Injury to the spinal cord without radiological abnormality (SCIWORA) in adults

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.

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.

Sequential neurological improvements after conservative treatment in patients with complete motor paralysis caused by cervical spinal cord injury without bone and disc injury

OBJECTIVE This study investigated neurological improvements after conservative treatment in patients with complete motor paralysis caused by acute cervical spinal cord injury (SCI) without bone and disc injury. METHODS This study was retrospective. The authors evaluated neurological outcomes after conservative treatment of 62 patients with complete motor paralysis caused by cervical SCI without bone and disc injury within 72 hours after trauma. The sequential changes in their American Spinal Injury Association Impairment Scale (AIS) grades were reviewed at follow-up 24-72 hours, 1 week, and 1, 3, and 6 months after treatment. RESULTS Of the 31 patients with a baseline AIS grade of A, 2 (6.5%) patients improved to grade B, 5 (16.1%) improved to grade C, and 2 (6.5%) improved to grade D by the 6-month follow-up. The 22 (71.0%) patients who remained at AIS grade A 1 month after injury showed no neurological improvement at the 6-month follow-up. Of the 31 patients with a baseline AIS grade of B, 12 (38.7%) patients showed at least a 1-grade improvement at the 1-month follow-up; 11 (35.5%) patients improved to grade C and 16 (51.6%) patients improved to grade D at the 6-month follow-up. CONCLUSIONS Even in patients with complete motor paralysis caused by cervical SCI without bone and disc injury within 72 hours after trauma, approximately 30% of the patients with an AIS grade of A and 85% of the patients with an AIS grade B improved neurologically after conservative treatment. It is very important to recognize the extent of neurological improvement possible with conservative treatment, even for severe complete motor paralysis.

Effects of Treatment of Cervical Spinal Cord Injury without Fracture and Dislocation in A Medium-to Long-Term Follow-Up Study

OBJECTIVES

The purpose of this study is to evaluate the clinical effects of cervical spinal cord injury without fracture and dislocation (CSCIWFD) treatment in a medium-to long-term follow-up study. The clinical treatment of CSCIWFD is also discussed.

METHODS

A consecutive series of 42 CSCIWFD patients with complete follow-up data were retrospectively analyzed. Among these patients, 9 received conservative treatment and 33 underwent surgical treatment from June 2009 to March 2013. Neurologic functional recovery was evaluated according to the Japanese Orthopaedic Association (JOA) scoring system and the Frankel grade on admission, during hospital discharge, and at final follow-up. The average follow-up time was 49.6 months (range, 36-68 months).

RESULTS

The 33 cases with surgical treatment showed significantly higher JOA scores at the final follow-up than those with conservative treatment. In addition, statistically significant differences were found in all of the follow-up visits between patients whose operations were performed within 7 days after injury and those performed after 7 days (P < 0.05). Early surgery promoted spinal cord recovery. However, JOA scores at 49.6 months postsurgery were not significantly different between patients treated via the anterior approach and those treated via the posterior approach (P > 0.05). On the basis of Frankel functional classification, differences were also significant between surgical treatment and conservative treatment at all of the follow-up visits.

CONCLUSIONS

Early surgical treatment for CSCIWFD can directly relieve spinal cord compression. The medium-to long-term follow-up revealed that surgery clearly promotes decompression.

