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

Authors

  • Nikolaos Siatos
  • Ioannis S. Benetos
  • Dimitrios-Sergios Evangelopoulos
  • John Vlamis
  • Maria-Eleftheria Evangelopoulos

Keywords:

Spinal cord injury; 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.

Downloads

Download data is not yet available.

References

El Masri WS, Kumar N. Traumatic spinal cord injuries. Lancet. 2011 Mar 19;377(9770):972-4.
Pang D, Wilberger JE, Jr. Spinal cord injury without radiographic abnormalities in children. J Neurosurg. 1982 Jul;57(1):114-29.
Barnes R. Paraplegia in cervical spine injuries. J Bone Joint Surg Br. 1948 May;30B(2):234-44.
Hirsh LF, Duarte L, Wolfson EH. Thoracic spinal cord injury without spine fracture in an adult: case report and literature review. Surg Neurol. 1993 Jul;40(1):35-8.
Gupta SK, Rajeev K, Khosla VK, Sharma BS, Paramjit, Mathuriya SN, et al. Spinal cord injury without radiographic abnormality in adults. Spinal Cord. 1999 Oct;37(10):726-9.
Tewari MK, Gifti DS, Singh P, Khosla VK, Mathuriya SN, Gupta SK, et al. Diagnosis and prognostication of adult spinal cord injury without radiographic abnormality using magnetic resonance imaging: analysis of 40 patients. Surg Neurol. 2005 Mar;63(3):204-9; discussion 9.
Tator CH, Duncan EG, Edmonds VE, Lapczak LI, Andrews DF. Changes in epidemiology of acute spinal cord injury from 1947 to 1981. Surg Neurol. 1993 Sep;40(3):207-15.
Como JJ, Samia H, Nemunaitis GA, Jain V, Anderson JS, Malangoni MA, et al. The misapplication of the term spinal cord injury without radiographic abnormality (SCIWORA) in adults. J Trauma Acute Care Surg. 2012 Nov;73(5):1261-6.
Tator CH. Spine-spinal cord relationships in spinal cord trauma. Clin Neurosurg. 1983;30:479-94.
Saruhashi Y, Hukuda S, Katsuura A, Asajima S, Omura K. Clinical outcomes of cervical spinal cord injuries without radiographic evidence of trauma. Spinal Cord. 1998 Aug;36(8):567-73.
Dreizin D, Kim W, Kim JS, Boscak AR, Bodanapally UK, Munera F, et al. Will the Real SCIWORA Please Stand Up? Exploring Clinicoradiologic Mismatch in Closed Spinal Cord Injuries. AJR Am J Roentgenol. 2015 Oct;205(4):853-60.
Kothari P, Freeman B, Grevitt M, Kerslake R. Injury to the spinal cord without radiological abnormality (SCIWORA) in adults. J Bone Joint Surg Br. 2000 Sep;82(7):1034-7.
Bhatoe HS. Cervical spinal cord injury without radiological abnormality in adults. Neurol India. 2000 Sep;48(3):243-8.
Diaz JJ, Jr., Aulino JM, Collier B, Roman C, May AK, Miller RS, et al. The early work-up for isolated ligamentous injury of the cervical spine: does computed tomography scan have a role? J Trauma. 2005 Oct;59(4):897-903; discussion -4.
Kasimatis GB, Panagiotopoulos E, Megas P, Matzaroglou C, Gliatis J, Tyllianakis M, et al. The adult spinal cord injury without radiographic abnormalities syndrome: magnetic resonance imaging and clinical findings in adults with spinal cord injuries having normal radiographs and computed tomography studies. J Trauma. 2008 Jul;65(1):86-93.
Barnett I, Malik N, Kuijjer ML, Mucha PJ, Onnela JP. EndNote: Feature-based classification of networks. Netw Sci (Camb Univ Press). 2019 Sep;7(3):438-44.
Asan Z. Spinal Cord Injury without Radiological Abnormality in Adults: Clinical and Radiological Discordance. World Neurosurg. 2018 Jun;114:e1147-e51.
Boese CK, Nerlich M, Klein SM, Wirries A, Ruchholtz S, Lechler P. Early magnetic resonance imaging in spinal cord injury without radiological abnormality in adults: a retrospective study. J Trauma Acute Care Surg. 2013 Mar;74(3):845-8.
