Cervical Spine Trauma in Children: A Review

Todd Mccall, MD; Dan Fassett, MD; Douglas Brockmeyer, MD

Disclosures

Neurosurg Focus. 2006;20(2):E5 

In This Article

Identifying SCIWORA

Spinal cord injury without radiographic abnormality is a clinical entity primarily affecting children. In 1982, Pang and Wilberger[72] defined this disorder as marked by objective signs of myelopathy resulting from trauma, with no evidence of ligamentous injury or fractures on plain x-ray films or tomographic studies. The original definition excludes penetrating trauma, electrical shock, obstetric complications, and congenital spine anomalies. Most studies of traumatic myelopathy in children report an incidence of SCIWORA greater than 20%,[19,40,64,80] and in a review of 14 series involving 617 children with traumatic myelopathy, the incidence of SCIWORA was found to be 36%.[76] This disorder is more common in children younger than 8 years of age, and the distribution of injuries is the same as in other cervical spine injuries, with younger patients sustaining upper cervical injuries.[39,68,70,72,76] Younger patients are more likely to have severe neurological injuries,[40,68,70,106] and neurological deficits are often delayed.[2,21,101] Factors predisposing young children to SCIWORA include a more tenuous spinal cord blood supply[22] and greater elasticity in the vertebral column than in the spinal cord.[58] Flexion and extension injuries are the most common mechanism, but lateral bending, distraction, rotation, axial loading, or a combination may also be involved.

The MR imaging modality is an invaluable tool for evaluating patients with SCIWORA. Findings on MR images obtained in children with this disorder can include ligamentous or disc injury, complete spinal cord transection, and spinal cord hemorrhage.[23,39] Still, other patients with SCIWORA will have normal findings on MR imaging. Cases that meet the definition of SCIWORA as proposed by Pang and Wilberger[72] but have a demonstrated cervical spine injury on MR imaging demonstrate that the original definition of this disorder is antiquated and should also take into account MR imaging findings along with those on plain x-ray films and CT scans.

The injuries associated with SCIWORA are generally considered stable lesions, and immobilization for up to 3 months is the recommended care.[70] Before immobilization is discontinued, stability should be confirmed using dynamic lateral radiographs. In cases of SCIWORA in which the results of dynamic studies are normal but ligamentous injury is noted on MR imaging, serial dynamic plain x-ray films should be obtained to rule out the possibility of delayed instability.

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