SCIWORA: Spinal Cord Injury Without Radiographic Abnormality

Posted by Nurse Linda in Life After Paralysis on November 02, 2021 # Health

Child standing with a walkerThere are all types of causes for spinal cord injury in children. These can include trauma to the spinal cord that may be due to bones pressing on the spinal cord, gunshot wounds, and bruising the spinal cord. Diseases can also be the cause of spinal cord injury, such as spina bifida, cerebral palsy, transverse myelitis and Guillain Barré Syndrome, as well as many others.

Another type of spinal cord injury can occur, especially in younger children, which is called SCIWORA. This stands for Spinal Cord Injury Without Radiographic Abnormality. It is a spinal cord injury that cannot be seen using standard imaging. With the advent and development of MRI scans, the area of concern can usually be determined. However, there are still some diagnoses of SCIWORA, or your child may have had this diagnosis in the past. Although it is a rare diagnosis, it is more common in children. It is rarely seen in adults.

Diagnosis of SCIWORA is made without evidence of a fracture or dislocation in the vertebral bones (boney spinal skeleton). Also excluded from a SCIWORA diagnosis is spinal cord injury from something penetrating the spinal cord, electrical shock, birth injuries, and congenital abnormalities. A disruption in the spinal cord cannot be seen on x-rays, tomography, CT Scan, myelography or dynamic flexion/extension studies. MRI scans can detect more detailed images of the spinal cord. Still, SCIWORA can be noted in up to 65% of young children’s MRI scans. If no visualization of injury to the spinal cord is made, but symptoms are present, SCIWORA is diagnosed.

There are some anatomical differences in children that affect spinal cord trauma. In children, the elasticity of the spine provides more self-reduction of spinal vertebrae displacement. Bones are slightly more forgiving to stiffness, allowing more flexibility than after puberty when the bones are set. Ligaments and joints are more supple. Facet joints between each vertebrae of the spine are shallow and horizontally oriented, allowing greater mobility, flexibility, and extension with movement.

On the other hand, children’s vertebrae can also be susceptible to more wedging and slippage. They do not allow extensive rotational and lateral bending. End plates of bones where growth occurs are more vulnerable to injury and may not show evidence of a fracture.

Most often, internal injury to the spinal cord is the cause of SCIWORA. This can include intervertebral disk rupture, spinal epidural hematoma, cord contusion or hematomyelia (blood in the spinal cord). Most often causes of SCIWORA include overstretching of the spinal cord, buckling of ligamentum flavum into the spinal canal (connections to the vertebrae holding the spinal cord in place), kinetic energy (movement to the spinal cord or within the spinal cord), traction to the spinal cord, compression, indirect injury to the spinal cord or vascular/ischemic injury. There may also be a rupture of ligaments outside of the spinal cord.

The result of these injury processes to the spinal cord can be complete spinal cord disruption, hemorrhage (bleeding into the spinal cord), or swelling of the spinal cord. The onset of symptoms can be 30 minutes to 4 days. The body will immediately begin to react to the injury, but it may take time for the accumulation of internal response before symptoms appear due to internal body inflammation, occlusion of the arteries at the injury site caused by thrombosis (blood clots) or spasms. Repeated trauma can occur to the unstable spinal cord because the injury has not yet been detected.

Symptoms are as with detected causes of spinal cord injury. These can include paralysis or paresthesia, decreased sensation, loss of bowel and bladder function. Some will have weakness or paresthesia that is temporary. Noted might be paraplegia, tetraplegia, or spinal cord syndromes:

Brown-Séquard syndrome- results in a vibrating sensation on the same side of the injury, pain, and temperature loss on the opposite side of the injury.

Anterior cord syndrome-injury to the front section of the spinal cord causes loss of movement, and pain and temperature loss, but preserves light touch sensations.

Central cord syndrome affects the center of the spinal cord, resulting especially in the loss of hand and arm function, although leg function is sometimes also affected.

Posterior cord syndrome-injury to the backside of the spinal cord causes loss of light touch sensation, with preserved movement, and pain and temperature sensation.

SCIWORA most often occurs in children from ages birth to 16 years old. Children eight years and younger account for 30% of SCIWORA cervical injuries, 10% in those 9-16 years old. It is the diagnosis in about 20% of all pediatric spinal cord injuries. The cervical and thoracic regions are the most common level, rarely is it in the lumbar or sacral levels.

Common causes of SCIWORA injury are MVA (motor vehicle accident), motor vehicle-pedestrian accident or falls. Sports injury is also a cause, especially football, diving, wrestling, and gymnastics or cheerleading.

If you suspect your child might have trauma to their spinal cord, you must have them examined immediately. This is not a wait-and-see event. An unstable spine will continue to be injured from regular activity or even gentle movement. If your child was injured previously, or recently, have them checked thoroughly by a healthcare professional. Transportation should be made using 911 services. They can safely move your child without further damage to the spinal cord.

Rehabilitation should begin as soon as the spinal cord is stabilized. Treatments depend on the severity of the injury. Interventions can range from the use of a cervical collar or supportive back brace to spinal stabilization surgery. A halo brace might be used to immobilize the neck to prevent further injury for up to twelve weeks. The steroid, Methylprednisolone, may be given to reduce inflammation within eight hours of injury. The specifics of your child’s treatment will be determined by their healthcare professional. If spinal cord injury is suspected, your child will most likely be transferred to a major pediatric medical center as soon as it is safe for them to travel.

Pediatric habilitation/rehabilitation will be needed to help restore function and improve independence. Pediatric rehabilitation specialists in medicine, neurology, neurosurgery, radiology, nursing, physical therapy, occupational therapy, and speech therapy will develop a treatment program that is age and developmentally appropriate for your child. Pediatric facilities have child life therapists who assist with providing appropriate diversional activities during procedures and at playtime. These individuals are extremely helpful in making the hospitalization process less stressful for your child.

Therapy will continue at home through home health services or with ongoing therapy that you, the parent or guardian has learned. Schools will provide education for your child both within the hospital setting, at home or in the classroom as your child progresses.

You and your child, when appropriate, will work toward reducing risks of secondary complications such as pressure injury, bowel and bladder care, and respiratory complications. It is important to note any neurological changes to avoid progression of the spinal cord injury, although once the spine is stabilized, that risk is greatly reduced.

As medical advances are rapidly improving, especially in the progression of MRI scanning, the incidence of SCIWORA is decreasing. More often, the MRI examination demonstrates the presence of SCI or not. However, there are many children who have been previously diagnosed with SCIWORA and some in which this still occurs. Prognosis is related to the severity of changes on the MRI. Because of the developing nervous system, younger children may advance more quickly than older children. The key to all healthcare issues is prompt care. Nurse Linda

Linda Schultz is a leader, teacher, and provider of rehabilitation nursing for over 30 years. In fact, Nurse Linda worked closely with Christopher Reeve on his recovery and has been advocating for the Reeve Foundation ever since.

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The National Paralysis Resource Center website is supported by the Administration for Community Living (ACL), U.S. Department of Health and Human Services (HHS) as part of a financial assistance award totaling $8,700,000 with 100 percent funding by ACL/HHS. The contents are those of the author(s) and do not necessarily represent the official views of, nor an endorsement, by ACL/HHS, or the U.S. Government.