The Adult Spinal Cord Injury Without Radiographic Abnormalities Syndrome: Magnetic Resonance Imaging and Clinical Findings in Adults With Spinal Cord Injuries Having Normal Radiographs and Computed Tomography Studies

Association Between Preoperative Neuropathic Pain and Patient Reported Outcome Measures After Cervical Spinal Cord Decompression Surgery

STUDY DESIGN

A prospective observational study.

OBJECTIVE

To evaluate the impact on surgical outcomes of preoperative neuropathic pain (NeP) assessed by the painDETECT questionnaire (PDQ) administered to participants undergoing cervical decompression surgery for degenerative cervical myelopathy (DCM).

METHODS

Participating patients were separated into the Non-NeP group (preoperative PDQ score ≤ 12), and NeP group (score ≥ 13). They were asked to complete a booklet questionnaire, including NRS for pain, the Short Form-12 for PCS and MCS, EQ-5D, NDI, and COMI-Neck, at baseline and 1 year after surgery. The JOA score for DCM and radiological changes were also evaluated. Propensity scores were used for the generalized linear model to adjust the patients' backgrounds.

RESULTS

Of the 116 patients recruited, 105 completed the one-year follow-up. In this study, 31 (29.5%) and 74 (70.5%) patients in the NeP and non-NeP groups, respectively, were compared. Except for the higher female ratio in the NeP group (64.6% vs 33.2%, P = .009), preoperative demographic data and surgical factors were not significantly different between both groups. The NeP group showed greater neck/arm/hand NRS scores and worse pre- and postoperative NDI/EQ-5D/COMI-Neck scores at baseline and 1 year after surgery, but this was not significant in the MCS/PCS and JOA scores. Change scores of neck/arm/hand NRS scores and MCS/PCS/NDI/EQ-5D/COMI-Neck scores were not significant between both groups.

CONCLUSIONS

The preoperative NeP, assessed by PDQ, was observed in approximately 30% of patients with DCM who underwent decompression surgery. The presence of NeP was associated with worse pre- and postoperative NDI/EQ-5D/COMI-Neck scores.

Computed tomography predictors of adult spinal cord injury without radiographic abnormality

Objective

Elasticity of the skeletal system in children and degenerative changes in adults are responsible for SCIWORA. The purpose of this study was to determine those degenerative changes on CT scan that predispose adults to SCIWORA, their correlation with MRI findings, clinical presentation and recovery.

Materials and Methods

This prospective study was conducted over a period of 1.5 years and 30 patients were enrolled. Apart from the demographic profile, mode of injury, clinical symptoms, ASIA at admission, X-ray, CT and MRI findings were noted. All patients were managed conservatively and were followed up after 3 months. NCCT and MRI findings were correlated with each other, with clinical presentation and with recovery. Recovery was defined as any improvement in ASIA class.

Statistical Analysis

Data was collected and organized. For normally distributed data parametric test and for others non-parametric test was used. Kendall tau rank correlation coefficient was used to measure the ordinal association between two measured quantities.

Results

28 (93.3%) patients were males and 2 (6.7%) were females. Patients with osteoporosis and/or osteophytes (n = 16) had a higher incidence of development of cord edema or non-haemorrhagic contusion (n = 15) (P = 0.028) while patients with canal stenosis and/or ligamentous calcification (n = 14) had a higher incidence of development of haemorrhagic contusion (n = 12) (P = 0.04). Patients with canal stenosis and/or ligament calcification showed significantly less recovery (n = 3) when compared with patients of osteophytes and/or osteoporosis (n = 6) (P = 0.04). Disc abnormality was seen in 1 patient only. 9 patients showed recovery and maximum recovery was seen in ASIA D (n = 4) class while no patient recovered in ASIA A class.

Conclusion

Osteoporosis, osteophytes, canal stenosis and ligament calcification are the factors that predispose adults to SCIWORA. The final outcome seems to be poorer in cases of canal stenosis when compared with osteophytes and osteoporosis. NCCT findings can be used as an adjunct to MRI to predict clinical presentation, severity and recovery in adult SCIWORA.

Diagnosis, management and outcome of Spinal Cord Injury without Radiographic Abnormalities (SCIWORA) in adult patients with trauma: a case series

Background: Spinal cord injury without radiographic abnormality (SCIWORA) in adults causes diagnostic and prognostic dilemma as radiography and/or computed tomography does not clearly detect bone lesions during the initial assessment. Herein, we report our experience on 11 spinal cord injury cases without radiographic abnormality, regarding the clinicoradiological features, management, and outcomes.

Methods: We conducted a case series of adult patients with SCIWORA who were admitted at the level 1 trauma center at Hamad General Hospital from January 2008 to July 2018. All patients underwent initial head and spine X-ray imaging, computed tomography, magnetic resonance imaging, and 12 months of clinical follow-up.

