Spinal cord injury without radiographic abnormality in children--the SCIWORA syndrome

Spinal cord injury in children frequently occurs without fracture or dislocation. The clinical profiles of 55 children with spinal cord injury without radiographic abnormalities (SCIWORA) are reported in detail to illustrate features of this syndrome. No patient had vertebral fracture or dislocation on plain films and tomographies. There were ten upper cervical (C1-C4), 33 lower cervical (C5-C8), and 12 thoracic cord injuries; of these, 22 were complete or severe lesions and 33 were mild lesions. The mechanism of the neural injury probably relates to the inherent elasticity of the juvenile spine, which permits self-reducing but significant intersegmental displacements when subjected to flexion, extension, and distraction forces. The spinal cord is therefore vulnerable to injury even though the vertebral column is spared from disruption, and this vulnerability is most evident in children younger than 8 years. All but one of the 22 children with profound neurologic injuries were younger than 8 years (p less than 0.000001), whereas 24 of 33 children with mild injuries were older. Younger children were also more likely to have severe upper cervical lesions (p less than 0.05); lower cervical lesions were distributed evenly through the ages of 6 months to 16 years. Thoracic injuries most commonly resulted from distraction or crushing. Distraction invariably involved violent forces, and crush injuries were usually caused by children being run over while lying prone, when the spinal column was acutely bowed towards the spongy abdominal and thoracic cavities. Fifteen children had delayed onset of neurologic deficits; nine of these had transient warning symptoms of paresthesia, subjective paralysis, and Lhermitte's phenomenon 30 minutes to 4 days before the onset of deterioration. Eight other children suffered a second SCIWORA 3 days to 10 weeks after the initial SCIWORA. The spines in these children were presumably rendered incipiently unstable by the initial injury and thus were susceptible to additional, often more severe, neurologic trauma. The long-term neurologic outcome in children with SCIWORA is solely determined by their admission neurologic status. Realistically, the outcome can thus only be improved by: 1) ruling out occult fractures and subluxation which will require surgical fusion; 2) identifying patients likely to have delayed deterioration; and 3) preventing recurrent SCIWORA. Our experience and recommendations in these regards are discussed.