spinal trauma literature review

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Spinal Cord Injury Update

Fall 2009: volume 18, number 3, literature review.

The articles previewed below were selected by the editors because they include potentially useful information on the diagnosis or management of spinal cord injury and its complications. How to obtain complete articles.

Repair and restorative therapies

Hypothermia for acute care, assistive technology, pressure ulcer prevention, bowel management, neurological change.

Stem cell-based therapies for spinal cord injury. This paper reviews stem cell applications for spinal cord repair. It provides a definition of different stem cell types and describes the mechanisms that could be used to limit damage or repair the spinal cord, including neuroprotective strategies and axon regeneration. The paper reviews the ethical issues surrounding the use of embryonic stem cells (ESCs), and summarizes the advantages and disadvantages of using adult stem cells as an alternative to ESCs. While stem cell therapies have shown promise in animal studies of spinal cord injury, the risks to humans are unclear and several hurdles still need to be overcome. Ethical concerns surrounding the use and possible misuse of both embryonic and adult stem cells also need to be resolved. Tewarie RS, Hurtado A, Bartels RH, et al. J Spinal Cord Med. 2009;32(2):105-14.

Systemic administration of an antagonist of the ATP-sensitive receptor P2X7 improves recovery after spinal cord injury. Traumatic spinal cord injury is characterized by an immediate, irreversible loss of tissue at the lesion site, followed by secondary expansion of tissue damage over time. No effective treatment options currently exist to prevent secondary injury. Excessive release of the chemical ATP at the time of injury plays a role in secondary injury. The authors found that administering Brilliant blue G (BBG) a P2X7R antagonist, 15 minutes after injury in rats, reduced spinal cord anatomic damage and improved motor recovery without evident toxicity. Moreover, BBG treatment directly reduced local activation of astrocytes and microglia, as well as neutrophil infiltration. BBG is a derivative of a commonly used blue food color (FD&C blue No. 1), which crosses the blood–brain barrier. The authors suggest that this may be a feasible approach to treating traumatic SCI in humans. Peng W, Cotrina M, Han X, et al. PNAS July 28, 2009 vol. 106 no. 30 12489-12493

Activity-based restorative therapies: Concepts and applications in spinal cord injury-related neurorehabilitation. This article reviews basic and clinical science evidence pertaining to using physical activity and exercise as a therapeutic tool in the management of chronic spinal cord-related neurological paralysis. The concept of an irreparable central nervous system (CNS) is slowly being replaced with evidence related to CNS plasticity, repair and regeneration, all related to persistently maintaining appropriate levels of neurological activity both below and above the area where the damage occurred. Activity-based restorative therapies (ABRTs) are a new fundamental approach to deficits induced by neurological paralysis. The goal of this approach is to achieve activation of the neurological levels located both above and below the injury level using rehabilitation therapies. While ABRTs are not the “cure” for paralysis, they are evidence-based therapeutic interventions that can be used as a tool for neurological recovery. Sadowsky CL, Mcdonald JW Developmental Disabilities Research Reviews 15: 112 – 116 (2009)

Toward the restoration of hand use to a paralyzed monkey: brain-controlled functional electrical stimulation of forearm muscles. Functional electrical stimulation (FES) of forearm and hand muscles has been used to provide basic, voluntary hand grasp to hundreds of individuals with SCI. However, even the most advanced systems limit hand function to the few tasks programmed into the controller. In contrast, the authors are developing a system that uses neural signals recorded from a multi-electrode array implanted in the motor cortex of the brain. This system has the potential to provide independent control of multiple muscles over a broad range of functional tasks. Two monkeys were able to use this cortically controlled FES system to control the contraction of four forearm muscles despite temporary limb paralysis. Furthermore, the monkeys were able to control the magnitude and time course of the force with sufficient accuracy to match a cursor to targets at different force levels. The authors are working to refine this approach to allow voluntary control of more complex and varied hand movements. These results suggest that brain-controlled FES prostheses may ultimately benefit paralyzed patients with injuries in the mid-cervical spinal cord and be of even greater benefit to individuals with high-cervical injuries and paralysis of the entire upper limb. Pohlmeyer EA, Oby ER, Perreault EJ, et al. PLoS One. 2009 Jun 15;4(6):e5924.

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Therapeutic hypothermia for spinal cord injury. This review summarizes experimental and clinical studies of the use of hypothermia (cooling the body) for treatment of acute spinal cord injury (SCI). While early investigations evaluated the beneficial effects of more profound levels of local hypothermia treatment following SCI, recent studies have concentrated on the benefits of mild hypothermia in protecting and promoting functional recovery in animal (rat) models. In these studies, early cooling strategies improved locomotive function as well as forelimb gripping strength and coordination. In a small human study (14 subjects), modest hypothermia was found to be safe in severely injured SCI patients. Larger studies are needed to determine if therapeutic hypothermia is safe and beneficial in large numbers of SCI patients. Dietrich, W Dalton III PhD Crit Care Med. 2009 Jul;37(7 Suppl):S238-42.

Clinical and neurophysiologic assessment of strength and spasticity during intrathecal baclofen titration in incomplete spinal cord injury: single-subject design. Spasticity after spinal cord injury (SCI) is commonly managed with oral and intrathecal baclofen (ITB) (baclofen delivered directly into the cerebrospinal fluid surrounding the spinal cord by means of a catheter connected to a battery-powered pump implanted in the abdominal wall). The effects of ITB on strength and voluntary muscle activation have been largely ignored because most users have either (1) complete SCI or (2) incomplete SCI with only traces of voluntary movements and need ITB to manage spasticity that interferes with self-care or transfers. For a subset of patients who rely on residual motor control for functional mobility such as walking, there may be a fine balance between controlling spasticity and maintaining strength. This study evaluated the effects of varying doses of oral baclofen and ITB on clinical and neurophysiologic measures of strength and spasticity in a patient with an incomplete SCI. Results showed that control of spasticity can be achieved without reducing strength in incomplete SCI and suggests the need for including strength testing in comprehensive clinical assessment of spasticity. Bowden M, Stokic DS. J Spinal Cord Med. 2009;32(2):183-90.