Neurological and spinal manifestations of the Ehlers-Danlos syndromes

The Ehlers-Danlos syndromes (EDS) are a heterogeneous group of heritable connective tissue disorders characterized by joint hypermobility, skin extensibility, and tissue fragility. This communication briefly reports upon the neurological manifestations that arise including the weakness of the ligaments of the craniocervical junction and spine, early disc degeneration, and the weakness of the epineurium and perineurium surrounding peripheral nerves. Entrapment, deformation, and biophysical deformative stresses exerted upon the nervous system may alter gene expression, neuronal function and phenotypic expression. This report also discusses increased prevalence of migraine, idiopathic intracranial hypertension, Tarlov cysts, tethered cord syndrome, and dystonia, where associations with EDS have been anecdotally reported, but where epidemiological evidence is not yet available. Chiari Malformation Type I (CMI) has been reported to be a comorbid condition to EDS, and may be complicated by craniocervical instability or basilar invagination. Motor delay, headache, and quadriparesis have been attributed to ligamentous laxity and instability at the atlanto-occipital and atlantoaxial joints, which may complicate all forms of EDS. Discopathy and early degenerative spondylotic disease manifest by spinal segmental instability and kyphosis, rendering EDS patients prone to mechanical pain, and myelopathy. Musculoskeletal pain starts early, is chronic and debilitating, and the neuromuscular disease of EDS manifests symptomatically with weakness, myalgia, easy fatigability, limited walking, reduction of vibration sense, and mild impairment of mobility and daily activities. Consensus criteria and clinical practice guidelines, based upon stronger epidemiological and pathophysiological evidence, are needed to refine diagnosis and treatment of the various neurological and spinal manifestations of EDS. © 2017 Wiley Periodicals, Inc.

Clinical Influence of Cervical Spinal Canal Stenosis on Neurological Outcome after Traumatic Cervical Spinal Cord Injury without Major Fracture or Dislocation

Study Design

Retrospective case series.

Purpose

To clarify the influence of cervical spinal canal stenosis (CSCS) on neurological functional recovery after traumatic cervical spinal cord injury (CSCI) without major fracture or dislocation.

Overview of Literature

The biomechanical etiology of traumatic CSCI remains under discussion and its relationship with CSCS is one of the most controversial issues in the clinical management of traumatic CSCI.

Methods

To obtain a relatively uniform background, patients non-surgically treated for an acute C3–4 level CSCI without major fracture or dislocation were selected. We analyzed 58 subjects with traumatic CSCI using T2-weighted mid-sagittal magnetic resonance imaging. The sagittal diameter of the cerebrospinal fluid (CSF) column, degree of canal stenosis, and neurologic outcomes in motor function, including improvement rate, were assessed.

Results

There were no significant relationships between sagittal diameter of the CSF column at the C3–4 segment and their American Spinal Injury Association motor scores at both admission and discharge. Moreover, no significant relationships were observed between the sagittal diameter of the CSF column at the C3–4 segment and their neurological recovery during the following period.

Conclusions

No relationships between pre-existing CSCS and neurological outcomes were evident after traumatic CSCI. These results suggest that decompression surgery might not be recommended for traumatic CSCI without major fracture or dislocation despite pre-existing CSCS.

Treatment of Atypical Central Cord Injury Without Fracture or Dislocation

In general, spinal cord injury without radiological abnormality (SCIWORA) with spondylosis is considered to be a central cord injury. This article describes the clinical features and surgical outcomes of atypical central cord injury in patients with spondylotic SCIWORA (ACCISS). Fifty-two patients were enrolled in the study from January 2006 to December 2011. Diagnoses were made from imaging (computed tomography, magnetic resonance imaging) and clinical findings. The neurologic status of patients was assessed using the American Spinal Injury Association (ASIA) score and Japanese Orthopaedic Association (JOA) score. Patients were divided into 3 groups with regard to the timing of surgery after injury: those undergoing early surgery (less than 24 hours after injury), those undergoing late surgery (more than 24 hours after injury but during initial admission to the hospital and within 3 weeks from injury), and those undergoing delayed surgery (during second admission to the hospital, within 3 months but later than 3 weeks from injury). Seventeen patients underwent early surgery, 22 underwent late surgery, and 13 underwent delayed surgery. Mean follow-up was 15 months (range, 5-33 months). Patients in all groups showed very good recovery after surgical treatment, with the recovery rate of ASIA and JOA scores being 68.6% and 60.2%, respectively. No significant difference in recovery rate was found between the groups with regard to the timing of surgery. This retrospective study supports the notion that surgical decompression is effective in the treatment of patients with ACCISS. Timing of surgery (less than 3 months) was not significantly associated with neurologic recovery.