Boese CK, Müller D, Bröer R, Eysel P, Krischek B, Lehmann HC, et al. Spinal cord injury without radiographic abnormality (SCIWORA) in adults: MRI type predicts early neurologic outcome. Spinal Cord. 2016 Oct;54(10):878-83.
Cao B, Li F, Tang Y, Jia L, Chen X. Risk Factors for Poor Prognosis of Spinal Cord Injury without Radiographic Abnormality Associated with Cervical Ossification of the Posterior Longitudinal Ligament. Biomed Res Int. 2022;2022:1572341.
Guo H, Liu J, Qi X, Ning G, Zhang H, Li X, et al. Epidemiological characteristics of adult SCIWORA in Tianjin, China: a preliminary study. Eur Spine J. 2012 Jan;21(1):165-71.
Hendey GW, Wolfson AB, Mower WR, Hoffman JR. Spinal cord injury without radiographic abnormality: results of the National Emergency X-Radiography Utilization Study in blunt cervical trauma. J Trauma. 2002 Jul;53(1):1-4.
Huang SL, Yan HW, Wang KZ. Use of Fidji cervical cage in the treatment of cervical spinal cord injury without radiographic abnormality. Biomed Res Int. 2013;2013:810172.
Kawano O, Ueta T, Shiba K, Iwamoto Y. Outcome of decompression surgery for cervical spinal cord injury without bone and disc injury in patients with spinal cord compression: a multicenter prospective study. Spinal Cord. 2010 Jul;48(7):548-53.
Liu Q, Zhao J, Yu H, Ma X, Wang L. Early MRI finding in adult spinal cord injury without radiologic abnormalities does not correlate with the neurological outcome: a retrospective study. Spinal Cord. 2015 Oct;53(10):750-3.
Machino M, Yukawa Y, Ito K, Nakashima H, Kanbara S, Morita D, et al. Can magnetic resonance imaging reflect the prognosis in patients of cervical spinal cord injury without radiographic abnormality? Spine (Phila Pa 1976). 2011 Nov 15;36(24):E1568-72.
Machino M, Ando K, Kobayashi K, Ota K, Morozumi M, Tanaka S, et al. MR T2 image classification in adult patients of cervical spinal cord injury without radiographic abnormality: A predictor of surgical outcome. Clin Neurol Neurosurg. 2019 Feb;177:1-5.
Maeda T, Ueta T, Mori E, Yugue I, Kawano O, Takao T, et al. Soft-tissue damage and segmental instability in adult patients with cervical spinal cord injury without major bone injury. Spine (Phila Pa 1976). 2012 Dec 1;37(25):E1560-6.
Martinez-Perez R, Munarriz PM, Paredes I, Cotrina J, Lagares A. Cervical Spinal Cord Injury without Computed Tomography Evidence of Trauma in Adults: Magnetic Resonance Imaging Prognostic Factors. World Neurosurg. 2017 Mar;99:192-9.
Na BR, Seo HY. Adult Spinal Cord Injury without Major Bone Injury: Effects of Surgical Decompression and Predictors of Neurological Outcomes in American Spinal Injury Association Impairment Scale A, B, or C. J Clin Med. 2021 Mar 6;10(5).
Neva MH, Roeder CP, Felder U, Kiener B, Meier W, Perler M, et al. Neurological outcome, working capacity and prognostic factors of patients with SCIWORA. Spinal Cord. 2012 Jan;50(1):78-80.
Ouchida J, Yukawa Y, Ito K, Katayama Y, Matsumoto T, Machino M, et al. Delayed Magnetic Resonance Imaging in Patients With Cervical Spinal Cord Injury Without Radiographic Abnormality. Spine (Phila Pa 1976). 2016 Aug 15;41(16):E981-E6.
Qi C, Xia H, Miao D, Wang X, Li Z. The influence of timing of surgery in the outcome of spinal cord injury without radiographic abnormality (SCIWORA). J Orthop Surg Res. 2020 Jun 16;15(1):223.
Qi C, Cao J, Xia H, Miao D, Liu Y, Guo J, et al. Does cervical curvature affect neurological outcome after incomplete spinal cord injury without radiographic abnormality (SCIWORA): 1-year follow-up. J Orthop Surg Res. 2022 Jul 26;17(1):361.
Sharma S, Singh M, Wani IH, Sharma N, Singh D. Adult Spinal Cord Injury without Radiographic Abnormalities (SCIWORA): Clinical and Radiological Correlations. J Clin Med Res. 2009 Aug;1(3):165-72.