Results: Eleven patients (mean age, 46.5 ± 14.4 years) met the criteria of SCIWORA. The neurologic status on admission and 12 months after hospital discharge were classified according to the American Spinal Injury Association (ASIA) impairment scale (AIS). On admission, 6 (54.5%) patients had ASIA grade C: 2 (18.2%) each had AIS grade D and B and 1 (9.1%) had AIS grade A. Five cases were treated conservatively with rehabilitation and physiotherapy, and five were treated surgically by anterior cervical discectomy with fusion. One patient who declined surgery was managed with a sternal occipital mandibular immobilizer brace and underwent rehabilitation.

Conclusion: SCIWORA requires higher clinical suspicion and thorough neurological and radiologic assessment to prevent secondary spinal cord injuries and complications.

Mechanisms of Stem Cell Therapy in Spinal Cord Injuries

Every year, 0.93 million people worldwide suffer from spinal cord injury (SCI) with irretrievable sequelae. Rehabilitation, currently the only available treatment, does not restore damaged tissues; therefore, the functional recovery of patients remains limited. The pathophysiology of spinal cord injuries is heterogeneous, implying that potential therapeutic targets differ depending on the time of injury onset, the degree of injury, or the spinal level of injury. In recent years, despite a significant number of clinical trials based on various types of stem cells, these aspects of injury have not been effectively considered, resulting in difficult outcomes of trials. In a specialty such as cancerology, precision medicine based on a patient’s characteristics has brought indisputable therapeutic advances. The objective of the present review is to promote the development of precision medicine in the field of SCI. Here, we first describe the multifaceted pathophysiology of SCI, with the temporal changes after injury, the characteristics of the chronic phase, and the subtypes of complete injury. We then detail the appropriate targets and related mechanisms of the different types of stem cell therapy for each pathological condition. Finally, we highlight the great potential of stem cell therapy in cervical SCI.

Expression of AIF and Caspase-3 in New Zealand rabbit with Cervical Spondylosis Myelopathy model

Introduction

Cervical spondylosis myelopathy (CSM) is a clinical syndrome of motoric or sensoric, caused by degenerative process chronically causing narrowing of cervical canal and compressing the spinal cord. The narrowing of canalis spinalis causing chronic compression and disrupting vascular patency in spinal cord. This is worsened on repetitive trauma on flexion, extension and rotation. CSM has an incidence of 4.04 in 100.000 cases per year and the total patients undergoing treatment operative or nonoperatively in year increasing for 7 times. Apoptosis plays a critical role in important biological processes such as morphogenesis, tissue homeostasis, and immunity; furthermore, its aberrant activation or impairment may contribute to a number of diseases. The understanding of CSM pathophysiology from apoptotic pathway is an essential topic to discussed and the treatment of this case in future.

Method

This study uses experimental study with Post test Only Control Group, using New Zealand rabbits. The rabbits given the compression on cervical as high as C5 to induce CSM. The tissue was taken from spinal cord on compression area and histopathology examination was done to calculate apoptotic factor expression such as AIF and caspase-3.

Result

Chronic compression on spinal cord causing myelopathy clinically on animal study, resulted in weakness of all extremities. Based on this study, the expression of AIF and caspase-3 is increasing in compression group in day 14 to day 21.

Conclusion

Chronic compression in spinal cord causing increase in AIF and caspase-3 in day 14 and day 21, and this may be caused by increasing of apoptotic expression on animal study.

Thoracic ligamentum flavum ossification: a rare cause of spinal cord injury without tomographic evidence of trauma in a Caucasian patient. Case report and literature review

INTRODUCTION

Acute spinal cord injury without tomographic evidence of vertebral fracture or dislocation in patients post trauma can represent a diagnostic challenge for the treating physician. The ossification of thoracic ligamentum flavum has been widely published as a cause of thoracic myelopathy, however its association with acute traumatic spinal cord injury is limited to isolated cases.

CASE PRESENTATION

we report a Caucasian 37-year-old man who suffered a high-energy thoracolumbar spine trauma in a motorcycle accident with acute paraplegia. He presented ossification of the ligamentum flavum between the thoracic vertebrae T10 and T11 with a decrease in the diameter of the vertebral canal as the only pathological finding. We treated the patient with early surgical release before 72 h of trauma. We performed a posterior approach with hemilaminectomy and T10-T11 flavectomy. Arthrodesis was done with T10-T11 pedicle screws. Postoperative neurological status improved from ASIA Impairment Scale (AIS) A to C with severe functional dependence.

DISCUSSION

Ossification of the ligamentum flavum should be considered in the differential diagnosis in patients presenting with acute traumatic spinal cord injury without tomographic evidence of trauma. A proper diagnosis in time is the key to decision making and treatment of spinal cord injury. Especially in adult patients, we must consider nontraumatic associated factors that could be involved in the spinal cord injury mechanism, such as ossification of the ligamentum flavum.