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>

Emergency department evaluation and treatment of cervical spine injuries

Most spinal cord injuries involve the cervical spine, highlighting the importance of recognition and proper management by emergency physicians. Initial cervical spine injury management should follow the ABCDE (airway, breathing, circulation, disability, exposure) procedure detailed by Advanced Trauma Life Support. NEXUS (National Emergency X-Radiography Utilization Study) criteria and Canadian C-spine Rule are clinical decision-making tools providing guidelines of when to obtain imaging. Computed tomography scans are the preferred initial imaging modality. Consider administering intravenous methylprednisolone after discussion with the neurosurgical consultant in patients who present with spinal cord injuries within 8 hours.

Traumatic atypical tetraplegia without radiologic abnormalities including magnetic resonance imaging in an adult: a case report

Although spinal cord injury without radiographic abnormality (SCIWORA) literally refers to the specific type of spinal cord injury, however, some extents of spinal cord injuries can be detected by magnetic resonance imaging (MRI) in most of cases. We introduce an atypical case of spinal cord injury without radiologic abnormality. A 42-year-old male tetraplegic patient underwent MRI and computed tomography, and no specific lesions were found in any segments of the spinal cord. Moreover, the tetraplegic patient showed normal urodynamic function despite severe paralysis and absent somatosensory evoked potentials from the lower limbs.

Spinal cord injury without radiological abnormality in adult thoracic spinal trauma

Introduction:

Spinal cord injury without radiological abnormality (SCIWORA) is a rare entity and usually involves the cervical spine. Thoracic spine involvement is very rare due to the stability provided by the rib cage. The mechanisms of injury and pathophysiology are still debatable.

Case Presentation:

We present a case of an adult male who had road traffic accident and presented with paraplegia. The initial radiological investigations carried out in the emergency department were reported to be normal, however, subsequent magnetic resonance imaging revealed spinal cord contusion without vertebral column disruption. The patient recovered partially with conservative treatment measures including bed rest and methylprednisolone.

Conclusions:

Spinal trauma patients presenting with neurological deficit but no radiological abnormality should be treated as a case of SCIWORA.

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.

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.

Clinical relationship between cervical spinal canal stenosis and traumatic cervical spinal cord injury without major fracture or dislocation

PURPOSE

The purpose of the study was to evaluate the clinical relationship between cervical spinal canal stenosis (CSCS) and incidence of traumatic cervical spinal cord injury (CSCI) without major fracture or dislocation, and to discuss the clinical management of traumatic CSCI.

METHODS

Forty-seven patients with traumatic CSCI without major fracture or dislocation (30 out of 47 subjects; 63.83 %, had an injury at the C3-4 segment) and 607 healthy volunteers were measured the sagittal cerebrospinal fluid (CSF) column diameter at five pedicle and five intervertebral disc levels using T2-weighted midsagittal magnetic resonance imaging. We defined the sagittal CSF column diameter of less than 8 mm as CSCS based on the previous paper. We evaluated the relative and absolute risks for the incidence of traumatic CSCI related with CSCS.

RESULTS

Using data from the Spinal Injury Network of Fukuoka, Japan, the relative risk for the incidence of traumatic CSCI at the C3-4 segment with CSCS was calculated as 124.5:1. Moreover, the absolute risk for the incidence of traumatic CSCI at the C3-4 segment with CSCS was calculated as 0.00017.

CONCLUSIONS

In our results, the relative risk for the incidence of traumatic CSCI with CSCS was 124.5 times higher than that for the incidence without CSCS. However, only 0.017 % of subjects with CSCS may be able to avoid developing traumatic CSCI if they undergo decompression surgery before trauma. Our results suggest that prophylactic surgical management for CSCS might not significantly affect the incidence of traumatic CSCI.

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.

Lower thoracic spinal cord injury without radiographic abnormality in an amateur rugby player

A 37-year-old man, amateur rugby player sustained a hyperextension injury to his lower thoracic spine during a scrum collapse. The patient developed extreme hyperpathia in the T10-12 dermatome, and parasthesia from T12 to S1 in the left lower limb. Medical Research Council grade 5 power was regained rapidly within minutes of the accident, and the hyperpathia resolved within a week. MRI showed contusion of the spinal cord at T10 level but no associated osseoligamentous injury. Six months later, parasthesia and subjective weakness remained in the left lower limb. To our knowledge, this is the first description of a lower thoracic spinal cord injury without radiographic abnormality following an isolated low-energy injury in a skeletally mature patient.

