Spinal cord injury without radiographic abnormality (SCIWORA) in children
- Julie C Leonard, MD, MPH
Julie C Leonard, MD, MPH
- Associate Professor of Pediatrics
- Nationwide's Children's Hospital
- The Ohio State University, College of Medicine
- Department of Pediatrics, Division of Emergency Medicine and
- Nationwide Children’s Hospital
- 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
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 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 on presentation or a history of transient paresthesias, numbness, or paralysis. Approximately half of patients presented with delayed onset (up to four days after injury) of permanent paralysis.
However, with 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.
SCIWORA should not be confused with cervical "burners" or "stingers", which refers to peripheral brachial plexus injuries, typically at the C5-C6 level resulting from trauma to the neck and shoulder (table 1). When children present with transient neurologic symptoms and normal neurologic exams, it may be difficult to distinguish between brachial plexus injuries and SCIWORA, leading to over-reporting of SCIWORA . (See "Overview of cervical spinal cord and cervical peripheral nerve injuries in the child or adolescent athlete", section on 'Cervical burners'.)To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:
- 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.
- 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.
- Leonard JR, Jaffe DM, Kuppermann N, et al. Cervical spine injury patterns in children. Pediatrics 2014; 133:e1179.
- 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.
- Boese CK, Müller D, Bröer R, et al. Spinal cord injury without radiographic abnormality (SCIWORA) in adults: MRI type predicts early neurologic outcome. Spinal Cord 2016; 54:878.
- Martinez-Perez R, Munarriz PM, Paredes I, et al. Cervical Spinal Cord Injury without Computed Tomography Evidence of Trauma in Adults: Magnetic Resonance Imaging Prognostic Factors. World Neurosurg 2017; 99:192.
- 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.
- Farrell CA, Hannon M, Lee LK. Pediatric spinal cord injury without radiographic abnormality in the era of advanced imaging. Curr Opin Pediatr 2017; 29:286.
- Cirak B, Ziegfeld S, Knight VM, et al. Spinal injuries in children. J Pediatr Surg 2004; 39:607.
- 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.