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Redefining Pediatric SCIWORA: A Systematic Review of the Literature on Clinical Patterns, Imaging Profiles, and
Davide Palombi1,2, Marco Galeazzi1,2, Paolo Brigato3,4
1Department of Pediatric Neurosurgery, Fondazione Policlinico Agostino Gemelli IRCCS, Università Cattolica del Sacro Cuore, 00168 Roma, Italy.
Insights
Pediatric Spinal Cord Injury Without Radiographic Abnormality (SCIWORA) outcomes depend on MRI findings and initial neurological status. Most children improve with conservative treatment, but surgery may be needed for specific MRI-positive lesions.
Area of Science:
- Pediatric neurology
- Neurosurgery
- Radiology
Background:
- Spinal Cord Injury Without Radiographic Abnormality (SCIWORA) presents diagnostic and therapeutic challenges due to its heterogeneity.
- While most pediatric SCIWORA cases resolve with conservative management, some require surgical intervention based on imaging.
- Standardized criteria and evidence-based algorithms are needed for consistent care and improved outcomes.
Purpose of the Study:
- To clarify the understanding of pediatric SCIWORA.
- To differentiate "real" SCIWORA from SCIWORA-like conditions.
- To synthesize current evidence on epidemiology, mechanisms, presentation, MRI findings, and management.
Main Methods:
- Systematic literature search of PubMed, Cochrane, Scopus, and Embase databases.
- Inclusion of studies on pediatric SCIWORA (<18 years) reporting demographics, clinical, radiological features, management, and outcomes.
- Adherence to PRISMA guidelines for study selection.
Main Results:
- Eighty-four percent of pediatric patients (n=848) were included from 60 studies; mean age 9.33 years, male predominance.
- MRI revealed intraneural lesions (46%), no abnormality (39%), combined lesions (9%), or extraneural abnormalities (6%).
- Most patients presented with ASIA A (46.25%), but 49.78% achieved ASIA E at follow-up; 66.2% improved neurologically. Conservative treatment (95.41%) was primary; surgery (4.59%) was for instability or compression.
Conclusions:
- Pediatric SCIWORA is uncommon but severe, with outcomes linked to MRI findings and initial neurological status.
- MRI classification aids in understanding injury patterns and guiding treatment.
- Further research should focus on standardized diagnostic criteria and treatment algorithms for pediatric SCIWORA.
Abstract:
Objectives: Among the spectrum of spinal injuries, Spinal Cord Injury Without Radiographic Abnormality (SCIWORA) occupies a unique and challenging position. SCIWORA presents diagnostic and therapeutic challenges due to its broad clinical and radiological heterogeneity. While most children recover favorably with conservative treatment, a subset may require surgery based on imaging findings. The findings underscore the need for standardized diagnostic criteria, MRI-based classification systems, and evidence-based treatment algorithms to improve consistency in care and long-term neurological outcomes. Methods: A systematic search of PubMed, Cochrane, Scopus, and Embase databases was performed through June 2025 following PRISMA guidelines. Inclusion criteria encompassed studies of pediatric SCIWORA (age < 18 years) reporting demographics, clinical and radiological features, management, and outcomes. Results: Sixty studies encompassing a total of 848 pediatric patients were included. The mean patient age was 9.33 years (±2.52), with a slight male predominance. The most common trauma mechanisms were road traffic accidents (40.3%), sports injuries (22%), and falls (18.8%). MRI findings were available in 399 cases: 46% had intraneural lesions (Type IIb), 39% showed no abnormality on MRI (Type I, or "real SCIWORA"), 9% had combined lesions (Type IIc), and 6% had extraneural abnormalities (Type IIa). Neurological severity at presentation was primarily ASIA Grade A (46.25%), but follow-up data showed substantial improvement, with ASIA E (normal function) increasing to 49.78%. Overall, 66.2% of patients experienced neurological improvement, while 33.8% remained stable. Conservative treatment was employed in 95.41% of cases. Only 4.59% underwent surgery, which was typically reserved for MRI-positive lesions demonstrating spinal instability or compression. Conclusions: Pediatric SCIWORA remains an uncommon but potentially devastating injury, with an outcome highly dependent on MRI findings and initial neurological status. This systematic review aims to clarify the contemporary understanding of pediatric SCIWORA, delineating "real" SCIWORA from other SCIWORA-like entities, and synthesizing the latest evidence regarding epidemiology, mechanisms, clinical presentation, MRI findings, and management in children.
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