Signature: © Pol J Radiol, 2014; 79: 461-464

DOI: 10.12659/PJR.890944
REVIEW ARTICLE

Received: 2014.04.29
Accepted: 2014.07.24 Spinal Cord Injury without Radiographic Abnormality
Published: 2014.12.08
(SCIWORA) – Clinical and Radiological Aspects
Authors’ Contribution: Dawid Szwedowski1 EF, Jerzy Walecki2 EF
A Study Design
B Data Collection 1 Department of Orthopedic and Trauma, District Hospital, Toruń, Poland
C Statistical Analysis 2 Department of Radiology and Diagnostic Imaging, Medical Center of Postgraduate Education, Warsaw, Poland
D Data Interpretation
E Manuscript Preparation
Author’s address: Dawid Szwedowski, Department of Orthopedic and Trauma, District Hospital, Toruń, Poland,
F Literature Search e-mail: [email protected]
G Funds Collection

Summary
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.

MeSH Keywords: Central Cord Syndrome • Magnetic Resonance Imaging • Spinal Cord Injuries

PDF fi­le: http://www.polradiol.com/abstract/index/idArt/890944

Background diagnostic options that can be used to investigate this clini-

cal-radiological condition.
The acronym SCIWORA (Spinal Cord Injury Without
Radiographic Abnormality) was first developed and intro- Physiopathology
duced by Pang and Wilberger who used it to define “clinical
symptoms of traumatic myelopathy with no radiographic Based on reports from different authors, SCIWORA is
or computed tomographic features of spinal fracture or responsible for 6 to 19% and 9% to 14% of spinal injuries
instability’’. The first case of SCIWORA was reported by in children and adults, respectively. The prevalence of this
Burke in 1974 [1]. The definition does not include spinal condition is highest among children below 8 years of age
cord injury from electric current, obstetric complica- who also have the most unfavorable prognosis, which is
tions, congenital spinal anomalies or penetrating injury probably associated with relatively heavy head, weaker
to the spinal canal [2]. Differential diagnosis of non-trau- neck muscles and greater elasticity of vertebral ligaments
matic degenerative changes versus acute traumatic inju- in this patient population [4–6]. More horizontal orienta-
ries in adults is difficult, and sometimes even impossible. tion of facet joints further increases susceptibility to these
Therefore, some authors use the term SCIWORET (Spinal injuries. Specific biomechanics of the vertebral column
Cord Injury Without Radiographic Evidence of Trauma) as in children allows the musculoskeletal system to move
more appropriate [3]. beyond the normal physiological range of motion without
the risk of fracture. The injury to the spinal cord is caused
Recent advances in neuroimaging techniques, especially by a contusion or ischemia due to temporary occlusion of
in magnetic resonance imaging, made it possible to detect vertebral arteries followed by a spontaneous return of ver-
damages typical of SCIWORA. The aim of the paper was tebrae to their original position [7].
to discuss physiopathology of SCIWORA and current

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High-energy injuries are often associated with vertebral

