SCIWORA Syndrome

SCIWORA syndrome stands for spinal cord injury without radiographic abnormality. Spinal cord injury without radiographic abnormality or SCIWORA is an injury in the cervical [most common] or thoracic spine, in the absence of identifiable bony or ligamentous injury on radiographs or computed tomography. That means there is an injury to the cervical spine, but the X-rays and/or are essentially normal. It affects children more commonly than adults due to the elasticity of the tissues and a more tenuous spinal cord blood supply. Few cases have been reported in adults too.

This disorder was defined by Pang and Wilberger in 1982.

The incidence of SCIWORA is estimated to be around 20%. These injuries account for about 60% of severe cervical injuries in children < 8 years of age. In the younger patients, upper cervical injuries are more common and they are more likely to have severe neurological injuries.

Flexion and extension injuries are the most common mechanism, but lateral bending, distraction, rotation, axial loading, or a combination may also be involved.

SCIWORA was first defined in a series of children of acute traumatic myelopathy in the absence of spinal column findings on x-rays,  and/or CT.

SCIWORA should be suspected in patients subjected to blunt trauma who report early or transient symptoms of neurologic deficit or who have a neural deficit on clinical examination.

With MRI, two-thirds of cases of SCIWORA have been found to have a demonstrable injury to the spinal cord, ligaments, capsules, or muscles, or vertebral body endplate.

Thus, the diagnosis of SCIWORA in real terms is less common now.

Injuries in SCIWORA

Following injuries have been noted in cases of SCIWORA

• 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
• Adult with acute traumatic disc prolapse
• Hyperextension injury in cervical spondylosis

Imaging in SCIWORA

MRI is able to describe the injury. As noted above, Most of the cases with SCIWORA either have a ligamentous injury, disc prolapse or disc injury, complete spinal cord transection, and spinal cord hemorrhage.

Some patient with SCIWORA may also be normal on MRI.

Treatment

In children, most SCIWORA injuries are stable lesions, and immobilization for up to 3 months is the recommended care. After that, dynamic cervical x-rays should be done. If these are normal, immobilization should be discontinued. In the case of patients with ligamentous injuries as noted on MRI, the patient needs to be followed with serial dynamic x-rays to detect any instability that may develop after immobilization is discontinued.

Immobilization which aims at prevention of movement and preserving cervical alignment.

Few cases may require traction for the restoration of alignment.

Immobilization is more difficult in the neonates and customized orthoses may be required.