Early durotomy with duroplasty for severe adult spinal cord injury without radiographic abnormality: a novel concept and method of surgical decompression

PURPOSE

Treatment options for adult spinal cord injury without radiographic abnormality (ASCIWORA) varied. Compression of ASCIWORA may more likely result from spinal cord lesions such as edema and hemorrhage or contusion. This study aimed to explore the clinical effect of early durotomy with duroplasty decompression in the treatment of severe ASCIWORA.

METHODS

Data of 16 patients with ASCIWORA who underwent early ( < 72 h) posterior laminectomy followed by durotomy with duroplasty decompression from June 2015 to January 2017 were retrospectively analyzed. Patients' prognosis was analyzed by American Spinal Injury Association Impairment Scale (AIS) grades and scores. In 3 patients, intraspinal pressure (ISP) was continuously monitored for 1 week.

RESULTS

Cervical magnetic resonance imaging (MRI) revealed spinal cord edema in 9 patients and suspected hemorrhage or contusion in 7 cases. Pathological manifestations of spinal cord injury found during the operation were consistent with preoperative MRI findings. Of the 16 cases, AIS grade was improved by 1 grade in 3 cases, 2 grades in 11 cases, and 3 grades in 1 case. The AIS scores at the last follow-up were significantly higher than preoperative scores. There was a high level of ISP after laminectomy, whereas ISP continued to decrease steadily after durotomy.

CONCLUSIONS

Durotomy helps thoroughly decompress the spinal cord and improve cerebrospinal fluid circulation in severe ASCIWORA cases. Cervical MRI and pathological investigation of the spinal cord can be used to evaluate and predict the prognosis of ASCIWORA patients. ISP monitoring is an effective method for evaluating intramedullary pressure and decompression. These slides can be retrieved under Electronic Supplementary Material.

Differences in clinical outcomes between traumatic cervical myelopathy and degenerative cervical myelopathy: A comparative study of cervical spinal cord injury without major bone injury and cervical spondylotic myelopathy

A comparative study to examine the surgical outcomes of traumatic cervical myelopathy (TCM) patients was designed. The study aim was to compare the surgical outcomes between TCM and degenerative cervical myelopathy (DCM) and to characterize the preoperative symptoms and postoperative residual symptoms in TCM patients. One hundred consecutive patients with TCM (81 men, 19 women; mean age, 57.7 years; range, 31-79 years) and 100 consecutive patients with DCM (88 men, 12 women; mean age, 58.4 years; range, 36-78 years) were included in this study. All patients were treated by laminoplasty. The pre- and postoperative neurological statuses were evaluated according to the Japanese Orthopaedic Association (JOA) scoring system for cervical myelopathy. The recovery rate (RR) of each function was compared between the two groups. The mean preoperative JOA scores of motor function of the upper extremity in the TCM and DCM groups were 1.9 and 2.3, respectively (P < 0.01). After surgery, the mean RRs of motor function of the upper extremity in the TDM and DCM groups were 36.4% and 55.7%, respectively (P < 0.01) and in the lower extremity were 32.3% and 46.5%, respectively (P < 0.05). The RR for sensory function of the lower extremity was significantly lower in TCM patients than in DCM patients (39.6 vs 68.2, respectively; P < 0.0001). Motor function impairments of the upper and lower extremities and sensory function impairments of the lower extremities after surgery were more persistent in the TCM group than in the DCM group.

Adult Spinal Cord Injury Without Radiographic Abnormality (SCIWORA). Two case reports and a narrative review

The term SCIWORA (Spinal Cord Injury Without Radiographic Abnormality) indicates a clinically appreciable post-traumatic myelopathy in the absence of spinal column findings on radiographs and/or computed tomography (CT), but with pathologic findings at magnetic resonance imaging (MRI) in approximately two-thirds of cases. Affecting mainly children younger than 8 years, SCIWORA has been, however, also described in adult patients, but, due to the uncertainty of classification and frequent co-morbidity, the term “adult SCIWORA” has generated controversy, and some debate is still active. In this article, we report two different cases of adult SCIWORA involving cervical spinal cord, characterized by distinct and peculiar clinical features. A literature review and some clinical suggestions are also reported, mainly focused on the importance of a high level of suspicion in order to achieve a timely diagnosis and optimize the management and, consequently, the outcome of these trauma patients. (www.actabiomedica.it)

MR T2 image classification in adult patients of cervical spinal cord injury without radiographic abnormality: A predictor of surgical outcome

OBJECTIVES

Although patients with cervical spinal cord injury without radiographic abnormality (SCIWORA) present increased signal intensity (ISI) on magnetic resonance imaging (MRI), its degree has not been examined. This study evaluated the clinical effectiveness of MRI-based ISI in adult patients of SCIWORA. Its predictive value for symptom severity was also evaluated.

PATIENTS AND METHODS

One-hundred consecutive SCIWORA patients who had undergone expansive laminoplasty were enrolled. Among them, 79 were male and 21 were female. The mean age was 55 years (range 20-87). All patients underwent MRI in the acute phase, and ISI was classified into three groups based on sagittal T2-weighted MRI: Grade 0, none; Grade 1, light (obscure); and Grade 2, intense (bright). The pre- and postoperative neurological status was evaluated using the Japanese Orthopaedic Association scoring system for cervical myelopathy (JOA score) and the ASIA impairment scale (AIS).

