Significance of SCIWORA in adults

Significância da SCIWORA em adultos

Trascendencia del cuadro SCIWORA en adultos

Pedro Luis Bazán About the author

Abstracts

OBJECTIVE:

Recognizing the importance of SCIWORA in adult age; analyze the usefulness of complementary studies; evaluating therapeutic options; learn about the evolution of the treated patients.

METHODS:

A prospective evaluation with a minimum follow-up of 5 years, eight elderly patients with cervical arthrosis and diagnosis of SCIWORA. The Japanese Orthopaedic Association (JOA) scale and ASIA were used on admission and at 6, 12, 24, 36, 48 and 60 months.

RESULTS:

The central cord syndrome (CCS) was the neurological condition at admission. One patient recovered after corticosteroid therapy, but later, his disability worsened, and he was operated at 18 months, another patient recovered and a third died. The other patients underwent laminoplasty in the first 72 hours; patients with partial severity condition had a minimum improvement of five points in JAO scale and those with severe conditions died.

CONCLUSIONS:

The low-energy trauma can decompensate the relationship between container and content in the spine with asymptomatic arthrosis, and can be devastating to the patient. The diagnosis of intramedullary lesion is made by magnetic resonance imaging. Patients with incomplete deficit undergoing laminoplasty reached at least one level in ASIA score. The potential postoperative complications can be serious.

Spinal cord injury; Central cord syndrome; Cervical vertebrae


OBJETIVO:

Reconhecer a importância de SCIWORA na idade adulta; analisar a utilidade dos estudos complementares; avaliar as opções terapêuticas; conhecer a evolução dos pacientes tratados.

MÉTODOS:

Foi realizada uma avaliação prospectiva com acompanhamento mínimo de 5 anos em oito pacientes idosos com artrose cervical e diagnóstico de SCIWORA. Foram usados a escala da Associação Japonesa de Ortopedia (JOA) e o escore da ASIA à internação e aos 6, 12, 24, 36, 48 e 60 meses.

RESULTADOS:

A síndrome medular central (SMC) foi o quadro neurológico à internação. Um paciente recuperou-se depois de corticoterapia, mas a incapacidade piorou posteriormente, sendo operado aos 18 meses; outro atingiu a recuperação e outro morreu. Os outros pacientes foram submetidos à laminoplastia nas primeiras 72 horas; os que tinham gravidade parcial tiveram melhora mínima de cinco pontos na escala da JAO os que tinham afecção mais grave morreram.

CONCLUSÕES:

O trauma de baixo impacto pode desequilibrar a relação entre o continente e o conteúdo na coluna vertebral com artrose, podendo ser devastador para o paciente. O diagnóstico de lesão intramedular é realizado por ressonância magnética. Os pacientes com déficit incompleto tratados com laminoplastia atingiram pelo menos um nível na escala ASIA. As possíveis complicações pós-operatórias podem ser graves.

Traumatismos da medula espinal; Síndrome medular central; Vértebras cervicais


OBJETIVO:

Reconocer la importancia de SCIWORA en la edad adulta; analizar la utilidad de los estudios complementarios; evaluar las opciones terapéuticas; conocer la evolución de los pacientes tratados.

MÉTODOS:

Se realiza una evaluación prospectiva con un seguimiento mínimo de 5 años, de ocho pacientes mayores con artrosis cervical y diagnóstico de SCIWORA. Se utilizaron la Escala de la Asociación de Ortopedia Japonesa (JOA) y ASIA al ingreso, 6, 12, 24, 36, 48 y 60 meses.

RESULTADOS:

El síndrome medular central (SMC) fue el cuadro neurológico de ingreso. Un paciente recupero luego de la corticoterapia, posteriormente, empeoró su discapacidad, siendo operado a los 18 meses, otro recupero y otro falleció. Al resto se les realizó laminoplastia en las primeras 72 horas; los cuadros de severidad parcial tuvieron una mejoría mínima de cinco puntos en escala JAO y los cuadros severos fallecieron.