Shen H, Tang Y, Huang L, Yang R, Wu Y, Wang P, et al. Applications of diffusion-weighted MRI in thoracic spinal cord injury without radiographic abnormality. Int Orthop. 2007 Jun;31(3):375-83.
Tan J, Hu F, Ou J, Su X, Liu J. Analysis of the Curative Effect and Prognostic Factors of Anterior Cervical Surgery for Spinal Cord Injury without Radiographic Abnormalities. Evid Based Complement Alternat Med. 2022;2022:6836966.
Wang Y, Xue Y, Zong Y, Ding H, Li Z, He D, et al. Treatment of Atypical Central Cord Injury Without Fracture or Dislocation. Orthopedics. 2015 Jun;38(6):e524-8.
Yaqoob Hakim S, Gamal Altawil L, Faidh Ramzee A, Asim M, Ahmed K, Awwad M, et al. Diagnosis, management and outcome of Spinal Cord Injury without Radiographic Abnormalities (SCIWORA) in adult patients with trauma: a case series. Qatar Med J. 2021;2021(3):67.
Zhang JD, Xia Q. Role of Intraoperative Disc Contrast Injection in Determining the Segment Responsible for Cervical Spinal Cord Injury without Radiographic Abnormalities. Orthop Surg. 2015 Aug;7(3):239-43.
Zhu F, Yao S, Ren Z, Telemacque D, Qu Y, Chen K, et al. Early durotomy with duroplasty for severe adult spinal cord injury without radiographic abnormality: a novel concept and method of surgical decompression. Eur Spine J. 2019 Oct;28(10):2275-82.
Pang D, Pollack IF. Spinal cord injury without radiographic abnormality in children--the SCIWORA syndrome. J Trauma. 1989 May;29(5):654-64.
Crooks F, Birkett AN. Fractures and dislocations of the cervical spine*. British Journal of Surgery. 2005;31(123):252-65.
Schneider RC, Cherry G, Pantek H. The syndrome of acute central cervical spinal cord injury; with special reference to the mechanisms involved in hyperextension injuries of cervical spine. J Neurosurg. 1954 Nov;11(6):546-77.
Holmes G. The Goulstonian Lectures ON SPINAL INJURIES OF WARFARE: Delivered before the Royal College of Physicians of London. Br Med J. 1915 Nov 27;2(2865):769-74.
Roberts TT, Leonard GR, Cepela DJ. Classifications In Brief: American Spinal Injury Association (ASIA) Impairment Scale. Clin Orthop Relat Res. 2017 May;475(5):1499-504.
Yamazaki M, Mochizuki M, Ikeda Y, Sodeyama T, Okawa A, Koda M, et al. Clinical results of surgery for thoracic myelopathy caused by ossification of the posterior longitudinal ligament: operative indication of posterior decompression with instrumented fusion. Spine (Phila Pa 1976). 2006 Jun 1;31(13):1452-60.
Fredrickson MD. Acute spinal cord injury management. J Trauma. 2007 Jun;62(6 Suppl):S9.
Parizel PM, van der Zijden T, Gaudino S, Spaepen M, Voormolen MH, Venstermans C, et al. Trauma of the spine and spinal cord: imaging strategies. Eur Spine J. 2010 Mar;19 Suppl 1(Suppl 1):S8-17.
Djang WT. Radiology of acute spinal trauma. Crit Care Clin. 1987 Jul;3(3):495-518.
Atesok K, Tanaka N, O’Brien A, Robinson Y, Pang D, Deinlein D, et al. Posttraumatic Spinal Cord Injury without Radiographic Abnormality. Adv Orthop. 2018;2018:7060654.
Bozzo A, Marcoux J, Radhakrishna M, Pelletier J, Goulet B. The role of magnetic resonance imaging in the management of acute spinal cord injury. J Neurotrauma. 2011 Aug;28(8):1401-11.
Lammertse D, Dungan D, Dreisbach J, Falci S, Flanders A, Marino R, et al. Neuroimaging in traumatic spinal cord injury: an evidence-based review for clinical practice and research. J Spinal Cord Med. 2007;30(3):205-14.
Goradia D, Linnau KF, Cohen WA, Mirza S, Hallam DK, Blackmore CC. Correlation of MR imaging findings with intraoperative findings after cervical spine trauma. AJNR Am J Neuroradiol. 2007 Feb;28(2):209-15.