RESULTS

Preoperative MRI showed Grade 0 in 8 patients, Grade 1 in 49 patients, and Grade 2 in 43 patients. There were no differences in age and gender among three groups. The pre- and postoperative JOA scores decreased significantly with an increasing ISI grade. The recovery rate of JOA score decreased with the ISI grade. The ISI grade tended to increase with the pre- and postoperative AIS grades. ISI Grade 2 on MRI was observed in severely paralyzed cases.

CONCLUSIONS

MRI-based ISI classification is correlated with preoperative symptom severity in adult patients with SCIWORA and can be a predictor of surgical outcome.

Thoracic spinal cord injury without radiologic abnormality in a pediatric patient case report

Spinal Cord Injury Without Radiologic Abnormality (SCIWORA) accounts for up to 19% of spinal cord related lesions in pediatric population, mostly comprising the cervical spine. A 2-year-old patient is presented, who suffered a motor-vehicle accident. After being admitted, neither X-Ray nor spinal TC scan showed any structural abnormalities. Neurological examination showed complete sensory and motor loss under T7 as well as bladder and bowel dysfunction. Magnetic resonance imaging (MRI) showed spinal cord lesion extending from T7 to T10. The patient was treated with external immobilization and physical therapy. Thoracic SCIWORA is an uncommon diagnosis that should be considered in pediatric patients who suffer spinal trauma. Spinal cord MRI has proven to be the most accurate modality for diagnosis.

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.

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.

Will the Real SCIWORA Please Stand Up? Exploring Clinicoradiologic Mismatch in Closed Spinal Cord Injuries

OBJECTIVE

This article aims to familiarize radiologists with the terms used to describe clinicoradiologic mismatch in blunt spinal cord injuries, and also assesses MRI findings and their prognostic value for both pediatric and adult patients.

CONCLUSION

Knowledge of the lexicon of spinal cord injury without radiographic abnormality, the spectrum of MRI findings, and imaging predictors of outcome can help render a precise imaging diagnosis and can provide evidence-based prognostic information.

Subacute T1-low intensity area reflects neurological prognosis for patients with cervical spinal cord injury without major bone injury

STUDY DESIGN

A retrospective imaging and clinical study.

OBJECTIVES

To evaluate the relationship between magnetic resonance imaging (MRI) features and neurological prognosis in patients with traumatic cervical spinal cord injury (CSCI) without major bone injury.

METHODS

A total of 72 patients with CSCI without major bone injury were treated conservatively in our hospital. MRI was performed for all patients at admission and 1 month following injury. We measured the antero-posterior and cranio-caudal diameter of intramedullary intensity changed area with T1-weighted images at the injured segment. Neurological evaluations were performed using the American Spinal Injury Association (ASIA) motor score and the modified Frankel grade at the time of admission and discharge.

RESULTS

There was a significant relationship between the antero-posterior diameter ratio of the T1-weighted low-intensity area on MRI at the subacute stage and the ASIA motor score. The optimal threshold of the T1-weighted low-intensity diameter ratio for predicting the patient's ability to walk with or without assistance at discharge was determined to be 46%. Moreover, 96.8% of the patients with <50% T1-weighted low-intensity area recovered to walk with or without a cane at discharge.

CONCLUSION

The T1-low intensity area may be an important predictive factor for the neurological recovery of CSCI without major bone injury.

Significance of SCIWORA in adults

<sec><title>OBJECTIVE:</title><p> Recognizing the importance of SCIWORA in adult age; analyze the usefulness of complementary studies; evaluating therapeutic options; learn about the evolution of the treated patients.</p></sec><sec><title>METHODS:</title><p> A prospective evaluation with a minimum follow-up of 5 years, eight elderly patients with cervical arthrosis and diagnosis of SCIWORA. The Japanese Orthopaedic Association (JOA) scale and ASIA were used on admission and at 6, 12, 24, 36, 48 and 60 months.</p></sec><sec><title>RESULTS:</title><p> The central cord syndrome (CCS) was the neurological condition at admission. One patient recovered after corticosteroid therapy, but later, his disability worsened, and he was operated at 18 months, another patient recovered and a third died. The other patients underwent laminoplasty in the first 72 hours; patients with partial severity condition had a minimum improvement of five points in JAO scale and those with severe conditions died.</p></sec><sec><title>CONCLUSIONS:</title><p> The low-energy trauma can decompensate the relationship between container and content in the spine with asymptomatic arthrosis, and can be devastating to the patient. The diagnosis of intramedullary lesion is made by magnetic resonance imaging. Patients with incomplete deficit undergoing laminoplasty reached at least one level in ASIA score. The potential postoperative complications can be serious.</p></sec>

Spinal Cord Injury without Radiographic Abnormality (SCIWORA) - Clinical and Radiological Aspects