CONCLUSIONES:

Un trauma de baja energía puede descompensar la relación continente contenido en columnas artrósicas asintomáticas, pudiendo ser devastador para el paciente. La resonancia magnética hace diagnóstico de lesión intramedular. Los pacientes con déficit incompleto, tratados con laminoplastia ganaron por lo menos un nivel de ASIA. Las posibles complicaciones post operatorias pueden ser graves.

Traumatismos de la médula espinal; Síndrome del cordón central; Vértebras cervicales


INTRODUCTION

Spinal cord injury is a devastating condition for the patient and their social circle. It is most frequently caused by fractures and/or dislocations, which are detected by radiographs or tomography scans. 1Hendey GW, Wolfson AB, Mower WR, Hoffman JR, National Emergency X-Radiography Utilization Study Group. Spinal cord injury without radiographic abnormality: results of the National Emergency X-Radiography Utilization Study in blunt cervical trauma. J Trauma. 2002;53(1):1-4.

The term SCIWORA defines spinal cord lesions that are observed in magnetic resonance, but that does not show bone lesion in complete studies of radiographs and/or tomography. 2Anglen J, Metzler M, Bunn P, Griffiths H. Flexion and extension views are not cost-effective in a cervical spine clearance protocol for obtunded trauma patients. J Trauma. 2002;52(1):54-9.

Barba CA, Taggert J, Morgan AS, Guerra J, Bernstein B, Lorenzo M, et al. A new cervical spine clearance protocol using computed tomography. J Trauma. 2001;51(4):652-6.

Berne JD, Velmahos GC, El-Tawil Q, Demetriades D, Asensio JA, Murray JA, et al. Value of complete cervical helical computed tomographic scanning in identifying cervical spine injury in the unevaluable blunt trauma patient with multiple injuries: a prospective study. J Trauma. 1999;47(5):896-902.

Blackley HR, Plank LD, Robertson PA. Determining the sagittal dimensions of the canal of the cervical spine. The reliability of ratios of anatomical measurements. J Bone Joint Surg Br. 1999;81(1):110-2.

Gupta SK, Rajeev K, Khosla VK, Sharma BS, Paramjit, Mathuriya SN, et al. Spinal cord injury without radiographic abnormality in adults. Spinal Cord. 1999;37(10):726-9.

Imajo Y, Hiiragi I, Kato Y, Taguchi T. Use of the finite element method to study the mechanism of spinal cord injury without radiological abnormality in the cervical spine. Spine (Phila Pa 1976). 2009;34(2):E83-7.

Sengupta DK. Neglected spinal injuries. Clin Orthop Relat Res. 2005;(431):93-103.
- 9Taylor AR, Blackwood W. Paraplegia in hyperextension cervical injuries with normal radiographic appearances. J Bone Joint Surg Br. 1948;30B(2):245-8. The first to mention this condition was Loyd in 1907 apud Fermin1010 Fermín, S: Síndrome sciwora. Arch Dom Ped. 2004;40:37-40. and Launay et al. 1111 Launay F, Leet AI, Sponseller PD. Pediatric spinal cord injury without radiographic abnormality: a meta-analysis. Clin Orthop Relat Res. 2005;(433):166-70. followed by Burke in 1947 apud Shen et al., 1212 Shen H, Tang Y, Huang L, Yang R, Wu Y, Wang P, et al. Applications of diffusion-weighted MRI in thoracic spinal cord injury without radiographic abnormality. Int Orthop. 2007;31(3):375-83. it was described by Pang1313 Pang D. Spinal cord injury without radiographic abnormality in children, 2 decades later. Neurosurgery. 2004;55(6):1325-42. , 1414 Pang D, Pollack IF. Spinal cord injury without radiographic abnormality in children--the SCIWORA syndrome. J Trauma. 1989;29(5):654-64. and Pang and Wilberger1515 Pang D, Wilberger JE Jr. Spinal cord injury without radiographic abnormalities in children. J Neurosurg. 1982;57(1):114-29. in 1982 for the pediatric population, particularly in children aged under 8 years, but authors like Hendey et al. 1Hendey GW, Wolfson AB, Mower WR, Hoffman JR, National Emergency X-Radiography Utilization Study Group. Spinal cord injury without radiographic abnormality: results of the National Emergency X-Radiography Utilization Study in blunt cervical trauma. J Trauma. 2002;53(1):1-4.describe the adulthood form, caused by degenerative pathology.