Establishment of parameters for congenital stenosis of the cervical spine: an anatomic descriptive analysis of 1,066 cadaveric specimens

PURPOSE

Congenital cervical stenosis (CCS) occurs when the bony anatomy of the cervical canal is smaller than expected in the general population predisposing an individual to symptomatic neural compression. No studies have defined CCS based on the normal population. The diagnosis is currently made based on clinical impression from radiographic studies. The aim of this study is to establish parameters that are associated with CCS, based on anatomic measurements on a large sample of skeletal specimens.

METHODS

From the Hamann-Todd collection at the Cleveland Museum of Natural History, 1,066 skeletal specimens were selected. Digital calipers were used to measure the sagittal canal diameter (SCD), interpedicular distance (IPD), and pedicle length. Canal area at each level was calculated using a geometric formula. A standard distribution was created and values that were 2 SD below mean were considered as congenitally stenotic. An analysis of deviance was performed to identify parameters that were associated with CCS. Regression analysis was used to determine odds ratios (OR) for CCS using these parameters.

RESULTS

CCS was defined at each level as: C3/4 = 1.82 cm(2), C4/5 = 1.80 cm(2), C5/6 = 1.84 cm(2), C6/7 = 1.89 cm(2), C7/T1 = 1.88 cm(2). Values of SCD < 13 mm and IPD < 22.5 mm were associated with CCS and yielded sensitivities and specificities of 88-100 % at each level. Logistic regression demonstrated a significant association between these parameters and presence of CCS with OR > 18 at each level.

CONCLUSIONS

Based on our study of a large population of adult skeletal specimens, we have defined CCS at each level. Values of SCD < 13 mm and IPD < 23 mm are strongly associated with the presence of CCS at all levels.

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.

Severe hypothermia in a patient with spinal cord injury without radiological abnormality

We report a case of a 64-year-old caucasian male who was transported to the emergency department (ED) after being found unconscious on the side of the road. On arrival to the ED the patient went into ventricular fibrillation and advanced cardiac life support was started at that time. Thirty minutes into the resuscitation, after multiple rounds of code drugs and defibrillation attempts, the patient was found to be severely hypothermic with a rectal temperature of 24.9°C (76.9°F). Through the use of passive and active re-warming measures the patient's temperature increased enough to allow successful cardioversion and stabilization. Within minutes of cardiac stabilization the patient regained consciousness and was able to follow commands, but was found to be paralyzed from the neck down. Subsequent CT scans revealed no acute fractures, subluxations or acute spinal cord injury. This case represents the rare finding of severe hypothermia secondary to occult spinal cord injury. Case report was taken from case at Bayfront Hospital, St. Petersburg, Florida.

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.

Surgical management of post-SCIWORA spinal deformities in children

BACKGROUND

Patients with spinal cord injury without radiographic abnormality (SCIWORA) are prone to develop spinal deformities. The purpose of this study is to report on the clinical and radiological features of post-SCIWORA spinal deformities.

METHODS

Four patients with SCIWORA and spinal deformities requiring surgery were analyzed clinically and radiographically.

RESULTS

All four SCIWORA patients developed progressive neuromuscular scoliosis. There were 2 males and 2 females. The mean age at spinal cord injury was 3.9 years (range 6 months to 7 years). Spinal deformity was first noticed at a mean of 17 months after their initial injury (range 9 months to 2 years), and surgical intervention was performed at a mean of 6.5 years following their injury (range 4-11 years). The mean preoperative curve was 54° (range 50-62°). The mean postoperative curve was 9.5° (range 5-16°). The level of injury was T5 in two patients, and T10 and L2 in one patient each. All but the lumbar level injury patient had complete paraplegia. One patient with complete injury (T10) and another with incomplete injury (L2) improved neurologically and were able to walk with the aid of orthoses and crutches. Pelvic obliquity improved in all patients following spinal reconstruction surgery, and none of the patients required additional surgery for spinal deformity. The mean postoperative follow-up was 51.75 months (range 24-93 months).