The acronym SCIWORA (Spinal Cord Injury Without Radiographic Abnormality) was first developed and introduced by Pang and Wilberger who used it to define "clinical symptoms of traumatic myelopathy with no radiographic or computed tomographic features of spinal fracture or instability". SCIWORA is a clinical-radiological condition that mostly affects children. SCIWORA lesions are found mainly in the cervical spine but can also be seen, although much less frequently, in the thoracic or lumbar spine. Based on reports from different authors, SCIWORA is responsible for 6 to 19% and 9% to 14% of spinal injuries in children and adults, respectively. Underlying degenerative changes, including spondylosis or spinal canal stenosis, are typically present in adult patients. The level of spinal cord injury corresponds to the location of these changes. With recent advances in neuroimaging techniques, especially in magnetic resonance imaging, and with increasing availability of MRI as a diagnostic tool, the overall detection rate of SCIWORA has significantly improved.

Severe hypothermia secondary to spinal cord injury without radiographic abnormality

Case

A 64-year-old female was found lying by a river. She was unconscious and her lower body was under water. The patient was transported to the emergency room of our hospital. On arrival, her rectal temperature was 24.6°C. We immediately started rewarming and artificial respiration. Five days after admission, rewarming was completed and she became conscious and could communicate. Initially, she had been injured and examination showed paraplegia. Magnetic resonance imaging of her cervical spine showed no findings indicating bony or ligament injury, but there was a T2 high intensity area at C5/6 and C6/7 levels. The patient was diagnosed with spinal cord injury without radiological abnormality.

Outcome

At 5 months post-injury, the patient was able to walk without crutches.

Conclusion

Spinal cord injury might be missed if there are no radiographic abnormalities. Spinal cord injury without radiological abnormality should be considered as a differential diagnosis of accidental hypothermia.

Prediction of prognosis in patients with cervical spinal cord injury without radiologic evidence of trauma using MRI

The purpose of this study was to investigate whether pre- to postoperative changes of increased signal intensity (ISI) of the spinal cord as seen on T2-weighted magnetic resonance imaging (MRI) reflect the surgical outcome in patients with cervical spinal cord injury without radiologic evidence of trauma (SCIWORET). In this study, 54 patients with SCIWORET who underwent expansive laminoplasty were retrospectively analyzed. All patients underwent MRI at an average of 1.9 days (range, 1-5 days) after injury and 7.9 days (range, 6-10 days) postoperatively. The pre- and postoperative range and degree of ISI were measured on computer software using the same sagittal view on T2-weighted MRI. Then, the post-preoperative ratio of range and degree of ISI were calculated. Pre- and postoperative neurologic evaluations were performed according to the criteria proposed by the Japanese Orthopedic Association (JOA). A significant negative correlation existed between the ratio of range of ISI and the recovery rate (r=-0.504, P<.01). The ratio of degree of ISI negatively correlated with the recovery rate, but this was not statistically significant. Patients were divided into 2 groups according to the ratio of degree of ISI: group A included patients with a ratio of degree of ISI of ≤1 (n=24) and group B included patients with a ratio of degree of ISI of >1 (n=30). Patients' mean recovery rate was 65.0%±6.3% in group A and 52.4%±7.4% in group B. A significant difference was found between the 2 groups (P<.001, Student's t test) when comparing recovery rate. The pre- to postoperative changes of the range and degree of ISI significantly reflected prognosis for surgical outcome in patients with SCIWORET.

Predictores en el cuadro SCIWORA del adulto

OBJETIVOS: Analizar cinemática, reconocer cuadro clínico de presentación, describir imágenes, considerar posibilidades terapéuticas y evaluar evolución. MÉTODO: Se analizan 13 pacientes del sexo masculino que presentaron SCIWORA (en inglés Spinal cord injury without radiographic abnormality) entre el 2005 al 2012. Se evalúan cuadro clínico, tratamiento, complicaciones y evolución. RESULTADOS: 10 pacientes mayores de 45 años presentaban signos de espondiloartrosis con mínimos síntomas. De los tres menores de esta edad solo uno presentaba estenosis de canal constitucional asintomática. Todos sufrieron trauma de baja energía. En la resonancia magnética prevaleció el hematoma intramedular y clínicamente todos los pacientes presentaban un síndrome medular central, con cuadro severo (ASIA A-B) en los mayores de 45 años. Siete pacientes fueron tratados inicialmente en forma conservadora; un paciente empeoró y tuvo que ser sometido a intervención quirúrgica 18 meses después y otro falleció en las primeras horas, el resto de los pacientes tuvieron buena evolución. Seis pacientes requirieron cirugía (laminoplastía) en los primeros 10 días; tres fallecieron y el resto mejoro por lo menos un nivel ASIA. CONCLUSIONES: La menor edad, los cuadros leves y el edema intramedular son factores de buen pronóstico y se ven favorecidos con el tratamiento conservador. La mayor edad, la espondiloartrosis y los cuadros severos o progresivos, son factores de mal pronóstico y puede ser necesario su tratamiento quirúrgico.

