Pediatric spinal cord injury without radiographic abnormality (SCIWORA) - The absence of occult instability and lack of indication for bracing

Study Design. A retrospective review of medical records and imaging studies of children diagnosed with spinal cord injury without radiographic abnormality (SCIWORA) or SCIWORA-like symptoms at Children's Hospital of Pittsburgh between 1965 and 1999 was undertaken. Objectives. To evaluate the existence of occult segmental spinal instability and a role for bracing as treatment for SCIWORA, we contrasted the Children's Hospital of Pittsburgh experience with literature reports on SCIWORA. Summary of Background Data. There is a great deal of confusion and conflicting evidence regarding pediatric SCIWORA in the literature. Previous reports from our institution reported unique findings, including the only description of serious, recurrent SCIWORA in the literature. These findings have frequently been cited as the justification for long-term immobilization in all cases of SCIWORA. Methods. All records on patients coded as spinal cord injury without fracture or dislocation (ICD-9 code 952.xx) were reviewed. Children 17 years of age or younger with traumatic spinal cord injury and normal plain radiographic findings were included. Penetrating trauma, infection, or metabolic diseases were excluded. Results. A total of 189 patients were diagnosed with SCIWORA at our institution over the 35-year review period. These patients differed from those reported in the literature with respect to a higher incidence, older age, less involved neurologic injury, and more low-energy mechanisms, such as sports and falls. There were no cases of a patient with SCIWORA who deteriorated and developed a permanent neurologic deficit after having either recovered or plateaued from an initial SCIWORA. All recurrent SCIWORA recovered to normal neurologic function. Bracing did not demonstrate any benefit in preventing these minor recurrent SCIWORAs. Conclusion. We identified no cases of serious, recurrent SCIWORA at our institution from 1965 to 1999. A case-by-case evaluation is required for the treatment of spinal cord injury without apparent spinal column injury, and bracing is not uniformly indicated.