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SCIWORA? Sci-what’s that?

CASE

A 95-year-old female presented to the ED after a mechanical fall into the grass of her front yard, striking her back and her head, witnessed by her friend, without LOC or a history of anticoagulation use. In the ED, her sole complaint was bilateral wrist pain, believing it to be due to an attempt to break her fall. She was placed in a cervical collar while awaiting workup. CT scan of the head and neck were negative for acute findings. The hand and wrist pain does not at first appear to be in a dermatomal distribution, but it worsened over the course of her ED stay despite a substantial pain management regimen. The patient also began endorsing numbness and tingling in her bilateral wrists despite normal strength and sensation examinations. Neurosurgery was consulted and an MRI was ordered which showed a rupture of the anterior spinal ligament as well as spinal stenosis, both at the C6/7 vertebral level. No urgent intervention was planned.

Clinical Question: When is an emergent MRI indicated in the setting of suspected cord injury without radiographic abnormality (SCIWORA) for adult patients presenting with blunt trauma?


SUMMARY OF EVIDENCE

  • SCIWORA is defined as a “clinically appreciable post-traumatic myelopathy” without the presence of acute findings on plain radiographs or CT imaging, but often with pathologic findings seen on MRI. Though the pathophysiology is not always clear, some trauma mechanisms of injury include hyperextension or traction injuries as well as damage secondary to edema.[1]

    • Some authors define SCIWORA by presence of radiographic evidence of cord injury on MRI instead of the clinical presentation.[6] The variance in definition of the term may complicate the reported rates of SCIWORA among C-spine injuries; they have been reported from 3.3% to 32.[2] of all C-spine injuries, with children being especially susceptible.[2-4,6] Further complicating this point, imaging technology has improved over time and usage patterns have changed: more sensitive and specific advanced CT imaging is now widely available and in use while plain radiography is falling out of favor.[15]

    • In the adult population, some prefer the term SCIWORET (suspected cord injury without radiographic evidence of trauma) as many patients have degenerative findings on CT or plain films.[1]

  • There is some quality evidence that the utility of MRI in trauma patients with negative CT scans is not high. One study found that c-collar clearance after negative CTs did not result in any new neurologic changes and the CTs had a 91% negative predictive value, though this was a study of only obtunded blunt trauma patients.[10] Two systematic reviews found no missed C-spine injuries in studies of trauma patients with negative CT findings.[11,12] Another study of nearly three thousand patients found that MRI added little value to management of patients that had negative CT findings.[13]

  • One small study of 40 patients found prognostic value in C-spine MRI imaging of patients with negative CT findings but clinical suspicion of neurological traumatic injury.[5]

  • In terms of management, one study found 0.4% of patients with SCIWORA had their management changed to surgical intervention following MRI.[8] Others placed that number at 3% and 6%.[7,9]

  • It is notable that there have been no randomized trials to date comparing outcomes for trauma patients undergoing CT alone vs. CT with MRI (or any other imaging modality combination) and so the body of evidence is purely observational.

RECOMMENDATIONS

  1. Perform a very thorough neurological examination of trauma patients with a potential neck injury and take steps to protect their C-spine if they cannot be cleared clinically. Rigid collars (e.g. MiamiJ) are the most appropriate choice while workup is pending and/or while c-spine injury is suspected. If CT imaging is negative, reevaluate the patient and consider if SCIWORA is a possibility.

  2. If cord injury symptoms or focal neurological deficits are present, an MRI of the cervical spine can be warranted, though it will often not change the management of the patient. For any case in which MRI is considered, a neurosurgery/spine consult should be called. In obtunded patients with normal gross motor function, MRI is not indicated.[10,14]

    1. Paresthesia, or symptoms concerning for paresthesia, present on multiple limbs specifically (like those of the patient in our case) should be included in the list of concerning symptoms

  3. If there is equipoise as to whether a patient’s clinical picture represents a SCIWORA after negative radiographs, consider whether positive MRI findings could change the management of the patient in the acute phase before ordering an MRI in the ED. For example, a patient who is a very poor surgical candidate may not benefit from an emergent MRI, even if an MRI is felt to be indicated at some point soon.

    1. The longer symptoms or exam findings persist, the more you should lean towards and MRI. Symptoms or exam findings that wane over time are less concerning and are less likely to warrant an MRI. This is because these features make it more likely that an intervention may be required. This decision should be done in consultation with neurosurgery colleagues whenever possible, as they will ultimately decide whether the patient requires or is able to undergo any particular intervention.

  4. If an MRI of the c-spine is negative for acute findings or abnormalities, cervical collars can be removed safely and the patient can be cleared.

REFERENCES

1. Bonfanti L, Donelli V, Lunian M, Cerasti D, Cobianchi F, Cervellin G. Adult Spinal Cord Injury Without Radiographic Abnormality (SCIWORA). Two case reports and a narrative review. Acta Biomed. 2019 Jan 15;89(4):593-598. doi: 10.23750/abm.v89i4.7532. PMID: 30657112; PMCID: PMC6502103.


2. Onoue K, Farris C, Burley H, Sung E, Clement M, Abdalkader M, Mian A. Role of cervical spine MRI in the setting of negative cervical spine CT in blunt trauma: Critical additional information in the setting of clinical findings suggestive of occult injury. J Neuroradiol. 2021 May;48(3):164-169. doi: 10.1016/j.neurad.2019.05.001. Epub 2019 May 24. PMID: 31132384.