Use of Fidji cervical cage in the treatment of cervical spinal cord injury without radiographic abnormality

Spinal cord injury without radiographic abnormality (SCIWORA) is a rare condition seen in adults. Many interbody fusion cages have been developed for its treatment, but clinical studies of Fidji cervical cage are still scarce. A total number of five patients (four male and one female) were reviewed. The ages of the patients ranged from 40 to 60 years. All the patients underwent neurological and radiological examinations. Neurological and functional outcomes were assessed on the basis of Frankel's grade. Three of the patients were Frankel B, and the rest two were Frankel C. Magnetic resonance imaging was also performed for the evaluation of spinal cord and intervertebral disc injury. Anterior cervical discectomy and Fidji cervical cage fusion were performed for all. The fusion status was evaluated on the basis of X-rays. After surgical intervention, the clinical symptoms improved for all the patients. The disc interspaces in all the patients achieved solid union at final follow-up. Fidji cervical cage is very efficient in achieving cervical fusion in patients with SCIWORA. There are few complications associated with the use of this cage, and the functional and neurological outcomes are satisfactory.

Clinical and radiological outcomes of spinal cord injury without radiologic evidence of trauma with cervical disc herniation

PURPOSE

To verify the relationship between neurologic deficit after spinal cord injury without radiologic evidence of trauma (SCIWORET) and coexisting cervical disc herniation (CDH).

METHODS

A retrospective review was made to compare the neurologic and radiological outcomes in SCIWORET patients with and without CDH. The neurologic deficit was evaluated by the American Spinal Injury Association (ASIA) scale at admission and last follow-up. The radiological evaluation was performed with magnetic resonance imaging to determine the maximum canal compromise (MCC) and maximum spinal cord compression (MSCC).

RESULTS

Prevalence of CDH was 37.1 % among all 70 SCIWORET cases. There was no significant difference between the CDH and non-CDH group in the ASIA grade at admission and last follow-up and the improvement. Patients with CDH had more substantial MSCC (P < 0.05) but not MCC than those without CDH. No significant correlation was noted between the extent of MSCC or MCC and the initial and final neurologic functions. 12 of 26 patients with CDH underwent anterior cervical discectomy fusion, while the remaining 14 received anterior cervical corpectomy fusion. No significant difference was noted in the neurologic outcomes between the two techniques.

CONCLUSIONS

CDH in most patients with SCIWORET likely occurred before rather than after trauma. CDH caused more severe cord compression but did not aggravate the neurologic injury. The extent of MSCC had no association with the initial neurologic deficit or final recovery.

Soft-tissue damage and segmental instability in adult patients with cervical spinal cord injury without major bone injury

STUDY DESIGN

A retrospective imaging and clinical study.

OBJECTIVE

To evaluate the extraneural soft-tissue damage and its clinical relevance in patients with traumatic cervical spinal cord injury (SCI) without major bone injury.

SUMMARY OF BACKGROUND DATA

To date, various kinds of cervical discoligamentous injuries have been demonstrated on magnetic resonance images in patients with SCI without bony injury. However, it has not been clear whether these magnetic resonance imaging abnormalities are actually related to spinal segmental instability and the patients' neurological status.

METHODS

Eighty-eight adult patients with acute traumatic cervical SCI without major bone injury were examined by flexion-extension lateral radiographs and magnetic resonance images within 2 days after trauma. We excluded patients with flexion recoil injury; therefore, most of the patients included were considered to have sustained a hyperextension injury. Instability of the injured cervical segment was defined when there was more than 3.5-mm posterior translation and/or more than a 11° difference in the intervertebral angle between the site of interest and adjacent segments. The neurological status was evaluated according to the American Spinal Injury Association motor score.

RESULTS

On magnetic resonance images, the damage to the anterior longitudinal ligament and intervertebral disc were apparent in 44 and 37 patients, respectively. Various degrees of prevertebral fluid collection (prevertebral hyperintensity) were demonstrated in 76 patients. These magnetic resonance imaging abnormalities were significantly associated with initial cervical segmental instability as judged by flexion-extension radiographs. Interestingly, the American Spinal Injury Association motor score had a significant association with either magnetic resonance imaging abnormalities or segmental instability but not with the cervical canal diameter.

CONCLUSION

A considerable proportion of the patients with traumatic cervical SCI without major bone injury were shown to have various types of soft-tissue damage associated with cervical segmental instability at the early stages of the injury. The severity of paralysis greatly depended on these discoligamentous injuries.