CONCLUSIONS

Long scoliotic curves extending to the pelvis should be expected in SCIWORA. Early intervention may prevent severe deformities. Modern instrumentation techniques employing pedicle screws provided satisfactory correction, improved hip subluxation, and did not adversely affect the ambulatory ability or functional level of the patients in this series.

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.

Does ossification of the posterior longitudinal ligament affect the neurological outcome after traumatic cervical cord injury?

STUDY DESIGN

Retrospective outcome measurement study.

OBJECTIVES

The purpose of this study is to assess whether ossification of the posterior longitudinal ligament (OPLL) affects neurologic outcomes in patients with acute cervical spinal cord injury (SCI).

SUMMARY OF BACKGROUND DATA

There have so far been few reports examining the relationship between OPLL and SCI and there is controversy regarding the deteriorating effects of OPLL-induced canal stenosis on neurologic outcomes.

METHODS

To obtain a relatively uniform background, patients nonsurgically treated for an acute C3-C4 level SCI without any fractures or dislocations of the spinal column were selected, resulting in 129 patients. There were 110 men and 19 women (mean age was 61.1 years), having various neurologic conditions on admission (American Spinal Injury Association [ASIA] impairment scale A, 43; B, 16; C, 58; D, 12). The follow-up period was the duration of their hospital stay and ranged from 50 to 603 days (mean, 233 days). The presence of OPLL, the cause of injury, the degree of canal stenosis (both static and dynamic), and the neurologic outcomes in motor function, including improvement rate, were assessed.

RESULTS

Of the 129 patients investigated in this study, OPLL was identified at the site of the injury in 13 patients (10.1%). In this OPLL+ group, the static and dynamic canal diameters at C3 and C4 were significantly smaller than those of the remaining 116 patients (OPLL- group). However, no significant difference was observed between the 2 groups in terms of ASIA motor score both at the time of administration and discharge, and the mean improvement rate in ASIA motor score was 55.5 +/- 9.0% in OPLL+ group, while it was 43.1 +/- 2.8% in the OPLL-group. Furthermore, no significant correlation was observed between the static/dynamic canal diameters and neurologic outcome in all 129 patients.

CONCLUSION

No evidence was found for OPLL to have any effect on the initial neurologic status or recovery in motor function after traumatic cervical cord injury, suggesting that the neurologic outcome is not significantly dependent on canal space.

Use of the finite element method to study the mechanism of spinal cord injury without radiological abnormality in the cervical spine

STUDY DESIGN

Three-dimensional C3-C5 and C3-C4 finite element (FE) models were used to analyze biomechanical responses under compression and extension moments.

OBJECTIVE

To validate our models against other published FE models and experimental studies and improve our understanding of the mechanism of spinal cord injury without radiologic abnormality (SCIWORA) in cervical spine.

SUMMARY OF BACKGROUND DATA

The underlying mechanism for SCIWORA remains unclear. We hypothesized that the incidence of SCIWORA was associated with facet joint morphology and bony pincers mechanism.

METHODS

FE models were constructed using data from computed tomography scans of the cervical spine of a healthy young man. The C3-C5 FE models consisted of bony vertebra, articulating facets, and intervertebral disc. Facet surfaces were oriented at 30 degrees , 45 degrees , and 60 degrees from the transverse plane. These models were constrained in all degrees of freedom at the C5 inferior vertebral body and a uniform axial displacement of 1 mm was applied to the superior nodes of C3. Three model versions changed to C3-C4 models with ligaments. The C4 inferior-most bony nodes were constrained, whereas the top of the C3 superior-most bony nodes were left unconstrained. These models were subjected to an axial compression load of 73.6 N with extension moments (1.8 Nm) applied to the upper bony section C3 vertebra. The predicted responses were compared with published results.

RESULTS

The response under axial compression was validated and corresponded closely with published results. Under sagittal moment, the C3-C4 FE model with 60 degrees facet was the most flexible in extension (4.22 degrees ). Total translation was highest for the model with 60 degrees facet.

CONCLUSION

The load displacement response of C3-C5 FE models was in agreement with published data. We confirmed that the C3-C4 FE model with 60 degrees facet was the most susceptible to SCIWORA and that the bony pincers mechanism was dependent on facet joint inclination.

