Spinal cord injury without radiographic abnormality (SCIWORA) in children
- Alison Chantal Caviness, MD, MPH, PhD
Alison Chantal Caviness, MD, MPH, PhD
- Associate Professor of Pediatric Emergency Medicine
- Baylor College of Medicine
- Section Editor
- Richard G Bachur, MD
Richard G Bachur, MD
- Section Editor — Pediatric Trauma
- Professor of Pediatrics and Emergency Medicine
- Harvard Medical School
- Deputy Editor
- James F Wiley, II, MD, MPH
James F Wiley, II, MD, MPH
- Senior Deputy Editor — UpToDate
- Deputy Editor — Adult and Pediatric Emergency Medicine
- Deputy Editor — Primary Care Sports Medicine (Adolescents and Adults)
- Clinical Professor of Pediatrics and Emergency Medicine/Traumatology
- University of Connecticut School of Medicine
SCIWORA refers to spinal injuries, typically located in the cervical region, in the absence of identifiable bony or ligamentous injury on complete, technically adequate plain radiographs or computed tomography. The majority of children with SCIWORA do have demonstrable injury of the spinal cord, spinal ligaments, or vertebral body end plate on magnetic resonance imaging. SCIWORA should be suspected in patients subjected to blunt trauma who report early (immediate) or transient symptoms of neurologic deficit or who have existing findings upon initial assessment. Treatment and prognosis are based upon neurologic presentation and MRI findings.
This topic will review the clinical features and management of SCIWORA in children less than 18 years of age. The approach to ligamentous injury and SCIWORA in adults is discussed separately. (See "Evaluation and acute management of cervical spinal column injuries in adults", section on 'Evaluation for ligamentous injury and SCIWORA'.)
SCIWORA was first defined in a series of children as objective signs of acute traumatic myelopathy in the absence of spinal column findings on plain radiographs, flexion-extension radiographs, and/or computed tomography (CT) [1,2]. In this original report, it was noted that patients had neurologic deficits or a history of transient paresthesias, numbness, or paralysis. Delayed onset of permanent paralysis, up to four days after injury, occurred in approximately half of patients.
However, since the advent of magnetic resonance imaging (MRI) approximately two-thirds of cases described as SCIWORA in the literature actually have demonstrable injury to the spinal cord, soft tissue components of the spinal column (ligaments, capsules, or muscles), or vertebral body endplate [3,4]. With the increased availability of MRI, the diagnosis of "real" SCIWORA or spinal cord injury without neuroimaging abnormality is less common. The term "spinal cord injury without computed tomography evidence of trauma" (SCIWOCTET) is sometimes used to describe adult patients with neurologic findings suggestive of spinal cord injury with normal anatomic alignment and no bony abnormalities seen on CT .
Nonetheless, it is important to remember that patients with blunt trauma who have a history of transient neurologic symptoms that have resolved by the time of initial evaluation may have a significant injury to the spinal cord and/or spinal column despite a normal physical examination and normal spine radiographs and/or CT.
- Pang D, Wilberger JE Jr. Spinal cord injury without radiographic abnormalities in children. J Neurosurg 1982; 57:114.
- Dreizin D, Kim W, Kim JS, et al. Will the Real SCIWORA Please Stand Up? Exploring Clinicoradiologic Mismatch in Closed Spinal Cord Injuries. AJR Am J Roentgenol 2015; 205:853.
- Pang D. Spinal cord injury without radiographic abnormality in children, 2 decades later. Neurosurgery 2004; 55:1325.
- Yucesoy K, Yuksel KZ. SCIWORA in MRI era. Clin Neurol Neurosurg 2008; 110:429.
- TAYLOR AR, BLACKWOOD W. Paraplegia in hyperextension cervical injuries with normal radiographic appearances. J Bone Joint Surg Br 1948; 30B:245.
- LEVENTHAL HR. Birth injuries of the spinal cord. J Pediatr 1960; 56:447.
- Abroms IF, Bresnan MJ, Zuckerman JE, et al. Cervical cord injuries secondary to hyperextension of the head in breech presentations. Obstet Gynecol 1973; 41:369.
- Robles LA. Traumatic spinal cord infarction in a child: case report and review of literature. Surg Neurol 2007; 67:529.
- Hendey GW, Wolfson AB, Mower WR, et al. Spinal cord injury without radiographic abnormality: results of the National Emergency X-Radiography Utilization Study in blunt cervical trauma. J Trauma 2002; 53:1.
- Cirak B, Ziegfeld S, Knight VM, et al. Spinal injuries in children. J Pediatr Surg 2004; 39:607.
- Polk-Williams A, Carr BG, Blinman TA, et al. Cervical spine injury in young children: a National Trauma Data Bank review. J Pediatr Surg 2008; 43:1718.
- 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; 27:2788.
- Martin BW, Dykes E, Lecky FE. Patterns and risks in spinal trauma. Arch Dis Child 2004; 89:860.
- Mahajan P, Jaffe DM, Olsen CS, et al. Spinal cord injury without radiologic abnormality in children imaged with magnetic resonance imaging. J Trauma Acute Care Surg 2013; 75:843.
- Brown RL, Brunn MA, Garcia VF. Cervical spine injuries in children: a review of 103 patients treated consecutively at a level 1 pediatric trauma center. J Pediatr Surg 2001; 36:1107.
- Pang D, Pollack IF. Spinal cord injury without radiographic abnormality in children--the SCIWORA syndrome. J Trauma 1989; 29:654.
- Hamilton MG, Myles ST. Pediatric spinal injury: review of 174 hospital admissions. J Neurosurg 1992; 77:700.
- Osenbach RK, Menezes AH. Spinal cord injury without radiographic abnormality in children. Pediatr Neurosci 1989; 15:168.
- Hall DE, Boydston W. Pediatric neck injuries. Pediatr Rev 1999; 20:13.
- Peclet MH, Newman KD, Eichelberger MR, et al. Patterns of injury in children. J Pediatr Surg 1990; 25:85.
- Grabb PA, Pang D. Magnetic resonance imaging in the evaluation of spinal cord injury without radiographic abnormality in children. Neurosurgery 1994; 35:406.
- Felsberg GJ, Tien RD, Osumi AK, Cardenas CA. Utility of MR imaging in pediatric spinal cord injury. Pediatr Radiol 1995; 25:131.
- Matsumura A, Meguro K, Tsurushima H, et al. Magnetic resonance imaging of spinal cord injury without radiologic abnormality. Surg Neurol 1990; 33:281.
- Liao CC, Lui TN, Chen LR, et al. Spinal cord injury without radiological abnormality in preschool-aged children: correlation of magnetic resonance imaging findings with neurological outcomes. J Neurosurg 2005; 103:17.
- Davis PC, Reisner A, Hudgins PA, et al. Spinal injuries in children: role of MR. AJNR Am J Neuroradiol 1993; 14:607.
- Launay F, Leet AI, Sponseller PD. Pediatric spinal cord injury without radiographic abnormality: a meta-analysis. Clin Orthop Relat Res 2005; :166.