Spinal cord injury without radiographic abnormality (SCIWORA) is a spinal cord injury (SCI) with no evidence of injury to the spinal column present on radiographs. Spinal column injury is trauma that causes fracture of the bone or instability of the ligaments in the spine; this can coexist with or result in injury to the spinal cord itself but each injury can occur without the other. Abnormalities might show up on magnetic resonance imaging (MRI), but the term was coined before MRI was in common use.
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History
The acronym SCIWORA was coined by Pang and Wilderer in 1982 This first description on spinal cord injuries with clinics-radiological mismatch was followed by a large number of case reports and case series.Later, a similar condition was reported in adults. It is most common in children. There seem to be relevant differences between pediatric and adult SCIWORA. In particular, adults often present with degenerative changes of the spinal column resulting in predisposing spinal stenosis. SCI in adults could be due to instability of vertebral ligaments or a herniation of a disk or a hematoma around the spinal cord that presses on it--none of which would show up on X-rays. In older people, spondylosis or problems with blood vessels can cause SCIWORA. The most common cause is being hit by a vehicle while on foot.
Before 1982, the phenomenon of clinics-radiological mismatch was known as well. Historical literature regarding spinal cord concussion, spinal cord contusion and hyperextension/hyperflexion injuries to the spine describe similar cases to modern cases of SCIWORA.
After the introduction von SCIWORA, the term was expanded to adults presenting with degenerative changes. Some authors used the term spinal cord injury without radiographic evidence of trauma (SCIWORET) to describe these cases. Furthermore, the introduction of computed tomography enabled a more detailed depiction of the spine. Thus, the identification of injuries previously missed called for a delimitation from the classical SCIWORA and SCIWORET. The term SCIWOCTET (spinal cord injury without CT evidence of trauma) was introduced. Finally, the use of magnetic resonance imaging (MRI) allowed for even better depiction of the spine and soft tissue abnormalities in particular. Again, a novel acronym was proposed to classify patients without traumatic signs using radiographs, CT and MRI. The term spinal cord injury without neuroimaging abnormality (SCIWONA) was used. However, the novel acronyms were not generally accepted and the more general term SCIWORA is usually used to describe all variants of clinico-radiological mismatches.
Pediatric Spinal Cord Injury Video
Clinical presentation
SCIWORA may present as a complete spinal cord injury (total loss of sensation and function below the lesion) or incomplete spinal cord injury (some sensation and/or function is preserved). It is present in a significant number of children with SCI. Notably, the clinical symptoms can present with a delay of hours to days after the trauma. This phenomenon was primarily seen in children but was reported in adults as well. The duration of symptoms varies widely. A full recovery can be achieved without treatment within minutes to hours and permanent injuries might prevail. Overall, there seems to be a relation between extent of damage to the spinal cord and the clinical prognosis. The prognostic value of intra- and extra-medullary MRI findings is subject of ongoing research in the field of SCIWORA.
Diagnosis
The application of MRI plays a significant role in the early diagnosis and treatment of SCIWORA in children and adults. Recently, systematic reviews on SCIWORA described the clinical and radiological patterns and correlations with neurological outcome. Boese and Lechler proposed a MRI-based classification for SCIWORA which correlated with the neurological outcome:
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