Spinal cord injury without radiological abnormality in an infant with delayed presentation of symptoms after a minor injury

STUDY DESIGN

We present a very rare case of an infant with delayed presentation of spinal cord injury without radiologic abnormality (SCIWORA) after a minor injury.

OBJECTIVE

To emphasize the importance of spinal evaluation with MRI in selected cases, even after minor injuries, especially in infants.

SUMMARY OF BACKGROUND DATA

SCIWORA arises mainly in infants and children during accidental trauma or after sport injury. However, it has been very rare for a 6-day-delayed infant SCIWORA after a minor injury.

METHODS

An infant presented with transient nausea and vomiting after falling from a baby-rocking horse of less than 30-cm height. The patient demonstrated right hemiparesis 6 days later. Plain cervical radiographs and brain and cervical spine computed tomograms (CT) were normal, but the cervical magnetic resonance imaging (MRI) demonstrated a high signal in the T2-weighted image of the lower cervical cord, and a neck collar was applied.

RESULTS

A follow-up cervical MRI 1 month later showed that the high signal of the lower cervical cord had disappeared. Another follow-up cervical MRI 12 months later also showed normal radiographic findings but there still remained mild weakness of the right lower extremities.

CONCLUSION

The authors present a rare case of infant SCIWORA who developed delayed neurologic symptoms 6 days after a minor injury and suggest that spinal evaluation with MRI could be warranted in the selected case even after minor injuries, especially in infants.

Fall downstairs: accident, homicide or natural death?

In homicide cases a clear anatomical or toxicological cause of death is normally evident. In the following a case is described where, without clear anatomical or toxicological cause of death, the husband of the deceased-a trained anaesthesiologist-was charged with murder. Suspicion was raised since the autopsy findings did not correspond to a fatal fall downstairs but instead could be definitely ruled out as cause of death, since intracranial bleedings and cerebral contusions, the leading causes of death in fatal falls downstairs, were missing. Further suspicion was raised since electrocardiograms (ECGs), previously stated by the accused to have been recorded personally from his wife during cardiopulmonary resuscitation (CPR), were obviously faked. Additionally, an ampule of succinylcholine was missing from his emergency case. In a trial lasting more than three quarters of a year with several witnesses and experts heard by the court, the cause of death remained unclear. However, a natural cause of death and a fatal fall downstairs were ruled out. Subsequently the husband admitted during the trial to have killed his wife without elaborating on the circumstances for legal reasons. He was sentenced to prolonged imprisonment. Of special importance was that, based on the knowledge of typical autopsy findings in fatal falls downstairs, a lethal fall downstairs could be ruled out. Therefore even negative autopsy findings are of great forensic importance.

Objective assessment of cervical spinal cord injury levels by transcranial magnetic motor-evoked potentials

BACKGROUND

The neurologic examination serves as the optimal method to record the level of spinal cord injury (SCI). However, this test is subject to interexaminer variability. To address this shortcoming, we describe a technique that uses transcranial magnetic motor-evoked potentials (tcMMEPs) and dermatomal somatosensory-evoked potentials (d-SSEPs) to more accurately measure the precise level of SCI.

METHODS

Two groups of subjects were studied: (1) complete cervical SCI (n = 10) and (2) neurologically intact volunteers (n = 10). Two additional patients were evaluated: one with a cervical central spinal cord syndrome and another with a head injury with a suspected cervical SCI. Each subject underwent upper extremity tcMMEPs and d-SSEPs.

RESULTS

Transcranial magnetic motor-evoked potentials were elicited from all upper limb myotomes (C4-T1, bilaterally) in neurologically intact volunteers (20 sides). The level of injury was determined using tcMMEPs by observing the lowest level of measurable response. The level of injury obtained using tcMMEPs was the same as that determined by neurologic examination in 13 (65%) of the 20 sides. In 7 sides, tcMMEP responses were obtained 1 level lower than that assessed by physical examination. Dermatomal somatosensory-evoked potentials were obtained from all dermatomes of volunteers tested in the laboratory compared with only 5 of the 9 patients with SCI who underwent d-SSEP testing.