MRI as an Adjunct to Cervical Spine Clearance: A Utility Analysis

Cervical spine (CS) injury occurs in 1 to 3 per cent of blunt trauma patients. The goal of this study is to evaluate the use of magnetic resonance imaging (MRI) as an adjunct to CS computed tomography (CT) in the presence of persistent pain with a normal physical examination or obtundation. A retrospective chart review was performed on 389 blunt trauma patients undergoing both CS CT and MRI between 2007 and 2010. Abnormal CT findings were found in 199. The remaining 190 patients with normal CT scans underwent MRI for persistent pain (109), neurologic symptoms (57), or obtundation (24). Motor vehicle crashes predominated (50%) followed by falls (19%) and motorcycle crashes (12%). In the patients with persistent pain, CT showed no acute injury (89%) with subsequent MRI demonstrating ligamentous edema or injury not seen on CT in 12 per cent of patients. No patient required an operation for CS instability. All the obtunded patients demonstrated localizing motion of four extremities. MRI of these patients demonstrated ligamentous edema or injury not seen on CT in 20 per cent of patients. No obtunded patient had CS instability or needed operative intervention. A localizing physical examination in conjunction with normal CS CT safely precludes a CS injury requiring cervical fixation. MRI does not add substantially to this decision-making and the cervical collar can be safely removed.

Epidemiological characteristics of adult SCIWORA in Tianjin, China: a preliminary study

INTRODUCTION

The epidemiology of spinal cord injury without radiographic abnormality (SCIWORA) is less frequently reported in adults as compared with children. The annual incidence of SCIWORA was approximately 5.74% per million in Tianjin from 2004 to 2008. Importantly, the epidemiological characteristics of adult SCIWORA may be different from that in children. The aim of this study was to evaluate the radiological-clinical data of patients with adult SCIWORA, and to relatively analyze the epidemiological features.

MATERIALS AND METHODS

Inpatients with cervical SCIWORA who were 16 and above in Tianjin were admitted in municipal hospitals in Tianjin from 2004 to 2008; all the patients received MRI scanning in sagittal and axial views. Epidemiological characteristics, such as injury origin, injury level or severity, neurological scale and MRI feature were acquired.

RESULTS

In total, 203 patients were enrolled. The average age among the adult groups was 55.9 years (men 55.8 years, women 53.6 years). SCIWORA occurred more commonly in adults in the 46-60 age group, and falls were the leading cause of injury (52.2%), followed by vehicular injury (28.6%). The most predominantly affected level was C4/5 (48.7%), followed by C5/6 (30.5%) and C3/4 (12.8%), respectively. The occurrence of central cord syndrome (50.2%) with posterior longitudinal ligament tear (43.8%) was relatively higher than other injury patterns.

CONCLUSION

It is clear that adult cervical SCIWORA is different from that in the pediatric group. Our study highlights the epidemiological properties of adult SCIWORA in Tianjin, China. Differing from other reports, particularly epidemiology study, we represent the first report regarding adult SCIWORA from China. As the geriatric population increases, it is very important to set up an individualized evaluation system based on a nationally scaled epidemiological database. The results from our study will be useful in assisting in the creation of such a database.

Can magnetic resonance imaging reflect the prognosis in patients of cervical spinal cord injury without radiographic abnormality?

STUDY DESIGN

This is a prospective imaging study of adult patients with cervical spinal cord injury without radiographic abnormality (SCIWORA).

OBJECTIVE

The purpose of this study was to investigate the occurrence rate of intramedullary high-signal intensity (increased signal intensity [ISI]) and prevertebral hyperintensity (PVH) in patients with SCIWORA, and examine their relationship to symptom severity and surgical outcome.

SUMMARY OF BACKGROUND DATA

SCIWORA is accompanied by the presence of neurologic symptoms in the absence of positive radiographic findings before the emergence of magnetic resonance imaging (MRI). There are few reports regarding the image features on MRI in these patients.

METHODS

One-hundred consecutive patients with SCIWORA who had undergone expansive laminoplasty were enrolled. There were 79 men and 21 women; the mean age was 55 years (range, 16-87 years). All patients underwent functional x-ray and MRI in the acute phase. On MR T2-weighted imaging sagittal view, occurrence of ISI and PVH was evaluated. Range of ISI and PVH was measured relative to C3 vertebral height. Japanese Orthopaedic Association (JOA) scoring system for cervical myelopathy (JOA score), it's recovery rate, and ASIA impairment scale were used to evaluate neurological status.

RESULTS

ISI was observed in 92 patients and PVH in 90 patients on MRI preoperatively. The range of ISI and PVH tended to increase with scores on the preoperative ASIA scale. ISI and PVH were seen in all patients with ASIA A and B. There was a significant negative correlation between the range of ISI and preoperative JOA score. A significant negative correlation between the range of ISI and recovery rate of JOA score was also seen.

CONCLUSION

ISI and PVH occurred in more than 90% of patients with SCIWORA. The range of ISI significantly reflected symptom severity and prognosis for neurologic outcome.

Spinal cord concussion in a professional ice hockey player

Spinal cord concussion (SCC) is an uncommon injury resulting in transient quadriplegia. The pathophysiology of SCC has been related to underlying spinal canal stenosis in many cases, yet is not always identified. The authors present the case of a professional ice hockey player, without evidence of canal compromise, who sustained an SCC during a regulation game after being struck by a puck in the upper cervical spine. The unusual mechanism of injury is discussed along with a comprehensive review of the literature.

