Cervical spinal cord injuries without radiographic evidence of trauma: a prospective study

Spina Bifida Occulta Is a Risk Factor for Spinal Cord Injury Without Fracture or Dislocation for Children Performing a Backbend During Dance

OBJECTIVE

This study aimed to explore the clinical features and outcomes of children with spinal cord injury (SCI) without fracture or dislocation.

METHODS

The clinical data of children with SCI without fracture or dislocation in this retrospective study were collected in Chongqing, China (January 2010 to December 2021). We collected patient demographics at admission including age, gender, cause, level, and severity of the injury in admission and complications. Reports from radiologic imaging were reviewed to identify spina bifida occulta (SBO). Neurological function was evaluated using the American Spinal Injury Association (ASIA) Impairment Scale (AIS) for an SCI.

RESULTS

A total of 74 children with SCI (male, 27%; female, 73%; male-to-female ratio, 1:2.7; average age, 5.7 years) were included. The main cause of injury was backbend during the dance (34 patients, 45.9%, including 2 patients who hugged back falling backward), followed by traffic accidents (17 patients, 23%). Children with backbend-related SCI were older than other children (6.9 vs. 4.9 years old, P < 0.001). When reviewing all radiological images, it was found that 20 (27%) patients with SCI had SBO. The proportion of SCI with SBO caused by backbend was considerably higher than those caused by non-backbend (41.2 vs. 15%, P = 0.012). The AIS were 22 (29.7%), 4 (5.4%), 8 (10.8%), 31 (41.9%), and 9 (12.2%) in A, B, C, D, and E, respectively. The prognosis was poorer in the backbend during dancing than other causes of injury (p = 0.003).

CONCLUSION

This study showed that backbend during the dance was the main cause of children's SCI without fracture or dislocation in Chongqing, China. The prognosis was poorer in those children than in other causes of injury. Meanwhile, we have established an association between SBO and SCI for children performing a backbend during the dance.

New Grading System for Cervical Paraspinal Soft Tissue Damage After Traumatic Cervical Spinal Cord Injury Without Major Fracture Based on the Short-T1 Inversion Recovery Mid-Sagittal MRI for Prediction of Neurological Improvements: The STIR-MRI Grade

STUDY DESIGN

Retrospective cohort study.

OBJECTIVE

To develop a grading method for cervical paraspinal soft tissue damage after cervical spinal cord injury (CSCI) without major fracture based on the short T1 inversion recovery (STIR) mid-sagittal magnetic resonance image (MRI) for prediction of neurological improvements.

METHODS

This study included 34 patients with CSCI without major fracture, treated conservatively for at least 1 year and graded using the STIR-MRI Grade. This system consists of anterior grades; A0: no high-intensity area (HIA), A1: linear HIA, and A2: fusiform HIA, and posterior grades; P0: no HIA, P1: HIA not exceeding the nuchal ligament, and P2: HIA exceeding the nuchal ligament, within 24 hours postinjury. The American Spinal Injury Association impairment scale (AIS) and the Japanese Orthopedic Association (JOA) scores were examined.

RESULTS

Anterior grades were not significantly correlated with the AIS and JOA score. At both injury and final follow-up, the AIS in P2 patients was significantly more severe (P = 0.007, P = 0.015, respectively) than that in P0 patients. At the injury, the AIS in P2 patients was significantly more severe (P = 0.008) than that in P1 patients. Among P2 patients only, the JOA score at the injury (1.4 points) did not improve by the final follow-up (3.9 points). The final follow-up JOA score (3.9 points) in P2 patients was significantly lower than that (13.6 points) in P0 patients (P = 0.016).

CONCLUSIONS

Grade P2 led to poor neurological outcomes. The STIR-MRI Grade is a prognostic indicator for neurological improvements past-CSCI.

The influence of timing of surgery in the outcome of spinal cord injury without radiographic abnormality (SCIWORA)

Background

Spinal cord injury without radiographic abnormality (SCIWORA) is a rare traumatic myelopathy. Although surgery is one of the most important treatments, the surgery for SCIWORA is controversial, especially the time of surgery is a topic of controversy. Here, we investigate the effects of difference in duration from injury to surgery on the outcome of SCIWORA.

Methods

This retrospective study was performed in all patients with spinal cord injury admitted to the Third Affiliated Hospital of Hebei Medical University from January 2013 to April 2017. Fifty-seven patients who met the study requirements were divided into 3 groups according to the duration from injury to surgery. Group A (surgery within 3 days of injury) had 18 patients, group B (surgery within 3–7 days) had 18 patients, and group C (surgery later than 7 days) had 21 patients. All the groups were compared with Mann–Whitney U test; the functional improvement of spinal cord was compared and analyzed using the ASIA sports score and ASIA Impairment Scale (AIS).