CONCLUSION

Testing using tcMMEPs provides an objective supplement to the neurologic examination after acute cervical SCI. Dermatomal somatosensory-evoked potentials were of limited value in determining the level of cervical SCI.

Spiral Computed Tomography for the Initial Evaluation of Spine Trauma: A New Standard of Care?

BACKGROUND

Although spiral computed tomographic scanning (SCT) is frequently used for spinal imaging in injured patients, many trauma centers continue to rely on plain film radiography (PFR). The purpose of this study was to determine the effects of a trauma center's transition from PFR to SCT for initial spine evaluation in trauma patients by comparing diagnostic sensitivity, time required for radiographic imaging, costs, charges, and radiation exposure.

METHODS

Registry-based review of all trauma patients evaluated for spinal trauma during two three-month intervals, one before (1999, "X-ray Group"), and one after (2002, "CT Group") adopting SCT as the initial spinal imaging method. Demographic data, mechanism of injury, Injury Severity Score (ISS), the presence and location of spine fractures, and the results of all spine imaging were recorded. The dates and diagnostic sensitivity for spine fractures, time for initial imaging, costs, and charges were compared between groups. Radiation exposure associated with both SCT and PFR of the spine was measured.

RESULTS

There were 254 patients in the X-ray Group and 319 in the CT Group, with similar demographic data, ISS, mechanism of injury, and incidence of spine fractures. Sensitivity in the detection of spine fractures was 70% (14 out of 20) in the X-ray Group compared with 100% (34 out of 34) for the CT Group (p < 0.001). Mean time in the radiology department during initial evaluation decreased significantly in the CT Group compared with the X-ray Group (1.0 hours vs. 1.9 hours; p < 0.001). SCT of the spine was associated with higher mean overall spinal imaging charges than PFR (4,386 dollars vs. 513 dollars, p < 0.001), but a similar mean overall spinal imaging cost per patient (172 dollars vs. 164 dollars). Radiation exposure was higher with SCT versus PFR for cervical spine imaging (26 mSv vs. 4 mSv) but SCT involved lower levels of exposure than PFR for thoracolumbar imaging (13 mSv vs. 26 mSv).

CONCLUSIONS

SCT is a more rapid and sensitive modality for evaluating the spine compared with PFR and is obtained at a similar cost. The advantages of SCT suggest that this readily available diagnostic modality may replace PFR as the standard of care for the initial evaluation of the spine in trauma patients.

Applications of diffusion-weighted MRI in thoracic spinal cord injury without radiographic abnormality

Diffusion-weighted MRI (DWI) has been proposed as a method to evaluate the integrity of white matter tracts in the spinal cord. The integrity of the spinal cord reflects the exact stage of traumatic injury. The purpose of this study was to evaluate the diagnostic value of DWI in SCIWORA in the thoracic spine. A total of five patients with thoracic SCIWORA underwent MRI and DWI within 48 h of injury. DWIs were obtained with a single-shot fast spin-echo (SSFSE) sequence; TI- and T2-weighted images were obtained with spin echo. Consistency among the clinical presentation, outcome, MRI and DWI was analysed. There was complete injury in one patient and partial in four patients. Four patients showed hypointense T1-weighted signal and hyperintense T2-weighted signal, and one patient had no changes on MRI. All patients showed hyperintense signal on DWI. Two patients made good recoveries (ASIA grades D and E), one had a moderate recovery (ASIA grade C), and two showed minimal or no improvement (ASIA grade A or B) in neurological function. Patients with no cord changes on MRI showed abnormal signals on DWI. It is likely that in the future DWI may provide important information complimentary to conventional MRI and allow a better prognostic evaluation of recovery from SCIWORA.

Magnetic resonance imaging of spinal cord trauma: a pictorial essay

Assessing a patient with clinical signs of acute spinal cord trauma is an emergency. A radiological work-up is crucial in determining management, and magnetic resonance imaging (MRI) is the modality of choice. It should therefore be performed immediately, preferably within 3 hours, even when plain radiography does not show an abnormality. By choosing an appropriate imaging protocol, it is possible to assess the spinal cord, joints, muscles, ligaments and bone marrow of the spine. Moreover, early MRI findings assist in determining functional prognosis. A major limitation to early MRI is that the examination is usually restricted to stable trauma patients because of the difficulties in monitoring ventilated patients during scanning. However, when an anaesthesiologist with experience in MRI and MR-compatible monitoring equipment is available, even these patients can be safely examined. MRI is also indicated for the evaluation of patients with late complications and sequelae following spinal cord trauma, since many of these chronic lesions are potentially treatable.

