SCIWORA (spinal cord injury without radiologic abnormality)
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- occurs most often in pediatric population; range from birth to 16 yrs
a true incidence is probably close to 20% of all pediatric spinal cord injuries
- accounts for up to 30% of severe cervical injuries in children 8 years of age and younger
- 10% in children 9-16 yrs
- children < 8yrs have worse prognosis.
- cervical, thoracic SCI common, lumbar rare.
Direct spinal cord traction
- Longitudinal cord traction
- Root traction/avulsion
Direct spinal cord compression
- Ligamentous bulging
- Reversible disc protrusion
- Transient subluxation of vertebrae
Persistent compression (potentially requires operative intervention)
- Occult fracture with cord compression
- Spinal epidural hematoma
- Persistent disc herniation
- Occult subluxation/instability
Indirect spinal cord injury
- Transmission of externally applied kinetic energy to spinal cord-Spinal cord concussion (SCC)
Mainly due to MVA (motor vehicle accident) or MV – pedestrian accident, fall, or sports injury (football, diving,wrestling, gymnasts).
- Vascular occlusion, dissection, cord infarction
- Hypotension, impaired cord perfusion.
- transverse atlantal ligament injury
- fracture through the cartilaginous end plates (which are not visualized by x-rays), may be among the causes of this injury
unrecognized interspinous ligamentous injury
- in above 2 situations, flexion & extension views taken with pt awake and physician in attendance will demonstrate injury
- adult with acute traumatic disc prolapse
- cervical spondylosis
- C-spine trauma occurs w/ hyperextension injury to spine w/ vertebral canal whose diameter is already comprimised by spondylosis
excessive anterior buckling of ligamentum flavum into canal already compromised by posterior vertebral body osteophytes probably is cause of central cord syndrome:
- motor loss in arms > than in legs, & variable sensory loss
- typically, pts are managed nonsurgically w/ orthosis, & their neurologic status is carefully monitored.
Typical clinical history:
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 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.
wide spectrum of neurological dysfunction, ranging from mild, transient spinal cord concussive deficits to permanent, complete injuries of the spinal cord, incidence and severity are related to the patient’s age.
- Young children have a higher incidence of SCIWORA
- Transient neurological deficit (i.e. paraparesis or quadriparesis), or persisting subjective symptoms (i.e. numbness or dysesthesias) would be a candidate for the diagnosis of SCIWORA.
- Pang and Wilberger described 13 of their 24 children to have a “latent” period from 30 minutes to four days (mean 1.2 days) before the onset of objective sensorimotor deficits.
- Plain spinal radiographs of the region of injury and CT scan with attention to the suspected level of neurological injury to exclude occult fractures are recommended.
- MR of the region of suspected neurological injury may provide useful diagnostic information.
- Plain radiographs of the entire spinal column may be considered.
- Neither spinal angiography nor myelography is recommended in the evaluation of patients with SCIWORA.
- MRI may give a more anatomic diagnosis by showing hemorrhage or edema of the spinal cord;
- pseudosubluxation: anterior displacement may be up to 4 mm;
- SSEPs: Somatosensory Evoked Potentials, are electrophysiologic response of nervour system to sensory stimulation, used not diagnostically, but to test neurologic function, can relate any decrease or absence of impulse transmission through the spinal cord, obtained within 24 hrs of admission and compared in follow up analysis.
- Traumatic compressive myelopathy (compression by fractured vertebrae, disc herniation etc)
- Acute disseminated encephalomyelitis
- Transverse myelitis
- External immobilization is recommended until spinal stability is confirmed flexion and extension radiographs.
- External immobilization of the spinal segment of injury (collar or a more rigid brace) for up to 12 weeks may be considered.
- Avoidance of “high-risk” activities for up to six months following SCIWORA may be considered.
Hard collar immobilization for patients with cervical level SCIWORA for 12 weeks
- avoidance of activities that encourage flexion and extension of the neck for an additional 12 weeks has not been associated with recurrent injury.
Once deficits have resolved range of motion is gradually increased.
- To avoid the risk of recurrent injury, activity should be strictly limited for at least 3 months.
High dose steroids
- Methylprednisolone bolus of 30 mg/Kg iv within 8 hr s of injury, followed by infusion at 5.4 mg/Kg/hr for the next 23 hrs is beneficial in improving the outcome.
- When given over 48 hrs outcome at 6 wks and 6 months was better in a recent study.
- Role of stem cell transplant is emerging.
- spine stabilization,
- patient & parents counseling & explanation,
- regular neuro assessment;
- caution in turningpositioning,
- prevention of complications like pressure sore, pulmonary side effect, contractures.
- delay in onset or deterioration of neurologic symptoms
- recurrent injury