The incidence of spinal cord lesion in cervical trauma varies between 0.9% and 6%.6Gupta SK, Rajeev K, Khosla VK, Sharma BS, Paramjit, Mathuriya SN, et al. Spinal cord injury without radiographic abnormality in adults. Spinal Cord. 1999;37(10):726-9. , 1616 Crosby ET. Airway management in adults after cervical spine trauma. Anesthesiology. 2006;104(6):1293-318. , 1717 Griffen MM, Frykberg ER, Kerwin AJ, Schinco MA, Tepas JJ, Rowe K, et al. Radiographic clearance of blunt cervical spine injury: plain radiograph or computed tomography scan? J Trauma. 2003;55(2):222-6. When associated with other injuries, such as cranial trauma, the incidence increases to between 2% and 27%.1616 Crosby ET. Airway management in adults after cervical spine trauma. Anesthesiology. 2006;104(6):1293-318. , 1818 Demetriades D, Charalambides K, Chahwan S, Hanpeter D, Alo K, Velmahos G, et al. Nonskeletal cervical spine injuries: epidemiology and diagnostic pitfalls. J Trauma. 2000;48(4):724-7. The presence of neurological lesion without traumatic bone lesion in adults can vary between 0.08 and 15%.1Hendey GW, Wolfson AB, Mower WR, Hoffman JR, National Emergency X-Radiography Utilization Study Group. Spinal cord injury without radiographic abnormality: results of the National Emergency X-Radiography Utilization Study in blunt cervical trauma. J Trauma. 2002;53(1):1-4. , 1212 Shen H, Tang Y, Huang L, Yang R, Wu Y, Wang P, et al. Applications of diffusion-weighted MRI in thoracic spinal cord injury without radiographic abnormality. Int Orthop. 2007;31(3):375-83. , 1919 Fehlings MG, Skaf G. A review of the pathophysiology of cervical spondylotic myelopathy with insights for potential novel mechanisms drawn from traumatic spinal cord injury. Spine (Phila Pa 1976). 1998;23(24):2730-7.

20 Koyanagi I, Iwasaki Y, Hida K, Akino M, Imamura H, Abe H. Acute cervical Cord injury without fracture or dislocation of the spinal column. J Neurosurg. 2000;93(Suppl 1):15-20.
- 2121 Kothari P, Freeman B, Grevitt M, Kerslake R. Injury to the spinal cord without radiological abnormality (SCIWORA) in adults. J Bone Joint Surg Br. 2000;82(7):1034-7.

While children under 8 years and those over 60 years are the most predisposed, 1212 Shen H, Tang Y, Huang L, Yang R, Wu Y, Wang P, et al. Applications of diffusion-weighted MRI in thoracic spinal cord injury without radiographic abnormality. Int Orthop. 2007;31(3):375-83. , 2222 Yoo DS, Lee SB, Huh PW, Kang SG, Cho KS. Spinal cord injury in cervical spinal stenosis by minor trauma. World Neurosurg. 2010;73(1):50-2; due to anatomical and biomechanical differences, individuals can be divided into four age groups predisposed to this syndrome, namely:

  1. 1. At birth: particularly longitudinal traction;

  2. 2. <16 years: the distraction mechanism is prevalent due to the ligament elasticity;

  3. 3. Between 16 and 45 years of age: in this age range, it is rare to have a spinal cord lesion without bone and/or joint lesion, except in the constitutionally narrow cervical canal;

  4. 4. >45 years of age: here spondyloarthrosic degeneration is prevalent, and the main mechanism is hyperextension. 9Taylor AR, Blackwood W. Paraplegia in hyperextension cervical injuries with normal radiographic appearances. J Bone Joint Surg Br. 1948;30B(2):245-8. , 1515 Pang D, Wilberger JE Jr. Spinal cord injury without radiographic abnormalities in children. J Neurosurg. 1982;57(1):114-29. , 2222 Yoo DS, Lee SB, Huh PW, Kang SG, Cho KS. Spinal cord injury in cervical spinal stenosis by minor trauma. World Neurosurg. 2010;73(1):50-2;