Diagnosis and prognostication of adult spinal cord injury without radiographic abnormality using magnetic resonance imaging: analysis of 40 patients

BACKGROUND

Spinal cord injury without radiographic abnormality (SCIWORA) is not uncommon among middle-aged and elderly people. It is less reported in adults as compared with children. This study was undertaken to find the incidence, magnetic resonance imaging (MRI) changes, and outcome of SCIWORA in adults and to demonstrate the prognostic value of MRI in SCIWORA.

MATERIALS AND METHODS

Forty adult patients who sustained SCIWORA for a period of 2 years (January 1999 to December 2000) were admitted to our hospital. Methylprednisolone was given in therapeutic doses, for a period of 24 hours, to those arriving within 6 hours of injury. Magnetic resonance imaging was performed within 72 hours of admission to the hospital. In all patients, sagittal, axial, and coronal T1, spin, and T2 images of MRI were obtained. Clinical status of the patient at the time of admission and discharge was correlated with MRI.

RESULTS

Four patients (10%), who were in Frankel grade D, with no demonstrable injury on MRI, improved to Frankel grade E at the time of discharge. Two patients (5%) with cord edema and extraneural injury improved to a useful neurological grade (Frankel grades D or E), whereas 13 patients (32.5%) with MRI features of cord contusion and hemorrhage did not achieve useful neurological function.

CONCLUSION

Spinal cord injury without radiographic abnormality contributes 12% of cases of spinal cord injury. Magnetic resonance imaging is the investigation of choice, having diagnostic and prognostic value because it demonstrates neural and extraneural injuries and helps to pick up surgically correctable abnormality. Patients with minimal cord changes on MRI have the best outcome followed by those with cord edema. Patients with parenchymatous hemorrhage and contusion on MRI fare badly.

Cervical spine clearance: a review

Ethical concerns have hindered any randomised control blinded studies on the imaging required to assess the cervical spine in an unconscious trauma patient. The issue has been contentious for many years and has resulted in burgeoning but inconclusive guidance. MRI and multislice CT technology have made rapid advances, but the literature is slower to catch up. Never the less there appears to be an emerging consensus for the multiply injured patient. The rapid primary clinical survey should be followed by lateral cervical spine, chest and pelvic radiographs. If a patient is unconscious then CT of the brain and at least down to C3 (and in the USA down to D1) has now become routine. The cranio-cervical scans should be a maximum of 2 mm thickness, and probably less, as undisplaced type II peg fractures, can be invisible even on 1 mm slices with reconstructions. If the lateral cervical radiograph and the CT scan are negative, then MRI is the investigation of choice to exclude instability. Patients with focal neurological signs, evidence of cord or disc injury, and patients whose surgery require pre-operative cord assessment should be imaged by MRI. It is also the investigation of choice for evaluating the complications and late sequela of trauma. If the patient is to have an MRI scan, the MR unit must be able to at least do a sagittal STIR sequence of the entire vertebral column to exclude non-contiguous injuries, which, since the advent of MRI, are now known to be relatively common. Any areas of oedema or collapse then require detailed CT evaluation. It is important that cases are handled by a suitably skilled multidisciplinary team, and avoid repeat imaging due to technical inadequacies. The aim of this review is to re-examine the role of cervical spine imaging in the context of new guidelines and technical advances in imaging techniques.

[Disruption of the thoracic spinal cord with unilateral ligament damage and no spine fracture]

We report a case of total spinal cord disruption confirmed surgically. The spinal cord injury resulted from a traumatic event involving the thoracic spine which did not provoke any bone lesion. The patient presented joint injury and unilateral ligament damage. No spinal fracture was observed. In patients with neurological signs, the imaging work-up should associate CT-scan and magnetic resonance imaging to obtain a complete study of the bone and joint structures as well as the ligaments and the spinal cord.