SCIWORA Syndrome (Spinal Cord Injury without Radiologic Abnormality)

SCIWORA Syndrome (Spinal Cord Injury without Radiologic Abnormality) is a topic covered in the 5-Minute Clinical Consult.

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Also called spinal cord injury without radiographic evidence of trauma (SCIWORET), spinal cord injury without CT evidence of trauma (SCIWOCTET), or spinal cord injury without neuroimaging abnormality (SCIWONA)


  • SCIWORA occurs after trauma; it is an acute spinal cord injury (SCI) and nerve root trauma resulting in transient or permanent sensory, motor, or combined sensorimotor deficits.
  • Neural injuries occur without a fracture or misalignment visible on imaging (x-ray, CT).
  • SCIWORA has a broad presentation, from minor neurologic symptoms to complete quadriplegia.


  • Variable: reported to be 19–34% of pediatric SCIs (1)
  • Occurs in all populations—90% in pediatric patients (1)
  • Bimodal: affects children <8 years old and adults >60 years old; rarely occurs between 16 and 36 years (2)
  • There is no association between Chiari malformation type 1 and SCIWORA.

Etiology and Pathophysiology

  • Trauma (3)
    • Motor vehicle collision (MVC) (most common cause); either unrestrained passengers, pedestrians, or bicyclists struck by motor vehicles
    • Sports-related injury
    • Significant fall
    • Child abuse
  • Mechanism
    • Traumatic neural (edema, hematomyelia, cord disruption) and extraneural (disc injury or ligament disruption) injury occurs after (2,4):
      • Hyperextension
      • Hyperflexion
      • Longitudinal distraction
      • Ischemic damage
      • Secondary injury from inflammatory response to tissue damage
  • Age: Pediatric patients have a higher incidence of SCIWORA than adults due to anatomic differences and increased mobility and flexibility (1,5).
    • Horizontally oriented facet joints permit more translational motion in the coronal (AP) plane.
    • Anterior wedging of vertebral bodies
    • Ligament and joint capsule elasticity permits increased intersegmental movement and disc protrusion.
    • In patients age <8 years, head size-to-trunk ratio is disproportionately large.
    • Weaker nuchal musculature
    • Uncovertebral joints are absent.
    • Pseudosubluxation of C2–C3
  • Location
    • Cervical: upper > lower
    • Thoracic: protected and splinted by ribs preventing forced flexion and extension
    • Lumbar: rare and usually fatal (1)

Risk Factors

  • History of trauma
  • Age <8 years
  • Male: female
    • Adult; 4.5:1 (3), children; 2:1 (3)
  • Improper seatbelt wear

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