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Absence of MRI soft tissue abnormalities in severe spinal cord injury in children: case-based update
Martin M Mortazavi1, Nitin R Mariwalla, Eric M Horn
1Division of Neurological Surgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ, USA.
Insights
Pediatric spinal cord injury can be occult due to unique spinal biomechanics. Even advanced MRI may miss injuries, highlighting the need to consider patient age and injury mechanisms in diagnosis.
Area of Science:
- Pediatric Traumatology
- Spinal Biomechanics
- Pediatric Radiology
Background:
- Occult spinal cord injury (SCI) requires consideration of patient age and trauma mechanism.
- Pediatric spines possess unique biomechanical and anatomical characteristics influencing injury patterns.
- Hypermobility and elasticity in children's spines can lead to self-reducing injuries, masking SCI.
Observation:
- A 22-month-old male presented with ligamentous injury in the upper cervical spine detected by MRI.
- MRI failed to detect a serious injury in the lower thoracic spine.
- Spinal cord injury without radiographic abnormality (SCIWORA) remains a diagnostic challenge despite advanced imaging.
Findings:
- Magnetic resonance imaging (MRI) demonstrated inadequacy in revealing a thoracic SCIWORA.
- The case highlights limitations of MRI in diagnosing certain pediatric spinal cord injuries.
- Ligamentous injury was present in the upper cervical spine, but the significant insult was in the thoracic region.
Implications:
- The biomechanics of the pediatric spine are crucial for evaluating potential SCIWORA.
- Relying solely on advanced imaging like MRI may be insufficient for diagnosing pediatric SCIWORA.
- A comprehensive approach integrating biomechanical understanding and clinical suspicion is essential for diagnosing pediatric spinal cord injuries.
Introduction:
Occult spinal cord injury should be suspected based not only on the mechanism of trauma but also on the age of the patient. The pediatric spine has unique biomechanical and anatomical properties that must be considered carefully when evaluating spinal cord trauma. For instance, the hypermobility and elasticity of the spinal column in children often lead to self-reducing injuries that can mask spinal cord injury.
Case Illustration:
We present the case of a 22-month-old male patient who was found to have ligamentous injury detected by magnetic resonance imaging (MRI) in the upper cervical spine but missed by MRI in the lower thoracic spine. Furthermore, there was no spinal cord injury in the upper cervical spine, but indeed a serious insult in the thoracic region. Since the advent of MRI, spinal cord injury without radiographic abnormality (SCIWORA) has become increasingly rare but not altogether extinct.
Conclusions:
We present a noteworthy example of the inadequacy of MRI in revealing SCIWORA, a term that is antiquated as we combine the latest imaging techniques with a better understanding of the biomechanics of trauma and spine injury. Based on the literature and our case illustration, we believe that the biomechanics of the pediatric spine must be considered when children who may have sustained a SCIWORA are examined.
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