Results

There was a significant improvement in the long-term AIS (final follow-up) in all the 3 groups compared to before surgery. The final follow-up recovery rate of group C was worse than group A and group B. The curative effect of operation within 7 days was significantly better than the surgery done 7 days later. The recovery rate of group C was worse than group A and B. The ASIA sports score showed that recovery was quicker in the early stage and slow in the later stage.

Conclusions

The optimal schedule of surgical treatment was 3–7 days after injury, which can significantly improve the short-term and long-term follow-up effects. Longer the time to surgery from the time of injury, the worse was the prognosis.

Prognostic factors and optimal management for patients with cervical spinal cord injury without major bone injury

BACKGROUND

Even though the number of patients with cervical spinal cord injury (CSCI) without major bone injury is increased, the treatment with either surgery or conservative measures remains controversial. The aim of this study was to assess its prognostic value in the prediction of useful motor recovery and to clarify whether the patients should be treated surgically are present.

METHODS

We reviewed 63 patients (conservative, n = 36; surgery, n = 27) with CSCI without major bone injury (Frankel A-C). Neurological examination using modified Frankel grade at admission and 6 months after injury and International Stoke Mandeville Games (ISMG) classification at subacute phase after injury, MRI findings including rate of spinal cord compression, extent of cord damage and type of signal intensity change were assessed.

RESULTS

Thirty-five of 63 patients were improved to walk at 6 months after injury. In multivariate analysis, rate of spinal cord compression, extent of cord damage and improvement of ISMG grade were associated with useful motor recovery. There was no difference in the neurological improvement between conservative and surgical groups. However, patients with spinal cord compression of ≥33.2% showed better motor recovery at 6 months post-injury after surgery than those treated conservatively. There was a positive correlation between the improvement of ISMG grade at subacute phase and Frankel grade at 6 months post-injury. It is difficult to obtain satisfactory surgical outcome for patients with Frankel A or B1 on admission and/or extensive spinal cord damage on T2-weighted image.

CONCLUSIONS

Conservative treatment is recommended for patients with CSCI without major bone injury. However, we also recommend surgical treatment to acquire walking ability for patients with spinal cord compression of ≥33.2% and low ISMG grade at subacute phase. Among such patients, careful consideration should be given to patients with Frankel A or B1 and/or extensive spinal cord damage on MRI.

A geriatric patient with spinal cord injury without radiographic abnormality: outcomes and causes

Introduction

Although the prognosis of spinal cord injury without radiographic evidence of abnormality (SCIWORA) depends on the severity of the initial neurological damage, most patients with American Spinal Injury Association impairment scale grade D are expected to recover fully.

Case presentation

An 85-year-old patient with SCIWORA and urinary incontinence, who did not produce the expected response to rehabilitation, displayed the central, peripheral, and autonomic nervous system findings together. Conventional radiography, computed tomography, and even magnetic resonance imaging were unable to explain this complicated neurological condition thoroughly. More in-depth research into the patient's history revealed some sequelae left by urinary surgery and chemotherapy.

Discussion

Comorbidities in geriatric SCIWORA have severe effects on both etiology and prognosis. Furthermore, incontinence in SCIWORA is an essential condition that has not been addressed until now and may play a role in prognosis.

Posttraumatic Spinal Cord Injury without Radiographic Abnormality

“Spinal Cord Injury without Radiographic Abnormality” (SCIWORA) is a term that denotes objective clinical signs of posttraumatic spinal cord injury without evidence of fracture or malalignment on plain radiographs and computed tomography (CT) of the spine. SCIWORA is most commonly seen in children with a predilection for the cervical spinal cord due to the increased mobility of the cervical spine, the inherent ligamentous laxity, and the large head-to-body ratio during childhood. However, SCIWORA can also be seen in adults and, in rare cases, the thoracolumbar spinal cord can be affected too. Magnetic resonance imaging (MRI) has become a valuable diagnostic tool in patients with SCIWORA because of its superior ability to identify soft tissue lesions such as cord edema, hematomas and transections, and discoligamentous injuries that may not be visualized in plain radiographs and CT. The mainstay of treatment in patients with SCIWORA is nonoperative management including steroid therapy, immobilization, and avoidance of activities that may increase the risk of exacerbation or recurrent injury. Although the role of operative treatment in SCIWORA can be controversial, surgical alternatives such as decompression and fusion should be considered in selected patients with clinical and MRI evidence of persistent spinal cord compression and instability.

Chronic post-traumatic intramedullary lesions in dogs, a translational model

Objectives

Post-traumatic intramedullary myelopathies and cavitations are well described lesions following spinal cord injury (SCI) in humans and have been described in histopathological evaluations in dogs. Human intramedullary myelopathies/cavitations are associated with severe initial SCI and deterioration of clinical signs. Canine intervertebral disc extrusions share similarities with SCI in humans. In this descriptive study, magnetic resonance imaging (MRI) findings in spinal cords of dogs suffering from chronic post-traumatic myelopathies, including cavitations, are elucidated. An additional aim of the study was to compare diagnostic imaging and histopathological findings and identify similarities between human and canine chronic post-traumatic spinal cord lesions.