The neurological condition that prevails in these cases is central cord syndrome (CCS), 1Hendey GW, Wolfson AB, Mower WR, Hoffman JR, National Emergency X-Radiography Utilization Study Group. Spinal cord injury without radiographic abnormality: results of the National Emergency X-Radiography Utilization Study in blunt cervical trauma. J Trauma. 2002;53(1):1-4. , 6Gupta SK, Rajeev K, Khosla VK, Sharma BS, Paramjit, Mathuriya SN, et al. Spinal cord injury without radiographic abnormality in adults. Spinal Cord. 1999;37(10):726-9. , 1818 Demetriades D, Charalambides K, Chahwan S, Hanpeter D, Alo K, Velmahos G, et al. Nonskeletal cervical spine injuries: epidemiology and diagnostic pitfalls. J Trauma. 2000;48(4):724-7. , 2020 Koyanagi I, Iwasaki Y, Hida K, Akino M, Imamura H, Abe H. Acute cervical Cord injury without fracture or dislocation of the spinal column. J Neurosurg. 2000;93(Suppl 1):15-20. , 2323 Aarabi B, Alexander M, Mirvis SE, Shanmuganathan K, Chesler D, Maulucci C, et al. Predictors of outcome in acute traumatic central cord syndrome due to spinal stenosis. J Neurosurg Spine. 2011;14(1):122-30.

24 Kulkarni MV, McArdle CB, Kopanicky D, Miner M, Cotler HB, Lee KF, et al. Acute spinal cord injury: MR imaging at 1.5 T. Radiology. 1987;164(3):837-43.

25 Miranda P, Gomez P, Alday R. Acute traumatic central cord syndrome: analysis of clinical and radiological correlations. J Neurosurg Sci. 2008;52(4):107-12.
- 2626 Newey ML, Sen PK, Fraser RD. The long-term outcome after central cord syndrome: a study of the natural history. J Bone Joint Surg Br. 2000;82(6):851-5. particularly in cases of low-energy trauma, 2222 Yoo DS, Lee SB, Huh PW, Kang SG, Cho KS. Spinal cord injury in cervical spinal stenosis by minor trauma. World Neurosurg. 2010;73(1):50-2; such as falling backwards from one's own height (43%), car accidents (33%), and falling from a height (12%).9Taylor AR, Blackwood W. Paraplegia in hyperextension cervical injuries with normal radiographic appearances. J Bone Joint Surg Br. 1948;30B(2):245-8. , 2727 Saruhashi Y, Hukuda S, Katsuura A, Asajima S, Omura K. Clinical outcomes of cervical spinal cord injuries without radiographic evidence of trauma. Spinal Cord. 1998;36(8):567-73.

Magnetic resonance imaging (MRI) is the best exam to evaluate these patients. 1212 Shen H, Tang Y, Huang L, Yang R, Wu Y, Wang P, et al. Applications of diffusion-weighted MRI in thoracic spinal cord injury without radiographic abnormality. Int Orthop. 2007;31(3):375-83. , 2020 Koyanagi I, Iwasaki Y, Hida K, Akino M, Imamura H, Abe H. Acute cervical Cord injury without fracture or dislocation of the spinal column. J Neurosurg. 2000;93(Suppl 1):15-20. , 2828 Holmes JF, Mirvis SE, Panacek EA, Hoffman JR, Mower WR, Velmahos GC, et al. Variability in computed tomography and magnetic resonance imaging in patients with cervical spine injuries. J Trauma. 2002;53(3):524-9. , 2929 Schaefer DM, Flanders AE, Osterholm JL, Northrup BE. Prognostic significance of magnetic resonance imaging in the acute phase of cervical spine injury. J Neurosurg. 1992;76(2):218-23. This method can divide causes into extramedullary (herniated disc, spinal stenosis, injury to the anterior longitudinal ligament or posterior ligamentous complex and intracanal hematoma) and intramedullary (edema, contusion and bleeding). 2121 Kothari P, Freeman B, Grevitt M, Kerslake R. Injury to the spinal cord without radiological abnormality (SCIWORA) in adults. J Bone Joint Surg Br. 2000;82(7):1034-7. , 2929 Schaefer DM, Flanders AE, Osterholm JL, Northrup BE. Prognostic significance of magnetic resonance imaging in the acute phase of cervical spine injury. J Neurosurg. 1992;76(2):218-23. , 3030 Kasimatis GB, Panagiotopoulos E, Megas P, Matzaroglou C, Gliatis J, Tyllianakis M, et al. The adult spinal cord injury without radiographic abnormalities syndrome: magnetic resonance imaging and clinical findings in adults with spinal cord injuries having normal radiographs and computed tomography studies. J Trauma. 2008;65(1):86-93.

