladder was palpable and urine could be expressed out CASE REPORT
on abdominal pressure. There were no meningeal or cerebellar signs. A two and a half year old boy presented to us with 2 day CECT brain was normal. There was no evidence of any history of paucity of movement of both legs, inability to fracture or displacement of vertebra on radiograph of the bear weight on his legs, and inability to pass urine. spine and CT scan of the spine done on day 1 of illness. Previous day in the afternoon he had fallen from a tractor. Hemogram, LFTs, RFTs, electrolytes were within normal There was no history of any injury to head, limits. CSF done on day 2 had many RBCs, 10 unconsciousness, bleeding from ear nose or throat or any polymorphs, protein of 80 mg/dl and sugar of 30 mg/dl. seizures. Child was moving his legs after he fell and there MRI of spine done on day 4 showed edema of the cord with expansion from C6 to the lower end of cord (fig 1). In view of history of significant trauma, complete paraplegia, normal radiograph and CT spine, a diagnosis Correspondence and Reprint requests : Prof. Veena Kalra, Head,
of SCIWORA was made and this was confirmed by MRI Department of Pediatrics, All India Institute of Medical Sciences, New Delhi-110029, India; Fax No. : 91-11-26588663, 26588641. of the spine. Proper physiotherapy was advised and Indian Journal of Pediatrics, Volume 73—September, 2006 Veena Kalra et al
66% of all spinal cord injuries (mostly around 10-20% of all pediatric spinal trauma).1 Although Lloyd2 first proposed the concept of SCIWORA and Burke3 was the first to report it, Pang and Wilberger4 were the first to coin the acronym SCIWORA and define it as a clinicoradiological entity. Pathogenesis1,2,5: In young children, the pathogenesis of
SCIWORA may be related to the mismatch in the
elasticity of the tissue of the vertebral column and spinal
cord.
Neurological presentation: SCIWORA can have a wide
spectrum of neurological dysfunction, ranging from mild,
transient spinal cord concussive deficits to permanent,
complete injuries of the spinal cord. The incidence and
severity of injury are related to the patient’s age. Young
children have a higher incidence of SCIWORA; this age
group accounts for two-thirds of all reported cases. Until
the age of 8 years, neurological injuries tend to be severe.
Three quarters of the injuries in this group are complete.
Over half of the injuries in young children occur in the
thoracic spine; almost all of these thoracic injuries are
complete.
Fig. 1. MR T2 saggital image of the spinal cord shows increased
Adolescents sustain less severe, typically incomplete signal intensities within the cord extending from C6 to D3 injuries. A delay in the onset of neurological deficits or a level. No evidence of any spinal cord compression or delayed neurological deterioration had been reported. haemorrhage in the spinal cord. Vertebrae and ligaments are normal Brief transient motor or sensory symptoms are often associated with the initial injury. An asymptomatic parents were taught clean intermittent catheterization. In period usually intervenes. The delays in deficits can range view of young age, complete flaccid paraplegia the parents were counseled regarding the poor outcome. As MRI is preferred for acute assessment because it is non­ the child presented to us beyond 6 hours, high dose i.v. invasive, delineates spinal cord and soft tissue methylprednisolone infusion was not given. abnormalities, and can assess compressive pathology. If MRI facility is unavailable or not possible and acute Spinal Cord Injury WithOut Radiological Abnormality
assessment is indicated then, CT myelography should be (SCIWORA) : Spinal cord injury without radiological
abnormality (SCIWORA) is defined as the occurrence of Differential diagnosis : The possible differential
acute traumatic myelopathy despite normal plain diagnosis include, traumatic compressive myelopathy radiographs and normal computed tomography (CT) (compression by fractured vertebrae, disc herniation etc), studies. This occurs predominantly among the pediatric and if trauma is not very significant then acute population, where its reported incidence ranges from 4%- disseminated encephalomyelitis, transverse myelitis are Mechanisms of injury1, 5
a. Longitudinal cord traction b. Root traction/avulsion a. Transient compression
b. Persistent compression (potentially requires operative intervention)
i. Occult fracture with cord compression iii. Persistent disc herniation iv. Occult subluxation/instability Transmission of externally applied kinetic energy to spinal cord-Spinal cord concussion (SCC) a. Vascular occlusion, dissection, cord infarction b. Vasospasm c. Hypotension, impaired cord perfusion. Indian Journal of Pediatrics, Volume 73—September, 2006 SCIWORA-Spinal Cord Injury with Out Radiological Abnormality
VKH. Pediatric spinal cord injury without radiographic Treatment : SCIWORA involving the cervical spine
abnormalities: Report of 26 cases and review of literature. J should be treated by immobilization with a collar or a Spinal Disorders 1991; 4 : 296-205. 2. Pang D, Sahrarkar K, Sun PP. Pediatric spinal cord and more rigid brace until neurological deficits have resolved. vertebral column injuries. In: Youman JR, editor. Neurological After the acute phase of injury, it is advisable to repeat the Surgery, 4th ed. Philadelphia: WB Saunders; 1996. p 1991-2037. flexion/extension views of the spine to rule out 3. Burke DC. Traumatic spinal paralysis in children. Paraplegia ligamentous instability that may have been masked by paravertebral muscle spasm during the initial evaluation. 4. Pang D, Wilberger Jr JE. Spinal cord injury without radiological abnormality in children. J Neurosurg 1982; 57 : 114­ Once deficits have resolved range of motion is gradually increased. However, to avoid the risk of recurrent injury, 5. Pang D, Pollack IF. Spinal cord injury without radiographic activity should be strictly limited for at least 3 months. abnormality in children-The SCIWORA syndrome. J Trauma Patients with thoracic or lumbar myelopathy (SCIWORA) also are initially treated with bed rest and subsequent 6. Tiwari MK, Gifti DS, Singh P, Khosla VK, Mathuriya SN, Gupta SK et al. Diagnosis and prognostication of adult spinal gradual mobilization.1 High dose steroids- cord injury without radiographic abnormality using magnetic Methylprednisolone bolus of 30 mg/Kg iv within 8 hrs of resonance imaging analysis of 40 patients. Surgical neurology injury, followed by infusion at 5.4 mg/Kg/hr for the next 23 hrs is beneficial in improving the outcome.7 When 7. Bracken MB, Shepard MJ, Collins WF et al. A randomized, given over 48 hrs outcome at 6 wks and 6 months was controlled trial of methylprednisolone or naloxone in the better in a recent study.8 Role of stem cell transplant is treatment of acute spinal cord injury. Results of the second national acute spinal cord injury study. N Engl J Med 1990; 322: Outcome : The prognosis is related to the severity of
8. Bracken MB, Shepard MJ, Collins WF et al. A randomized, the spinal cord dysfunction. Young children tend to controlled trial of methylprednisolone or naloxone in the sustain complete injuries with permanent deficits; the rate treatment of acute spinal cord injury. Results of the second of functional recovery after complete neurological injuries national acute spinal cord injury study. N Engl J Med 1990; 322: 1405-1415. is reported to range from 0-10%. Outcome after 9. Bracken MB, Shepard MJ, Holford TR et al. Administration of incomplete injuries in older children in excellent.1 mehtylprednisolone for 24 or 48 hours or tirilazad mesylate for 48 hours in the treatment of acute spinal cord injury. REFERENCES
Results of the Third National Spinal Cord Injury Randomized Controlled Trial. National Acute Spinal Cord Injury Study. JAMA 1997; 277 : 1597-1610. 1. Dickman CA, Zabramski JM, Hadley MN, Rekate HL, Sonntag Indian Journal of Pediatrics, Volume 73—September, 2006

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