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Clinical Brief
SCIWORA-Spinal Cord Injury Without Radiological
Abnormality
Veena Kalra, Sheffali Gulati, Mahesh Kamate and Ajay Garg
1
Department of Pediatrics and
1
Department 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] E-mail : kalra_veena@hotmail.com
Key words : Spinal cord; Trauma; MRI
Spinal cord injury without radiological abnormality
(SCIWORA) is defined as the occurrence of acute
traumatic myelopathy despite normal plain radiographs
and normal computed tomography (CT) studies. Though
common in children compared to adults, overall incidence
is less. As both the radiograph and CT scan be normal and
early treatment with high dose methylprednisolone
improves the outcome, pediatrician who comes across
such a patient should be aware of such condition, its
treatment and outcome. We report here a case of a two
and a half year old child with SCIWORA who presented
to us late, 3 days after trauma with complete flaccid
paraparesis with bladder involvement.
CASE REPORT
A two and a half year old boy presented to us with 2 day
history of paucity of movement of both legs, inability to
bear weight on his legs, and inability to pass urine.
Previous day in the afternoon he had fallen from a tractor.
There was no history of any injury to head,
unconsciousness, bleeding from ear nose or throat or any
seizures. Child was moving his legs after he fell and there
Correspondence and Reprint requests : Prof. Veena Kalra, Head,
Department of Pediatrics, All India Institute of Medical Sciences,
New Delhi-110029, India; Fax No. : 91-11-26588663, 26588641.
Indian Journal of Pediatrics, Volume 73September, 2006
was no deformity of legs or spine. Next day when the
child woke up, the parents noted that the child was not
moving his legs and was not able to sit without support.
There was no history of fever or vomiting, no history of
any paucity of movement or weakness in upper limbs or
any history suggestive of cranial nerve involvement.
There was no breathing difficulty or bowel incontinence.
On general examination, there was pallor. There was no
evidence of any fracture of limb bones, lacerations or
deformity or tenderness over the spine. Neurological
examination revealed a conscious child with normal
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
on abdominal pressure. There were no meningeal or
cerebellar signs.
CECT brain was normal. There was no evidence of any
fracture or displacement of vertebra on radiograph of the
spine and CT scan of the spine done on day 1 of illness.
Hemogram, LFTs, RFTs, electrolytes were within normal
limits. CSF done on day 2 had many RBCs, 10
polymorphs, protein of 80 mg/dl and sugar of 30 mg/dl.
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
of SCIWORA was made and this was confirmed by MRI
of the spine. Proper physiotherapy was advised and
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Veena Kalra et al
Fig. 1. MR T2 saggital image of the spinal cord shows increased
signal intensities within the cord extending from C6 to D3
level. No evidence of any spinal cord compression or
haemorrhage in the spinal cord. Vertebrae and ligaments are
normal
parents were taught clean intermittent catheterization. In
view of young age, complete flaccid paraplegia the
parents were counseled regarding the poor outcome. As
the child presented to us beyond 6 hours, high dose i.v.
methylprednisolone infusion was not given.
Spinal Cord Injury WithOut Radiological Abnormality
(SCIWORA) : Spinal cord injury without radiological
abnormality (SCIWORA) is defined as the occurrence of
acute traumatic myelopathy despite normal plain
radiographs and normal computed tomography (CT)
studies. This occurs predominantly among the pediatric
population, where its reported incidence ranges from 4%-
Mechanisms of injury
1, 5
66% of all spinal cord injuries (mostly around 10-20% of
all pediatric spinal trauma).
1
Although Lloyd
2
first
proposed the concept of SCIWORA and Burke
3
was the
first to report it, Pang and Wilberger
4
were the first to coin
the acronym SCIWORA and define it as a
clinicoradiological entity.
Pathogenesis
1,2,5
: 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 patients 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.
Adolescents sustain less severe, typically incomplete
injuries. A delay in the onset of neurological deficits or a
delayed neurological deterioration had been reported.
Brief transient motor or sensory symptoms are often
associated with the initial injury. An asymptomatic
period usually intervenes. The delays in deficits can range
from hours to 4 days after injury.