31 Kim SH, Yoon SH, Cho KH, Kim SH. Spinal cord injury without radiological abnormality in an infant with delayed presentation of symptoms after a minor injury. Spine (Phila Pa 1976). 2008;33(21):E792-4.
- 3232 Tewari MK, Gifti DS, Singh P, Khosla VK, Mathuriya SN, Gupta SK, et al. Diagnosis and prognostication of adult spinal cord injury without radiographic abnormality using magnetic resonance imaging: analysis of 40 patients. Surg Neurol. 2005;63(3):204-9. The presence of hemorrhage in the spinal cord is a sign of poor prognosis in the patient's evolution. 6Gupta SK, Rajeev K, Khosla VK, Sharma BS, Paramjit, Mathuriya SN, et al. Spinal cord injury without radiographic abnormality in adults. Spinal Cord. 1999;37(10):726-9. , 2323 Aarabi B, Alexander M, Mirvis SE, Shanmuganathan K, Chesler D, Maulucci C, et al. Predictors of outcome in acute traumatic central cord syndrome due to spinal stenosis. J Neurosurg Spine. 2011;14(1):122-30. , 2929 Schaefer DM, Flanders AE, Osterholm JL, Northrup BE. Prognostic significance of magnetic resonance imaging in the acute phase of cervical spine injury. J Neurosurg. 1992;76(2):218-23. , 3232 Tewari MK, Gifti DS, Singh P, Khosla VK, Mathuriya SN, Gupta SK, et al. Diagnosis and prognostication of adult spinal cord injury without radiographic abnormality using magnetic resonance imaging: analysis of 40 patients. Surg Neurol. 2005;63(3):204-9.

33 Flanders AE, Schaefer DM, Doan HT, Mishkin MM, Gonzalez CF, Northrup BE. Acute cervical spine trauma: correlation of MR imaging findings with degree of neurologic deficit. Radiology. 1990;177(1):25-33.
- 3434 Tator CH, Fehlings MG. Review of the secondary injury theory of acute spinal cord trauma with emphasis on vascular mechanisms. J Neurosurg. 1991;75(1):15-26.