Hayashi K, Yone K, Ito H, Yanase M, Sakou T. MRI findings in patients with a cervical spinal cord injury who do not show radiographic evidence of a fracture or dislocation. Paraplegia. 1995 Apr;33(4):212-5.
Shimada K, Tokioka T. Sequential MRI studies in patients with cervical cord injury but without bony injury. Paraplegia. 1995 Oct;33(10):573-8.
Boese CK, Lechler P. Spinal cord injury without radiologic abnormalities in adults: a systematic review. J Trauma Acute Care Surg. 2013 Aug;75(2):320-30.
Mhuircheartaigh NN, Kerr JM, Murray JG. MR imaging of traumatic spinal injuries. Semin Musculoskelet Radiol. 2006 Dec;10(4):293-307.
Pérez-López C, Isla A, Gómez Sierra A, Budke M. Cervical epidural hematoma without fracture in a patient with ankylosing spondylitis. A case report. J Neurosurg Sci. 2004 Jun;48(2):91-4; discussion 4.
Grant GA, Mirza SK, Chapman JR, Winn HR, Newell DW, Jones DT, et al. Risk of early closed reduction in cervical spine subluxation injuries. J Neurosurg. 1999 Jan;90(1 Suppl):13-8.
Benzel EC, Hart BL, Ball PA, Baldwin NG, Orrison WW, Espinosa MC. Magnetic resonance imaging for the evaluation of patients with occult cervical spine injury. J Neurosurg. 1996 Nov;85(5):824-9.
Pang D. Spinal cord injury without radiographic abnormality in children, 2 decades later. Neurosurgery. 2004 Dec;55(6):1325-42; discussion 42-3.
Kulkarni MV, Bondurant FJ, Rose SL, Narayana PA. 1.5 tesla magnetic resonance imaging of acute spinal trauma. Radiographics. 1988 Nov;8(6):1059-82.
Ramón S, Domínguez R, Ramírez L, Paraira M, Olona M, Castelló T, et al. Clinical and magnetic resonance imaging correlation in acute spinal cord injury. Spinal Cord. 1997 Oct;35(10):664-73.
Ehara S, Shimamura T. Cervical spine injury in the elderly: imaging features. Skeletal Radiol. 2001 Jan;30(1):1-7.
Wilson JR, Cadotte DW, Fehlings MG. Clinical predictors of neurological outcome, functional status, and survival after traumatic spinal cord injury: a systematic review. J Neurosurg Spine. 2012 Sep;17(1 Suppl):11-26.
Varma A, Hill EG, Nicholas J, Selassie A. Predictors of early mortality after traumatic spinal cord injury: a population-based study. Spine (Phila Pa 1976). 2010 Apr 1;35(7):778-83.
Grabb PA, Pang D. Magnetic resonance imaging in the evaluation of spinal cord injury without radiographic abnormality in children. Neurosurgery. 1994 Sep;35(3):406-14; discussion 14.
Yucesoy K, Yuksel KZ. SCIWORA in MRI era. Clin Neurol Neurosurg. 2008 May;110(5):429-33.
Dare AO, Dias MS, Li V. Magnetic resonance imaging correlation in pediatric spinal cord injury without radiographic abnormality. J Neurosurg. 2002 Jul;97(1 Suppl):33-9.
Schaefer DM, Flanders AE, Osterholm JL, Northrup BE. Prognostic significance of magnetic resonance imaging in the acute phase of cervical spine injury. J Neurosurg. 1992 Feb;76(2):218-23.
Boldin C, Raith J, Fankhauser F, Haunschmid C, Schwantzer G, Schweighofer F. Predicting neurologic recovery in cervical spinal cord injury with postoperative MR imaging. Spine (Phila Pa 1976). 2006 Mar 1;31(5):554-9.
Mazaki T, Ito Y, Sugimoto Y, Koshimune K, Tanaka M, Ozaki T. Does laminoplasty really improve neurological status in patients with cervical spinal cord injury without bone and disc injury? A prospective study about neurological recovery and early complications. Arch Orthop Trauma Surg. 2013 Oct;133(10):1401-5.
Bosch PP, Vogt MT, Ward WT. Pediatric spinal cord injury without radiographic abnormality (SCIWORA): the absence of occult instability and lack of indication for bracing. Spine (Phila Pa 1976). 2002 Dec 15;27(24):2788-800.

Downloads

Published

2024-06-25