1,5,6
MRI is preferred for acute assessment because it is non-
invasive, delineates spinal cord and soft tissue
abnormalities, and can assess compressive pathology. If
MRI facility is unavailable or not possible and acute
assessment is indicated then, CT myelography should be
performed.
Differential diagnosis : The possible differential
diagnosis include, traumatic compressive myelopathy
(compression by fractured vertebrae, disc herniation etc),
and if trauma is not very significant then acute
disseminated encephalomyelitis, transverse myelitis are
1. Direct spinal cord traction a. Longitudinal cord traction
b. Root traction/avulsion
2. Direct spinal cord compression a. Transient compression
i. Ligamentous bulging
ii. Reversible disc protrusion
iii. Transient subluxation of vertebrae
b. Persistent compression (potentially requires operative intervention)
i. Occult fracture with cord compression
ii. Spinal epidural hematoma
iii. Persistent disc herniation
iv. Occult subluxation/instability
3. Indirect spinal cord injury Transmission of externally applied kinetic energy to spinal cord-
Spinal cord concussion (SCC)
4. Vascular/ischemic injury a. Vascular occlusion, dissection, cord infarction
b. Vasospasm
c. Hypotension, impaired cord perfusion.
Indian Journal of Pediatrics, Volume 73September, 2006 830
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SCIWORA-Spinal Cord Injury with Out Radiological Abnormality
other diagnostic possibilities.
Treatment : SCIWORA involving the cervical spine
should be treated by immobilization with a collar or a
more rigid brace until neurological deficits have resolved.
After the acute phase of injury, it is advisable to repeat the
flexion/extension views of the spine to rule out
ligamentous instability that may have been masked by
paravertebral muscle spasm during the initial evaluation.
Once deficits have resolved range of motion is gradually
increased. However, to avoid the risk of recurrent injury,
activity should be strictly limited for at least 3 months.
Patients with thoracic or lumbar myelopathy (SCIWORA)
also are initially treated with bed rest and subsequent
gradual mobilization.
1
High dose steroids-
Methylprednisolone bolus of 30 mg/Kg iv within 8 hrs of
injury, followed by infusion at 5.4 mg/Kg/hr for the next
23 hrs is beneficial in improving the outcome.
7
When
given over 48 hrs outcome at 6 wks and 6 months was
better in a recent study.
8
Role of stem cell transplant is
emerging.
Outcome : The prognosis is related to the severity of
the spinal cord dysfunction. Young children tend to
sustain complete injuries with permanent deficits; the rate
of functional recovery after complete neurological injuries
is reported to range from 0-10%. Outcome after
incomplete injuries in older children in excellent.
1
REFERENCES
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VKH. Pediatric spinal cord injury without radiographic
abnormalities: Report of 26 cases and review of literature. J
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2. Pang D, Sahrarkar K, Sun PP. Pediatric spinal cord and
vertebral column injuries. In: Youman JR, editor. Neurological
Surgery, 4
th
ed. Philadelphia: WB Saunders; 1996. p 1991-2037.
3. Burke DC. Traumatic spinal paralysis in children. Paraplegia
1974; 11 : 268-276.
4. Pang D, Wilberger Jr JE. Spinal cord injury without
radiological abnormality in children. J Neurosurg 1982; 57 : 114-
129.
5. Pang D, Pollack IF. Spinal cord injury without radiographic
abnormality in children-The SCIWORA syndrome. J Trauma
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Gupta SK et al. Diagnosis and prognostication of adult spinal
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resonance imaging analysis of 40 patients. Surgical neurology
2005; 63: 204-209.
7. Bracken MB, Shepard MJ, Collins WF et al. A randomized,
controlled trial of methylprednisolone or naloxone in the
treatment of acute spinal cord injury. Results of the second
national acute spinal cord injury study. N Engl J Med 1990; 322:
1405-1415.
8. Bracken MB, Shepard MJ, Collins WF et al. A randomized,
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treatment of acute spinal cord injury. Results of the second
national acute spinal cord injury study. N Engl J Med 1990; 322:
1405-1415.
9. Bracken MB, Shepard MJ, Holford TR et al. Administration of
mehtylprednisolone for 24 or 48 hours or tirilazad mesylate
for 48 hours in the treatment of acute spinal cord injury.
Results of the Third National Spinal Cord Injury Randomized
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JAMA 1997; 277 : 1597-1610.
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