Imaging and clinical approaches in the management of patients with spinal cord injury without radiographic abnormality (sciwora)

Abstract

CIWORA is a syndrome that defines posttraumatic SCI in patients with abnormal clinical neurological examination and apparently normal radiological findings in plain X-rays and CT. Under the suspicion of SCIWORA, early MRI is recommended for definitive diagnosis while prompt neuroprotective measures have to be taken to prevent secondary SCI that may cause further neurological deterioration.
Introduction. SCIWORA (Spinal Cord Injury Without Radiographic Abnormalities) is a syndrome that defines posttraumatic SCI in patients with abnormal clinical neurological examination and apparently normal radiological findings in plain X-rays and CT. This syndrome most commonly affects children, but can be also found in adults, with a predilection for the cervical spine. The aim of this study is to review the imaging and clinical approaches in the management of SCIWORA patients.
Materials & Methods. A literature review was conducted based on the Pubmed internet database, following the PRISMA Guidelines. Article titles were searched with the use of the keywords: “Spinal Cord Injury without Radiographic Abnormality” OR “SCIWORA”. The search included only clinical studies evaluating SCIWORA in adults. Studies published in non-English language, animal studies, experimental studies, case reports, reviews, and commentary studies were excluded. Moreover, studies in children and adolescents were also excluded.
Results. Initially, 207 studies were identified after primary search on Pubmed electronic database. After screening of titles and abstracts, 15 articles were excluded. Among the remaining 192 studies, 167 were rejected for various reasons (figure 1). After checking the references lists of the included studies, 2 more studies were added, leaving 29 studies for final analysis. The total number of patients was 1418 (78.2%

Abstract
SCIWORA is a syndrome that defines posttraumatic SCI in patients with abnormal clinical neurological examination and apparently normal radiological findings in plain X-rays and CT. Under the suspicion of SCIWORA, early MRI is recommended for definitive diagnosis while prompt neuroprotective measures have to be taken to prevent secondary SCI that may cause further neurological deterioration.
Introduction. SCIWORA (Spinal Cord Injury Without Radiographic Abnormalities) is a syndrome that defines posttraumatic SCI in patients with abnormal clinical neurological examination and apparently normal radiological findings in plain X-rays and CT. This syndrome most commonly affects children, but can be also found in adults, with a predilection for the cervical spine. The aim of this study is to review the imaging and clinical approaches in the management of SCIWORA patients.
Materials & Methods. A literature review was conducted based on the Pubmed internet database, following the PRISMA Guidelines. Article titles were searched with the use of the keywords: “Spinal Cord Injury without Radiographic Abnormality” OR “SCIWORA”. The search included only clinical studies evaluating SCIWORA in adults. Studies published in non-English language, animal studies, experimental studies, case reports, reviews, and commentary studies were excluded. Moreover, studies in children and adolescents were also excluded.
Results. Initially, 207 studies were identified after primary search on Pubmed electronic database. After screening of titles and abstracts, 15 articles were excluded. Among the remaining 192 studies, 167 were rejected for various reasons (figure 1). After checking the references lists of the included studies, 2 more studies were added, leaving 29 studies for final analysis. The total number of patients was 1418 (78.2% men) with a mean age of 53.5 years. The incidence of SCIWORA among all SCI cases varies from 1.3 – 12%. The most common cause of SCIWORA is fall from a height (53%), followed by motor vehicle accidents (33.6%), sports injuries (6.4%), occupational injuries (2.8%) and other injuries (4.6%). 94.4% of the SCIWORA occurred in the cervical spine, while the rest 5.2% occurred in the thoracic spine. The most common mechanism of injury is hyperflexion of the cervical spine especially in patients with preexisting cervical spondylosis. 12% of patients were AIS grade A, 20% AIS grade B, 35% AIS grade C and 33% AIS grade D. In 14.2% of patients, no MRI abnormalities were detected, while 85.8% of patients had abnormal MRI scan results. Among them, 57.0% had extraneural, 36.3% had intraneural and 6.6% of patients had combined extraneural and intraneural MRI abnormalities. Initial treatment is conservative. Indications for surgical management include MRI findings of cord compression and instability, along with deterioration of neurological symptoms. Prognosis of SCIWORA depends on the initial neurological deficit and magnitude of SCI on MRI; however, neurological improvement is expected in at least 75% of patients.
Conclusions. SCIWORA is an underestimated clinical condition in adult SCI patients. In the suspicion of SCIWORA, early MRI is recommended for definitive diagnosis and prompt neuroprotective measures have to be taken to prevent secondary SCI that may cause further neurological deterioration for a better prognosis. According to MRI findings, surgical treatment is indicated in patients with cord compression and instability and worsening neurological symptoms. More high quality studies are needed to fully elucidate the optimal imaging and clinical approaches in the management of SCIWORA patients.