Methods

Thirty-seven dogs with thoracolumbar SCI and one or more 3Tesla MRI investigations more than 3 weeks after SCI were included. Extent of intramedullary lesions and particularly cavitations were evaluated and measured in sagittal and transverse MRI planes. These data were compared with clinical data.

Results

A total of 91.9% of study patients developed chronic intramedullary lesions, and 86.5% developed intramedullary cavitations. Paraplegia without deep pain perception at initial examination was significantly associated with longer chronic myelopathies/cavitations (P = 0.002/P = 0.008), and with larger maximal cross-sectional area (mCSA) of the lesions (P = 0.041/0.005). In addition, a non-ambulatory status after decompressive surgery was also associated with the development of longer intramedullary lesions/cavitations (P<0.001) and larger lesion mCSA (P<0.001/P = 0.012). All dogs with negative outcome developed myelopathies/cavitations. In the group of 21 dogs with positive outcome, 3 did not develop any myelopathies, and 5 did not develop cavitations.

Conclusions

Development of chronic intramedullary lesions/cavitations are common findings in canine SCI. Extensive chronic intramedullary lesions/cavitations reflect a severe initial SCI and negative clinical outcome. This supports the hypothesis that chronic spinal cord changes following SCI in humans share similarities with canine chronic spinal cord changes after spontaneous intervertebral disc extrusion.

Delayed Magnetic Resonance Imaging in Patients With Cervical Spinal Cord Injury Without Radiographic Abnormality

STUDY DESIGN

A prospective imaging study to develop diagnostic criteria.

OBJECTIVE

The aim of this study was to investigate image findings on delayed magnetic resonance imaging (MRI) after the acute phase of spinal cord injury without radiographic abnormality (SCIWORA) and their relationship with symptom severity.

SUMMARY OF BACKGROUND DATA

MRI is used to diagnose acute neurological injury, with increased signal intensity (ISI) and prevertebral hyperintensity (PVH) often seen in patients with SCIWORA; however, changes after the acute phase are unclear.

METHODS

We included 68 patients diagnosed with SCIWORA within 48 hours of injury. We then compared their acute (within 2 days) and delayed (after 2 weeks) MRI images. ISI grade (0-3) and ISI and PVH ranges (relative to the C3 vertebral height) were measured. Neurological status at admission and 2 weeks after injury was assessed by the Japanese Orthopaedic Association scoring system for cervical myelopathy (JOA score) and the American Spinal Injury Association impairment scale.

RESULTS

For acute MRI, the rates of grade 0, 1, and 2 ISI were 4, 54, and 10 patients, respectively. For delayed MRI, the rates of grade 0, 1, and 2 ISI changed to 3, 31, and 34 patients, respectively. ISI ranges reduced in delayed MRI, but there was no significance. PVH ranges were 3.0 ± 1.7 in acute MRI, and reduced to 1.3 ± 0.9 with significant difference (P < 0.001). There were significant negative correlations with the JOA score for ISI grades on delayed MRI only (r = -0.49). However, there were significant negative correlations with the JOA score for the PVH range on both the acute (r = -0.55) and delayed (r = -0.46) MRI.

CONCLUSION

When comparing acute and delayed MRI, there were significant differences in ISI and PVH findings. Delayed MRI also reflected the clinical symptom severity, giving useful information about the state of the spinal cord.

LEVEL OF EVIDENCE

3.

Spinal cord injury without radiographic abnormality (SCIWORA) in adults: MRI type predicts early neurologic outcome

OBJECTIVES

The present study aimed to analyse the clinical and neuroimaging features of a consecutive series of adult patients with spinal cord injury without radiographic abnormality (SCIWORA) receiving early magnetic resonance imaging (MRI), and to apply the recently proposed MRI classification system.

METHODS

Grade of neurologic impairment at admission and discharge was reported according to the American Spinal Injury Association Impairment Scale (AIS). A detailed analysis and categorisation of the extra- and intramedullary MRI findings was performed, and the relationship between imaging type and neurological outcome was described.

RESULTS

Twenty-six adult patients (17 male and 9 female) with SCIWORA were identified (mean age of 52 years). The distribution of the initial AIS grade was 8% A (n=2), 19% B (n=5), 31% C (n=8) and 42% D (n=11) at admission and 15% (n=4) C, 58% (n=15) D and 27% (n=7) E at discharge, respectively. Type I SCIWORA was found in 23% (n=6) and type II in 77% (n=20) (IIa: 0%, IIb: 25%, IIc: 75%). The mean improvement of AIS grade in patients with type I lesions was 1.5 (median 1, range 1-3) and 0.9 (median 1, range 0-3) in type II.

CONCLUSION

The findings underline the prognostic role of early MRI for adult patients with SCIWORA and support the use of the recently introduced MRI classification system.

LEVEL OF EVIDENCE

Prognostic study, level III.