Sciwora na população pediátrica após traumatismo cervical

OBJETIVO: Avaliar a incidência e as características das lesões tipo SCIWORA nos indivíduos até os 16 anos, da área de um hospital central entre 1989 e 2009, após traumatismo cervical. MÉTODOS: Estudo retrospectivo de consulta processual. RESULTADOS: Nove (10,5%) de 86 crianças apresentavam achados clínicos e radiológicos compatíveis com o diagnóstico de SCIWORA. A média de idades foi de 10,7 anos. A causa mais frequente foi o acidente de trânsito. Seis indivíduos eram classificáveis como Frankel D. Os restantes três casos eram Frankel C. Em três doentes a RMN mostrou imagem de lesão. Sete efetuaram metilprednisolona endovenosa e todos mantiveram imobilização com colar cervical até a primeira consulta de seguimento, às 2 semanas. Na alta, os seis doentes que apresentavam Frankel D à entrada melhoraram para um grau E. Dos doentes com Frankel C à entrada, um melhorou até Frankel D e os restantes dois mantiveram-se inalterados em Frankel C. CONCLUSÃO: Em um hospital de referência traumatológica, SCIWORA representa cerca de 10% das lesões cervicais pediátricas. Os défices neurológicos à entrada e a RMN têm valor prognóstico de recuperação. A corticoterapia em dose elevada não está formalmente indicada e não é consensual o tempo de utilização de imobilização ou a sua indicação em todos os SCIWORA.

Gunshot injury without direct injury to the cord may lead to complete paraplegia

Paraplegia following gunshot injury without direct injury to the cord is extremely rare. We describe the case of a 31-year-old woman who was admitted to our trauma resuscitation unit for a penetrating gunshot wound to the abdomen with hemorrhagic shock and paraplegia. Computed tomography (CT) scan of the abdomen showed severe hepatic and pulmonary injuries, with the trajectory of the missile away from the spinal canal. Magnetic resonance imaging (MRI) confirmed a spine contusion from T8 to T10. After 24 months, no significant neurologic improvement occurred. Physicians managing severe trauma should be aware of the possibility to observe severe neurologic deficit following gunshot wounds even without violation of the spinal canal. These injuries might be in relation to the kinetic energy emission to the surrounding tissue by the missile.

Advances in imaging of vertebral and spinal cord injury

BACKGROUND/OBJECTIVES

Imaging technology is an important part of the diagnosis and management of spinal trauma. Indications and findings in post-traumatic imaging of the vertebral column and spinal cord are reviewed.

METHODS

An extensive literature review was performed on the imaging of vertebral and spinal cord injury. Relevant images from a Level I trauma center were included as examples.

RESULTS

Imaging plays an important role in the evaluation of acute and chronic spinal injury. Spinal cord and soft-tissue injuries are best evaluated by magnetic resonance imaging (MRI), whereas spinal fractures are better characterized by computed tomography (CT). Vascular injuries can be evaluated using CT or MR angiography.

CONCLUSIONS

Imaging using CT and MRI is essential in the management of spinal cord injuries, both in the acute and in the chronic settings. MRI shows the status of ligamentous integrity and visualizes internal derangement of the spinal cord. Vascular compromise can be diagnosed by MR and CT angiography. Plain radiography now has a more limited, adjunctive role, and the need for higher risk myelography has been minimized.

Adult Spinal Cord Injury without Radiographic Abnormalities (SCIWORA): Clinical and Radiological Correlations

Background

This study is aimed to determine the clinical and radiological corellations of adult patients with Spinal Cord Injury Without Radiographic Abnormalities (SCIWORA).

Methods

The study population consisted of all adult patients with suspected cervical spine injury. SCIWORA was defined as the presence of either no injury or a neural injury on Magnetic Resonance Imaging (MRI) in the absence of radiographic or Computed Tomographic (CT) Scan findings suggestive of trauma in patients with neurological deficit. Purely extra neural compressive lesions were excluded from the study.

Results

Twelve of ninety seven (12.4%) patients had a neural injury on MRI with normal radiographs and CT scan. These included cord contusion in five cases, cord edema in five cases and cord hemorrhage in two cases. Ten patients were managed conservatively and two patients with disc prolapse were managed surgically. All patients showed at least one ASIA Impairment Scale (AIS) grade improvement and three patients (25%) recovered completely.

Conclusions

Parenchymal spinal cord injury is the single most important determinant in the long term outcome of adult SCIWORA patients. Cord hemorrhage has the worst prognosis and cord edema has the best. Longitudinal signal extension and associated extra neural injuries are also associated with poorer outcomes. Cases with purely neural injuries can be managed conservatively, but associated extra neural injuries, especially disc prolapse and ligamentous instability, warrant surgical management.

Keywords

Post Traumatic Myelopathy; Spinal Cord Trauma; Computed tomography; Magnetic resonance imaging; SCIWORA