The factors that influence the survival of a patient with spinal cord injury are age, level and degree of the primary injury, 2929 Schaefer DM, Flanders AE, Osterholm JL, Northrup BE. Prognostic significance of magnetic resonance imaging in the acute phase of cervical spine injury. J Neurosurg. 1992;76(2):218-23. , 3434 Tator CH, Fehlings MG. Review of the secondary injury theory of acute spinal cord trauma with emphasis on vascular mechanisms. J Neurosurg. 1991;75(1):15-26. , 3636 Sekhon LH, Fehlings MG. Epidemiology, demographics, and pathophysiology of acute spinal cord injury. Spine (Phila Pa 1976). 2001;26(Suppl 24):S2-12. and secondary injury. 2020 Koyanagi I, Iwasaki Y, Hida K, Akino M, Imamura H, Abe H. Acute cervical Cord injury without fracture or dislocation of the spinal column. J Neurosurg. 2000;93(Suppl 1):15-20. , 2323 Aarabi B, Alexander M, Mirvis SE, Shanmuganathan K, Chesler D, Maulucci C, et al. Predictors of outcome in acute traumatic central cord syndrome due to spinal stenosis. J Neurosurg Spine. 2011;14(1):122-30. , 2929 Schaefer DM, Flanders AE, Osterholm JL, Northrup BE. Prognostic significance of magnetic resonance imaging in the acute phase of cervical spine injury. J Neurosurg. 1992;76(2):218-23. , 3535 Fehlings MG, Tator CH. An evidence-based review of decompressive surgery in acute spinal cord injury: rationale, indications, and timing based on experimental and clinical studies. J Neurosurg. 1999;91(Suppl 1):1-11. Young patients with stable neurological conditions can be treated non-surgically, while the elderly or individuals with progressive defect should be treated surgically. 2727 Saruhashi Y, Hukuda S, Katsuura A, Asajima S, Omura K. Clinical outcomes of cervical spinal cord injuries without radiographic evidence of trauma. Spinal Cord. 1998;36(8):567-73. Between 4% and 11% of patients with SCIWORA die as a direct result of trauma or urinary complications (renal failure and infection) or cardiopulmonary complications (pulmonary thromboembolism, myocardial infarction or infection). 6Gupta SK, Rajeev K, Khosla VK, Sharma BS, Paramjit, Mathuriya SN, et al. Spinal cord injury without radiographic abnormality in adults. Spinal Cord. 1999;37(10):726-9. , 3737 Wenger M, Adam PJ, Alarcón F, Markwalder TM. Traumatic cervical instability associated with cord oedema and temporary quadriparesis. Spinal Cord. 2003;41(9):521-6.

The objectives of this study are: to recognize the importance of SCIWORA in adulthood; to analyze the usefulness of complementary studies; to evaluate the therapeutic options; and to follow the evolution of treated patients.

MATERIAL AND METHODS

A prospective observational study was conducted with eight male patients over 45 years of age suffering from cervical spondylosis who, following an injury, were admitted to the emergency service with a diagnosis of neurological deficit without traumatic osteoligamentary lesion, between June 2005 and May 2007, with a 5-year follow-up.

The neurological assessment on admission, and in the subsequent follow-up visits (6, 12, 24, 36, 48 and 60 months), was carried out using the ASIA scale and the Japanese Orthopaedic Association Scale.

In terms of imaging exams, x-rays, an MRI scan and a CT scan were performed on admission; the first two tests were repeated annually, with x-ray and MRI, followed by MRI only.

The treatment performed, the presence of complications, and the neurological clinical evolution were evaluated.

This study was not presented to the Ethics Committee as it was observational.

RESULTS

All patients reported mild symptoms associated with their spondyloarthrosis prior to the injury.

The traumas were related to car accidents in five cases, with two passive mobilizations (one rotation in a robbery situation and one case of flexion-extension) and one fall from the patient's own height. One patient confirmed multiple traumas by association of cranial and thoracic trauma. (Table 1)

Table 1
Kinematics and associated lesions.

Severe neurological impairment (3 ASIA A and 2 ASIA B) was prevalent on admission, and all the patients presented with central cord syndrome. (Table 2)

Table 2
Neurological syndrome according to the ASIA scale.

All the patients were submitted to X-rays and MRI, and 6 were also evaluated with axial tomographies. (Figure 1)

Figure 1
Patient aged 66, driver wearing safety belt with side impact . (A) Radiography showing cervical spondyloarthrosis; (B) axial sections with facet joint impairment and central osteophyte; (C and D) MRI scan showing spinal cord edema. Quadriplegic upon admission, with good response to corticoids.

All the patients received treatment with methylprednisolone, according to the NASCISS protocol.

Five patients underwent surgical release of pressure by the posterior approach using laminoplasty technique in the first 72 h. Two of the non-surgically treated patients died before the first follow-up visit, while another experienced deterioration of neurological state and had to undergo surgical intervention using the same technique, with good results, although with gait spasticity. (Figure 2)

Figure 2
Patient age 56, driver wearing seat belt who had his vehicle rear- -ended while stationary. Good initial response to treatment with corticoids and immobilization; however, in the annual follow-up visit he presents with deterioration of neurological state and undergoes surgery 18 months later with good functional outcome. A) Lateral radiography showing cervical spondyloarthrosis; B) axial sections with facet joint impairment and osteophytes; C) MRI axial section showing spinal cord compression due to narrow cervical spinal canal; D) MRI mediosagittal section showing spinal cord edema; E and F) Postoperative dynamic radiographies; G) MRI sagittal section one year after surgery showing correct spinal cord positioning.

