Spinal Cord Injury without Radiographic Abdnormalities SCIWORA

USE: To demonstrate the importance of thorough diagnostic exami- nation of trauma patients. TITLE: 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 CITATION: J Trauma. 2008; 65:86-93. AUTHORS: Georgios B. Kasimatis, MD; Elias Panagiotopoulos, MD, PhD; Panagiotis Megas, MD, PhD; Charalambos Matzaroglou, MD; John Gliatis, MD, PhD; Minos Tyllianakis, MD, PhD; and Elias Lambiris, MD, PhD. When evaluating the traumatically injured patient, correlation of all aspects of the diagnostic process is paramount to proper care. The diagnostic process starts with eliciting a complete and thorough history of the trauma and the resulting symptoms. "Eliciting" a history is different than "taking" a history. Elicit­ing a history involves the clinician asking pointed questions about each and cveiy part of the patient's body, to ensure subtle complaints are not overlooked. In many cases, these subjec­tive complaints help to direct objective testing. Correlating the patient's history with physical examination, lab results and imaging studies helps to complete the diagnostic picture and provide the doctor with an accurate causal relationship, prognosis and treatment plan. What if the history, objective and radiological testing do not correlate? Did the patient have an accident? Go to the ER for evaluation only to be released with radiographs and CT being normal? Is it your policy to evaluate the patient or do you rely on the testing of others to diagnose your patients? This very recent paper, published in The Journal of Trauma in 2008, by Kasimutis, et al.. discusses in deptli the presentation of patients with cervical spine injury that had a "radiologic-clinical mismatch." The authors state. "This retrospective review provides information on adult patients with cervical spinal cord injuries whose radiographs and computed tomography studies were normal." (Kasimatis, et al., 2008. p. 86) By definition. SC1W0RA consisted of negative radiologic investigation with plain radiographs and CT scans, but not MRI. It is important to note that the authors reported, "No patient with an up­per cervical spine injury did have any radiological and clinical mismatch." (Kasimatis, et al., 2008, p. 90) It was shown that, in the cases presented in this paper, the highest level of involvement was the C4-5 level. In all patients reviewed that had SCIWORA, it was the non-boncy components of the spinal cord, intervertebral disc or ligamcntum flavum, that caused injury to the spinal cord, or it was an epidural hematoma. The epidural he-matoma was particularly observed in the patients with a fused spinal column, such as ankylosing spondylitis or cervical spondylosis. The authors go on to say, "SCIWORA was first described by Pange, et al. (1982), and is a well known entity in pediatric populations, but its incidence in adults varies sienificantlv amnne studies " (Knsimntk et al., 2008, p. 90). When imaging studies are reviewed, they are often read as having, or not having, radiological evidence of trauma. This is an important point of discussion since all struc­tures in the spine must be evaluated. The physical examination plays a very important role, as does MRI. Since SC1WORA is an entity that evolved because of the lack of soft tissue imaging in the trauma patient. MRI becomes a vei'y important diagnostic tool prior to the chiropractic adjustment. The mechanism of injury in Spinal Cord Injury (SCI) is also important to understand, since two phases have been identi­fied. In the first phase, it is the primary injury or mechanical insult that results in the damage to spinal cord tissue. This is particularly important in patients with bone spurs, as the cord can be stretched across these structures. Secondly, there is a physiological and histochcmical response to the initial trauma The following review is provided for educational purposes only. It is not designed or intended to reproduce or replace the authors' work. Readers are encouraged to obtain full licensed versions of the article as determined by Copyright Law. For information on how to obtain a licensed copy, please contact the Academy directly. that causes further damage to the spinal cord, "...among which free radical forma­tion, vascular disturbances and apoptosis are the principal ones." (Kasimatis, et al., 2008, p. 91). This study reports some interesting final points: 1. "A rate of around 5% may be con­sidered as representative of the true incidence of cervical SWIWORA." (Kasimatis, etal., 2008, p. 90). 2. "Children below 8 years and the el­derly above 60 are mostly affected, but the two populations have different characteristics." (Kasimatis. et al., 2008, p. 90). In children, the dispro­portionate size of the head related to the neck causes excessive injury, while in the elderly it has more to do with pre-existing degenerative changes and loss of disc height. Since the pre-exist­ing changes in the spine are the issue, consideration of this phenomenon in any patient that has pre-existing changes in the spine, regardless of age, is appropriate. 3."....the physician dealing with a pos­sible SCIWORA patient should be aware that the correlation of physical examination with the radiological studies is mandatory, and he should perform MRI in all cases." (Kasimatis, et al., 2008, p. 92) When evaluating patients that are trau-matically injured, correlation of all clini­cal findings is mandatory, especially prior to chiropractic adjustment. In the case of spinal cord compromise, direct and speedy neurosurgical referral is critical. Each issue, a clinical topic will he provided by Drs. Mark Stiidin & William J. Owens of the American Academy of Medical Legal Pro­fessionals (AA A'ILP), which is a national non­profit organization comprised of doctors and lawyers. The purpose of the organization is to pmvide its members with current research in trauma and spinal-related topics to keep the professional on the culling edge of healthcare. Members may also sit for a Diplomate ex­amination and be conferred a DAAMLP. The organization also offers support to the indi­vidual member s practice. To learn more, go to www.aamlp.org or call 1-716-228-5X47.