1034 THE JOURNAL OF BONE AND JOINT SURGERY P. Kothari, MS(Orth), Specialist Orthopaedic Registrar B. Freeman, FRCS Orth, Senior Spinal Fellow M. Grevitt, FRCS Orth, Consultant Spinal Surgeon Centre for Spinal Studies and Surgery R. Kerslake, FRCR, Consultant Radiologist Department of Diagnostic Radiology University Hospital, Queen���s Medical Centre, Nottingham NG7 2UH, UK. Correspondence should be sent to Mr M. Grevitt. ��2000 British Editorial Society of Bone and Joint Surgery 0301-620X/00/710641 $2.00 Injury to the spinal cord without radiological abnormality (SCIWORA) in adults P. Kothari, B. Freeman, M. Grevitt, R. Kerslake From the University Hospital, Nottingham, England Injury to the spinal cord without radiological abnormality often occurs in the skeletally immature cervical and thoracic spine. We describe four adult patients with this diagnosis involving the cervical spine with resultant quadriparesis. The relevant literature is reviewed. The implications for initial management of the injury, the role of MRI and the need for a high index of suspicion are highlighted. J Bone Joint Surg [Br] 2000 82-B:1034-7. Received 12 October 1999 Accepted after revision 19 April 2000 Since its first description by Pang and Wilberger,1 injury to the spinal cord without radiological abnormality (SCI- WORA) has been well documented in the paediatric lit- erature.2,3 The relatively large size of the head and the greater inherent mobility in the immature axial skeleton, combined with ligamentous laxity or disruption, render the spinal cord vulnerable to damage in high-energy trauma. In the absence of osseous injury on plain radiographs or tomography, MRI should demonstrate abnormalities in all cases. SCIWORA in adults is rare, but is of considerable importance because of the potential problems of manage- ment inherent in the diagnosis. We report four such cases, highlighting common clinical features, and consider their relevance in general trauma practice. Case Reports Case 1. A 24-year-old male motorcyclist came off the road at high speed. He wore no helmet and had a severe head injury. When initially assessed at the receiving hospital the plain radiographs of the neck were normal apart from a narrow spinal canal (Fig. 1a). On regaining consciousness he was noted to be quadriparetic with MRC grade-II power in most muscle groups. Apart from some dysaesthesia in the upper limbs there were no other neurological symptoms or signs. He was transferred to our unit 48 hours later, by which time power in the upper limbs had recovered to MRC grade III and in the lower limbs to grade IV. MR images showed mild, focal swelling of the cord and oedema at C3/4, with prevertebral soft-tissue swelling and disrup- tion of the anterior longitudinal ligament. In addition, there was low signal intensity in the C3/4 disc with a shallow, posterior bulge without focal compression of the cord. There was oedema in the posterior ligamentous complex at the same level and at C4/5. Abnormalities were seen in the horizontal linear signal in the bodies of T2 to T6 indicative of undisplaced compression fractures (Fig. 1b). A diagnosis of central cord syndrome was made. The patient made further neurological recovery, and repeat MRI two months after the injury showed resolution of the oedema in the cord but persistent signal changes which were suggestive of myelomalacia. Fig. 1a Fig. 1b Case 1. Figure 1a ��� Lateral plain radiograph of the cervical spine showing minimal prevertebral soft-tissue swelling at C3/4 (arrows). No fracture is apparent. The alignment of the vertebral bodies is normal. Figure 1b ��� Sagittal MRI (T2-weighted) showing a small prevertebral haematoma with elevation of the anterior longitudinal ligament. A shallow posterior bulge of the C3/4 disc is apparent with focal oedema. The alignment of the vertebral bodies is normal. There are undisplaced linear fractures in the upper thoracic spine (arrow). Other images show posterior ligamentous disruption at C3/4 and C4/5 indicating a predominantly hyperflexion injury.