3. Kasimatis GB, Panagiotopoulos E, Megas P, Matzaroglou C, Gliatis J, Tyllianakis M, Lambiris E. 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 Jul;65(1):86-93. doi: 10.1097/TA.0b013e318157495a. PMID: 18580514.


4. Kato H, Kimura A, Sasaki R, Kaneko N, Takeda M, Hagiwara A, Ogura S, Mizoguchi T, Matsuoka T, Ono H, Matsuura K, Matsushima K, Kushimoto S, Fuse A, Nakatani T, Iwase M, Fudoji J, Kasai T. Cervical spinal cord injury without bony injury: a multicenter retrospective study of emergency and critical care centers in Japan. J Trauma. 2008 Aug;65(2):373-9. doi: 10.1097/TA.0b013e31817db11d. PMID: 18695474.


5. Tewari MK, Gifti DS, Singh P, Khosla VK, Mathuriya SN, Gupta SK, Pathak A. Diagnosis and prognostication of adult spinal cord injury without radiographic abnormality using magnetic resonance imaging: analysis of 40 patients. Surg Neurol. 2005 Mar;63(3):204-9; discussion 209. doi: 10.1016/j.surneu.2004.05.042. PMID: 15734500.


6. Hendey 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 Jul;53(1):1-4. doi: 10.1097/00005373-200207000-00001. PMID: 12131380.


7. Schoenfeld AJ, Bono CM, McGuire KJ, Warholic N, Harris MB. Computed tomography alone versus computed tomography and magnetic resonance imaging in the identification of occult injuries to the cervical spine: a meta-analysis. J Trauma. 2010 Jan;68(1):109-13; discussion 113-4. doi: 10.1097/TA.0b013e3181c0b67a. PMID: 20065765.


8. Malhotra A, Durand D, Wu X, Geng B, Abbed K, Nunez DB, Sanelli P. Utility of MRI for cervical spine clearance in blunt trauma patients after a negative CT. Eur Radiol. 2018 Jul;28(7):2823-2829. doi: 10.1007/s00330-017-5285-y. Epub 2018 Feb 15. PMID: 29450715.


9. Ackland HM, Cameron PA, Varma DK, Fitt GJ, Cooper DJ, Wolfe R, Malham GM, Rosenfeld JV, Williamson OD, Liew SM. Cervical spine magnetic resonance imaging in alert, neurologically intact trauma patients with persistent midline tenderness and negative computed tomography results. Ann Emerg Med. 2011 Dec;58(6):521-30. doi: 10.1016/j.annemergmed.2011.06.008. Epub 2011 Aug 5. PMID: 21820209.


10. Patel MB, Humble SS, Cullinane DC, Day MA, Jawa RS, Devin CJ, Delozier MS, Smith LM, Smith MA, Capella JM, Long AM, Cheng JS, Leath TC, Falck-Ytter Y, Haut ER, Como JJ. Cervical spine collar clearance in the obtunded adult blunt trauma patient: a systematic review and practice management guideline from the Eastern Association for the Surgery of Trauma. J Trauma Acute Care Surg. 2015 Feb;78(2):430-41. doi: 10.1097/TA.0000000000000503. PMID: 25757133; PMCID: PMC4409130.


11. Malhotra A, Wu X, Kalra VB, Nardini HK, Liu R, Abbed KM, Forman HP. Utility of MRI for cervical spine clearance after blunt traumatic injury: a meta-analysis. Eur Radiol. 2017 Mar;27(3):1148-1160. doi: 10.1007/s00330-016-4426-z. Epub 2016 Jun 22. PMID: 27334017.


12. Kirschner J, Seupaul RA. Does computed tomography rule out clinically significant cervical spine injuries in obtunded or intubated blunt trauma patients? [corrected]. Ann Emerg Med. 2012 Dec;60(6):737-8. doi: 10.1016/j.annemergmed.2012.01.026. Epub 2012 Mar 8. Erratum in: Ann Emerg Med. 2013 Feb;61(2):261. PMID: 22405685.


13. Liu Q, Liu Q, Zhao J, Yu H, Ma X, Wang L. Early MRI finding in adult spinal cord injury without radiologic abnormalities does not correlate with the neurological outcome: a retrospective study. Spinal Cord. 2015 Oct;53(10):750-3. doi: 10.1038/sc.2015.45. Epub 2015 Mar 17. PMID: 25777331.


14. Como JJ, Diaz JJ, Dunham CM, Chiu WC, Duane TM, Capella JM, Holevar MR, Khwaja KA, Mayglothling JA, Shapiro MB, Winston ES. Practice management guidelines for identification of cervical spine injuries following trauma: update from the eastern association for the surgery of trauma practice management guidelines committee. J Trauma. 2009 Sep;67(3):651-9. doi: 10.1097/TA.0b013e3181ae583b. PMID: 19741415.


15. Sciubba DM, McLoughlin GS, Gokaslan ZL, Bydon A, Bessman E, Pantle H. Are computed tomography scans adequate in assessing cervical spine pain following blunt trauma? Emerg Med J. 2007 Nov;24(11):803-4. doi: 10.1136/emj.2007.050997. PMID: 17954851; PMCID: PMC2658341.

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