There was one case of presurgical pneumonia, two of post-surgical pneumonia, and one of urinary infection.

All the patients initially treated surgically had neurological improvement, as did the patient who underwent surgery 18 months after the trauma, with improvement of at least one level on the ASIA scale (Table 3) and 5 points on the JAO scale (Table 4).

Table 3
Evolution of neurological syndrome according to the ASIA scale. Patients 4, 6, 7, and 8 died in follow-up

Table 4
Evolution of values of the Japanese Orthopaedic Association Scale (JOA). Patients 4, 6, 7, and 8 died in follow-up.

DISCUSSION

The most appropriate term for SCIWORA symptomatology in adults should be SCIWORET, which is the neurological deficit that presents no radiographic lesions in the absence of trauma, yet its occurrence in adults is rare. Degenerative changes produce excessive traction of the spinal cord during the accident, 3838 Onishi E, Sakamoto A, Murata S, Matsushita M. Risk factors for acute cervical spinal cord injury associated with ossification of the posterior longitudinal ligament. Spine (Phila Pa 1976). 2012;37(8):660-6. although there are other authors who dismiss this relationship, and believe that degenerative changes or calcification of the posterior common vertebral ligament is not directly related to the presence of neurological deficit following low-energy trauma. 3939 Hoffman JR, Mower WR, Wolfson AB, Todd KH, Zucker MI. Validity of a set of clinical criteria to rule out injury to the cervical spine in patients with blunt trauma. National Emergency X-Radiography Utilization Study Group. N Engl J Med. 2000;343(2):94-9.

MRI should be used for the diagnosis, 2121 Kothari P, Freeman B, Grevitt M, Kerslake R. Injury to the spinal cord without radiological abnormality (SCIWORA) in adults. J Bone Joint Surg Br. 2000;82(7):1034-7. , 4040 Yamazaki T, Yanaka K, Fujita K, Kamezaki T, Uemura K, Nose T. Traumatic central cord syndrome: analysis of factors affecting the outcome. Surg Neurol. 2005;63(2):95-9. but when this is not conclusive, diffusion MRI can be used instead. Proton emission tomography (PET) could be useful in cases with negative MRI, and is useful for the study of myelopathic neurological syndrome. Another option is somatosensory evoked potentials. 3131 Kim SH, Yoon SH, Cho KH, Kim SH. Spinal cord injury without radiological abnormality in an infant with delayed presentation of symptoms after a minor injury. Spine (Phila Pa 1976). 2008;33(21):E792-4. Lateral view radiography in maximum flexion and extension is contraindicated due to the possibility of exacerbating the neurological condition. 2Anglen J, Metzler M, Bunn P, Griffiths H. Flexion and extension views are not cost-effective in a cervical spine clearance protocol for obtunded trauma patients. J Trauma. 2002;52(1):54-9. , 4040 Yamazaki T, Yanaka K, Fujita K, Kamezaki T, Uemura K, Nose T. Traumatic central cord syndrome: analysis of factors affecting the outcome. Surg Neurol. 2005;63(2):95-9.