fractures or instability due to decreased flexibility of the
spine in adults. In most cases, SCIWORA occurs as a result
of hyperextension forces (e.g., during a rear-end car acci-
dent) or from a direct frontal impact to the face. Launay
et al. suggested that these injuries are likely to occur dur-
ing sports such as diving, rugby, wrestling, and baseball.
However, they are most often associated with low-ener-
gy falls in the elderly. 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 which may
suggest that degenerative spine conditions predispose to
SCIWORA injuries [8]. Even mild hyperextension injury
can cause a central cord syndrome in patients with spinal
stenosis. Both bone spur growth at the posterior margins
of vertebral bodies, and bulging of the yellow ligament
from the back side into the spinal canal (due to a decreased
height of vertebral bodies), can cause spinal cord compres- Figure 1. A sagittal T2-weighted spin-echo MR image of the cervical
sion and impingement (Figure 1). Venous congestion with- spine in a 65-year-old male patient. Arrows indicate the
in the compressed spinal cord is an additional pathogenic location of spinal cord compression: anterior impingement
factor. Neurological deficit, that is usually more severe from bone spurs at the margin of the vertebral body and
in the upper extremities than in the lower extremities, is posterior impingement from bulging yellow ligament.
the most typical clinical presentation in patients with
SCIWORA [9,10]. The onset of clinical symptoms is delayed Magnetic resonance imaging is the best modality for direct
from a few minutes to 48 hours after injury in about 50% evaluation of the spinal cord. Spin-echo T1 (T1 SE), gra-
of patients. This latency is associated with repeated micro- dient-echo T2* (T2-weighted GRE*) and STIR-weighted
insults to the spinal cord from striking against the unstable MRI pulse sequences are preferred in patients with spinal
vertebrae. injuries. Due to longitudinal anatomy of the spinal cord,
its integrity and possible location of changes can be eas-
Diagnostic Tests ily determined in sagittal plane. The main symptoms of
an acute spinal injury (SCI) include edema, hematoma,
Specific assessments to determine spine injury should anatomic transection (loss of continuity) of the spinal
include clinical examination, with a special focus on neu- cord and prolapsed nucleus pulposus. T1-weighted spin-
rological examination. Patients diagnosed with SCIWORA echo MR images provide information about morphology
have a broad spectrum of neurological deficits, from mild and anatomy of the spinal cord and should be performed
and transient symptoms such as paresthesia in fingers to as first diagnostic step. The bleeding can be best identi-
quadriplegia. Some patients experience symptoms only at fied on T2-weigted GRE sequences*. An increase in the
the moment of injury. When performing physical examina- concentration of deoxyhemoglobin in fresh hematoma
tion it is important to bear in mind that neurological defi- causes a decrease in signal intensity on T2-weigted imag-
cits may only become apparent after several days of injury. es (Figure 2A, 2B) and, in particular, on T2-weigted GRE
Since physical examination is limited, clinicians mainly rely images*. One week or more later, with the organization
on diagnostic imaging when planning treatment for these of the hematoma, resulting from the conversion of deoxy-
patients. Conventional x-rays are usually performed as the hemoglobin into methemoglobin, such lesions are seen as
first-line imaging test. A lateral spine x-ray can identify 75% hyperintense on T1- and T2-weighted images. However,
of fractures with sensitivity of 85%. The sensitivity increases hemorrhages will again appear hypointense on T2WI due
to over 90% when anteroposterior (AP), lateral, oblique and to the presence of hemosiderin-laden macrophages in the
open mouth or odontoid radiographs are taken [11]. The sta- chronic phase. A spinal cord edema is seen as hyperintense
bility of the cervical spine can also be assessed by flexion and signal on T2-weighted images against a background of
extension dynamic radiographs. However, it should be noted normal nervous tissue, and is best visible on STIR images
that plain x-rays provide inconclusive evidence in patients (Figure 3). Radiological features of post-traumatic disc her-
with post-traumatic cervical dystonia, so they should be niation are similar to those of non-traumatic. Therefore,
postponed until complete resolution of muscle spasm [12]. it is often virtually impossible to identify the difference
between the two forms of disc prolapse. Only the presence
Computed tomography is most accurate in detecting bony of other post-traumatic lesions at the same level may sug-
pathology. A CT scan can be used to visualize subtle inju- gest possible diagnosis [13,14]. Magnetic resonance imaging
ries to the posterior arch or lateral mass of the vertebra, is useful not only for investigating soft tissue abnormali-
and injuries to the atlas and odontoid process that are poor- ties, it also allows identification of bone marrow edema in
ly visible on standard x-rays. When a diagnosis of spinal injured vertebrae that cannot be seen on CT scans. Short
fracture can be excluded by x-rays and CT scan, SCIWORA tau inversion recovery (STIR) technique, which is used to
should be suspected and magnetic resonance tomography suppress the signal from fat, is most valuable in these cases
(MRT) performed in patients with blunt trauma injuries [15]. Differential diagnosis should include embolism from
and neurologic deficits. vertebral artery occlusion associated with cardiovascular

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© Pol J Radiol, 2014; 79: 461-464 Szwedowski D. et al. – Spinal cord injury wthout radiographic abnormality…

Figure 3. A sagittal STIR-weighted MR image of the spine. A

B hyperintense area pointed by an arrow represents edema of
the spinal cord.

hematomas (greater than 1/2 of the spinal cord diameter)

have poor prognosis and are manifested clinically as pare-
sis or paralysis [18].

The increasing use of MRI as the primary imaging study

for spinal trauma resulted in increased number of patients
diagnosed with SCIWORA who had normal MRI findings.
These cases should be classified as SCIWNA or spinal cord
injury without neuroimaging abnormality [14]. Shen et al.
have demonstrated clinical utility of diffusion weighted
imaging (DWI) in evaluation of patients with SCIWNA.
Patients with normal MRI findings had hyperintense
lesions on DWI [19]. Diffusion tensor magnetic resonance
imaging (DTI) also becomes an important diagnostic tool in
patients with SCIWORA due to its ability to assess white
matter integrity. Due to a small transverse diameter of the
spinal cord, DTI requires high spatial resolution and rela-
Figure 2. (A, B) A 23-year-old patient who suffers from a cervical spine tively small voxel volume. Moreover, the images may have
injury due to a fall from a platform. The patient exhibited artifacts introduced by breathing, swallowing or pulsatile
muscle weakness in the upper extremities and severe flow of the cerebrospinal fluid. The most modern parallel
neck pain on physical examination. There were no bony imaging methods, as well as ECG-triggering or ECG-gating
abnormalities on x-rays or CT scans. MR images revealed a scan techniques can improve the image quality [20,21].
large hyperintense lesion in the cervical spine corresponding Myelography or angiography would have no application as
to edema of the cervical spinal cord. A focal signal drop out diagnostic tools for SCIWORA.
can be seen in the center of the lesion (a region of hyperacute
hematoma). Chronic hematoma would give a similar Treatment
appearance, except for the presence of spinal edema.
External immobilization of the spine for up to 12 weeks is
diseases such as endocarditis, cardiac arrhythmia, persis- the main therapeutic option for patients with spinal injury.
tent foramen ovale, arteritis or bleeding disorder. Acute or Patients are also advised to avoid increased-risk activities
chronic myelitis should also be excluded [16,17]. for 6 months after diagnosis to prevent acute exacerba-
tions of symptoms and reduce the risk of another injury. In
Spinal cord lesions revealed by MRI are important prog- asymptomatic patients who obtained stable spine fixation
nostic factors in patients with SCIWORA. Small hemato- as assessed by flexion and extension dynamic radiographs,
mas (measuring up to 1/3 of the spinal cord diameter) or external immobilization devices can be removed earlier.
edema have favorable prognosis and resolve over time in Drug treatment includes the use of antihypertensive agents
most cases. Anatomic transection of the spinal cord or large to maintain blood pressure within normal limits [18].

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