SCIWORA
Spinal cord injury without radiographic abnormality (SCIWORA) in children has been a known entity since at least the early twentieth century (9), though the acronym did not come about until 1982 in an article by Pang and Wilberger (10).
The initial definition focused on children with traumatic SCI, who did not have evidence of vertebral column injury on spine x-rays, conventional and computed tomographic studies, myelograms, or dynamic flexion/extension studies. This excluded injuries caused by penetrating trauma, electrical shock, obstetric complications, and congenital spinal anomalies. In 2004, Pang published a review on what is now known about SCIWORA (11). Incidence of SCIWORA ranges between 5% and 67% of cases of pediatric SCI, with an average of 34.8%. The incidence is much higher in children 9 years and younger. Pooled data indicated an incidence of SCIWORA of 63.1% in younger children and only 19.7% in older children. Most injuries occur in the cervical cord, most commonly with C5-C8 lesions. Thirteen percent of injuries were in the thoracic cord. This injury is thought to be primarily present in children due to the unique physiology of the developing spine, being much more mobile, without resulting in bony fractures, but causing stretch injury to other tissues. This increased mobility was thought to result in damage to the soft tissue structure of the spine, including ligamentous and neural structures, which cannot be demonstrated on radiographic studies. The advent of more advanced imaging techniques has demonstrated these soft tissue injuries.SCIWORA has been reported to cause complete and incomplete SCI, as well as central cord and Brown- Sequard syndromes. Pang classified ASIA-B/C as severe injuries and ASIA-D as mild. From this pooled data, SCIWORA results in ASIA-A 22.1%, ASIA-B/C 12.6%, ASIA-D 23.2%, central cord syndrome 29.4%, and Brown-Sequard 12.7% (11).
With the development of magnetic resonance imaging (MRI), damage to the soft tissue structures in the spinal column is readily apparent. This information was recently reviewed by Yucesoy and Yuksel (12). These authors suggest that in the MRI era, SCIWORA may be an ambiguous term and suggest that those with no lesions on neuroimaging be classed as “real SCIWORA” or spinal cord injury without neuroimaging abnormality (SCIWNA). In a strict sense, radiographs do not include MRI, yet in standard use, most practitioners would consider most imaging to fall into the category of radiograph, regardless of the nature of the physics involved in the imaging process.