Case 2. A 33-year-old woman was admitted with quad- riparesis after a fall from a ladder. Physical examination revealed a sensory level at C5, MRC grade-II power in the upper and lower limbs but no tenderness in the neck. Plain radiographs showed congenital fusion at C2/3 and C7/T1 (Fig. 2a). No bony injury was apparent. She was given high-dose intravenous methylprednisolone. MRI showed marked constitutional narrowing of the cervical spinal canal from C3 to C7 with oedema of the cord between C4 and C7. There was focal compression of the cord at C5/6 caused by a spondylotic ridge. Posterior ligamentous oede- ma was apparent at the C4/5 and C5/6 segments with more diffuse soft-tissue oedema at the upper cervical levels (Fig. 2b). As there was no early evidence of neurological improve- ment she underwent laminectomy from C3 to C6 no dural tears were seen at operation. She was transferred to the regional spinal-injuries unit where she recovered MRC grade-IV power in the upper and lower limbs and regained some sphincter control. Case 3. An 18-year-old man was physically assaulted while drunk. He sustained a severe head injury with a Glasgow Coma Score of 7 on admission. A CT scan of the brain revealed contusion of the left parietal lobe. The patient���s level of consciousness returned to normal 48 hours later but he was quadriparetic. Review of the initial cervical radiographs was thought to show a minimal anterior com- pression fracture of C6 with slight rotation (Fig. 3a). On transfer to our unit he was noted to have a sensory level at C5 with no active movement in any of his four limbs but no posterior cervical tenderness. Catheter tug sensation was present but the anus was patulous. The bulbocavernosus reflex was present at that stage. MRI showed oedema of the mid-cervical cord and focal haemorrhage at C5/6 (Fig. 3b). There was a shallow, diffuse disc bulge at the same level. Subtle horizontal, linear oedema was seen in the vertebral bodies of C5 and C6 without evidence of discrete fractures. There was associated disruption of the posterior ligament at C4/5, C5/6 and C6/7 with diffuse soft-tissue oedema in the upper cervical region. He was managed conservatively but there was no neurological recovery. Case 4. A 49-year-old unsecured male passenger in a rear seat was ejected from a car in an accident at high speed. He sustained serious head, maxillofacial and abdominal inju- ries. Plain radiographs of the neck showed no bony injury. After resuscitation he required a laparotomy at which lac- erations of the liver were repaired. He was transferred to our neurosurgical unit where he was observed to have movement in all four limbs. Repeat CT scans of the brain, and sections through C7/T1 which had not been adequately demonstrated on the initial views, were normal. An intracranial pressure transducer was inser- ted and his maxillofacial fractures were reduced and stabi- lised. After four days in intensive care, following extubation and reversal of sedation, he was conscious enough to complain of neck pain. He remained quad- riparetic, however, with no useful motor function below C5. MRI of the spine revealed a constitutionally narrow canal. There was a small posterior disc protrusion at C5/6 with associated focal oedema of the cord at this level. There was also injury of the mid-cervical posterior liga- ment and horizontal, linear signal abnormalities in the vertebral bodies of T3 and T4 (Fig. 4). Subsequent CT of VOL. 82-B, NO. 7, SEPTEMBER 2000 Fig. 2a Fig. 2b Case 2. Figure 2a ��� A lateral plain radiograph of the cervical spine showing congenital fusion at C2/3 and C7/T1. Minor spondylotic changes are apparent at C5/6 but no fracture is evident. The central canal is narrow. Figure 2b ��� Sagittal MRI showing congenital fusion at C2/3 and C7/T1 and constitutional stenosis of the central canal. There are spondylotic changes at the mobile mid-cervical levels and a shallow traumatic protru- sion of the disc at C5/6, with associated oedema of the cord from C3 to C7. There is diffuse soft-tissue oedema (arrow) indicative of a hyper- flexion injury. Fig. 3a Fig. 3b Case 3. Figure 3a ��� Lateral plain radiograph of the cervical spine showing a small anterosuperior corner fracture of C6 (arrow). Figure 3b ��� Sagittal T2-weighted MRI. The images are degraded by movement artefact. The area of low-signal intensity centrally within the cord at C5/6 is indicative of haemorrhage and there is surrounding oedema. There is a shallow posterior bulge of the C5/6 disc although the small anterior fracture of C6 cannot be readily appreciated. Other images show posterior ligamentous injury indicative of a hyperflexion injury.