The likelihood of neurological recovery4141 Carlson GD, Gorden CD, Oliff HS, Pillai JJ, LaManna JC. Sustained spinal cord compression: part I: time-dependent effect on long-term pathophysiology. J Bone Joint Surg Am. 2003;85(1):86-94. in these patients is related, in the first instance, to the initial injury, the canal diameter, 1212 Shen H, Tang Y, Huang L, Yang R, Wu Y, Wang P, et al. Applications of diffusion-weighted MRI in thoracic spinal cord injury without radiographic abnormality. Int Orthop. 2007;31(3):375-83. , 5Blackley HR, Plank LD, Robertson PA. Determining the sagittal dimensions of the canal of the cervical spine. The reliability of ratios of anatomical measurements. J Bone Joint Surg Br. 1999;81(1):110-2. , 4242 Pavlov H, Torg JS, Robie B, Jahre C. Cervical spinal stenosis: determination with vertebral body ratio method. Radiology. 1987;164(3):771-5. , 4343 Bhatoe HS. Cervical spinal cord injury without radiological abnormality in adults. Neurol India. 2000;48(3):243-8. the patient's age, the extent of injury, and the severity of the neurological symptoms. 2323 Aarabi B, Alexander M, Mirvis SE, Shanmuganathan K, Chesler D, Maulucci C, et al. Predictors of outcome in acute traumatic central cord syndrome due to spinal stenosis. J Neurosurg Spine. 2011;14(1):122-30. Therefore, surgical intervention is not the gold standard for treatment. 1818 Demetriades D, Charalambides K, Chahwan S, Hanpeter D, Alo K, Velmahos G, et al. Nonskeletal cervical spine injuries: epidemiology and diagnostic pitfalls. J Trauma. 2000;48(4):724-7. , 3333 Flanders AE, Schaefer DM, Doan HT, Mishkin MM, Gonzalez CF, Northrup BE. Acute cervical spine trauma: correlation of MR imaging findings with degree of neurologic deficit. Radiology. 1990;177(1):25-33. For Saruhashi et al. 2727 Saruhashi Y, Hukuda S, Katsuura A, Asajima S, Omura K. Clinical outcomes of cervical spinal cord injuries without radiographic evidence of trauma. Spinal Cord. 1998;36(8):567-73. patients who responded well to corticoid therapy were indicated for immobilization, while those with severe or progressive symptoms should be surgically treated.

Bhatoe4343 Bhatoe HS. Cervical spinal cord injury without radiological abnormality in adults. Neurol India. 2000;48(3):243-8. advocate nonsurgical treatment in traumas by hyperflexion, considering them vascular lesions; authors like La Rosa et al. 4444 La Rosa G, Conti A, Cardali S, Cacciola F, Tomasello F. Does early decompression improve neurological outcome of spinal cord injured patients? Appraisal of the literature using a meta-analytical approach. Spinal Cord. 2004;42(9):503-12. also support nonsurgical treatment, due to the risk of increased complications.

On the other hand, authors like Dolan et al. 4545 Dolan EJ, Tator CH, Endrenyi L. The value of decompression for acute experimental spinal cord compression injury. J Neurosurg. 1980;53(6):749-55., Chen et al. 4646 Chen TY, Dickman CA, Eleraky M, Sonntag VK. The role of decompression for acute incomplete cervical spinal cord injury in cervical spondylosis. Spine (Phila Pa 1976). 1998;23(22):2398-403 and Lenehan4747 Lenehan B, Fisher CG, Vaccaro A, Fehlings M, Aarabi B, Dvorak MF. The urgency of surgical decompression in acute central cord injuries with spondylosis and without instability. Spine (Phila Pa 1976). 2010;35(Suppl 21):180-6.are in favor of rapid release to prevent secondary damage3434 Tator CH, Fehlings MG. Review of the secondary injury theory of acute spinal cord trauma with emphasis on vascular mechanisms. J Neurosurg. 1991;75(1):15-26. and complications. 4141 Carlson GD, Gorden CD, Oliff HS, Pillai JJ, LaManna JC. Sustained spinal cord compression: part I: time-dependent effect on long-term pathophysiology. J Bone Joint Surg Am. 2003;85(1):86-94.

CONCLUSION

Low energy trauma can cause an imbalance in the container-content relationship in symptomatic arthritic spines, which can be devastating for the patient.

Plain radiographies and CAT scans are useful for ruling out traumatic injuries, but MRI is used to perform the intramedullary diagnosis.

Laminoplasty patients gained at least one level on the ASIA scale, although the postoperative complications can be severe.

The patient who did not undergo surgery and with final follow-up lost one level on the ASIA scale 18 months later, and recovered satisfactorily with pressure release.

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  • Study conducted at the HIGA San Martín de La Plata y Hospital Italiano de La Plata, La Plata, Provincia de Buenos Aires, Argentina

Publication Dates

  • Publication in this collection
    June 2015

History

  • Received
    03 Mar 2015
  • Accepted
    24 Apr 2015
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