Evaluation of Tooth-Click Triggering and Speech Recognition in Assistive Technology for Computer Access. The Tooth-click (TC) detector is a small lightweight device that fits around the ear and senses jaw vibrations when teeth are clicked together. When paired with an optical or gyrometer head mouse, it may be used to control cursor movement and mouse button clicks. This study compared the effectiveness of TC to speech recognition (SR) and compared an optical head mouse (OHM) to a gyrometer head mouse (GHM) for cursor and mouse button control of a computer. Three individuals with tetraplegia and six able-bodied controls used the devices in four combinations (TC/OHM, TC/GHM, SR/OHM and SR/GHM) to perform specific tasks involving cursor movements and mouse clicks. TC was found to be significantly faster than SR in generating mouse button clicks when paired with either type of head mouse device. Such a system may improve computer access for people with tetraplegia. The study also found that with only five minutes of training, people with tetraplegia using TC paired with either OHM or GHM could achieve cursor movement and button clicking faster than an able-bodied person using a standard mouse. Simpson T, Gauthier M, Prochazka A Neurorehabil Neural Repair. 2009 Aug 13.

Development of hybrid orthosis for standing, walking, and stair climbing after spinal cord injury. This study explores the feasibility of a hybrid system of exoskeletal bracing and multichannel functional electrical stimulation (FES) to facilitate standing, walking, and stair climbing after spinal cord injury (SCI). The orthotic components consist of electromechanical joints that lock and unlock automatically to provide upright stability and free movement powered by FES. New orthotic components, including a variable constraint hip mechanism, were designed, prototyped and successfully tested on nondisabled volunteers and an individual with SCI. The power requirements are low enough to provide more than 4 hours of continuous operation with standard camcorder batteries. Further refinements of the mechanism and additional orthotic components for the trunk, knees and ankles need to be completed before this type of system can be a practical option for persons with SCI. Kobetic R, To CS, Schnellenberger JR, et al. J Rehabil Res Dev. 2009;46(3):447-62.

Whole-body vibration improves walking function in individuals with spinal cord injury: A pilot study. Whole-body vibration (WBV)—in which subjects stand on a vibration platform for short periods—has improved walking in elderly individuals and individuals with Parkinson’s disease in previous research. This study involved 17 individuals (14 men, 3 women; age 28–65) with motor-incomplete SCI of at least one year duration. All had the ability to rise from sitting to standing with no more than moderate assistance from one person, and ability to stand (using upper extremity support) for at least one minute. They also had asymmetrical leg strength. Subjects received WBV sessions three days/week for four weeks. After the 12-session intervention, there were significant improvements in walking speed, cadence and other walking parameters. All subjects tolerated the intervention, were able to maintain the standing posture for the 45-second bouts of WBV, and reported no adverse effects. Improvements in walking speed were comparable to improvements associated with locomotor training. These findings suggest that regular use of WBV may be a potent intervention for improving walking function in individuals with incomplete SCI. Ness LL, Field-Fote EC. Gait Posture. 2009 Jul 31.

Comparative study of pressure distribution at the user-cushion interface with different cushions in a population with spinal cord injury . Wheelchair cushions for people with SCI are used to redistribute pressure in the seating area and reduce the risk of developing pressure ulcers. While consensus is lacking on what is the critical pressure at which pressure ulcers develop, the general recommendation is that skin should be subjected to the lowest possible pressure. In this study, a user-cushion pressure-recording system was used for assessing the mechanical characteristics of different types of wheelchair seat cushions. Each one of 48 patients with spinal cord injury was seated in his or her own wheelchair on the four models of cushions analyzed (low-profile air, high-profile air, dual-compartment air, and gel and firm foam), which were presented in randomized order. The pressure distribution readings and support surface area of the user-cushion interface were obtained. The dual-compartment air cushion was found to have the best pressure distribution and largest contact surface of the user-cushion interface compared to the other three cushions studied. Gil-Agudo A, De la Peña-González A, Del Ama-Espinosa A, et al. Clin Biomech (Bristol, Avon). 2009 Aug;24(7):558-63 .

Effect of sacral anterior root stimulator on bowel dysfunction in patients with spinal cord injury . The sacral anterior root stimulator (SARS) has been used for neurogenic bladder, and there have been indications that it also may be useful for neurogenic bowel. In this study, 18 patients were evaluated for bowel function before and 12 months after receiving an SARS implant. Results showed that SARS improved constipation, increased the frequency of defecation, reduced time spent on defecation, and reduced the number of methods used to achieve evacuation. Most patients reported being more satisfied with bowel function after implantation of the SARS. However, further studies focused on the characteristics of stimulation parameters are required to obtain better results. Vallès M, Rodríguez A, Borau A, Mearin F. Dis Colon Rectum. 2009 May;52(5):986-92.

Conversion in ASIA Impairment Scale during the first year after traumatic spinal cord injury. When new therapeutic approaches to spinal cord repair and regeneration move from animal studies to human clinical trials, it will be important to understand the exact time course of spontaneous recovery in order to assess the effectiveness of new therapies. The aim of this study was to assess the extent and timing of the natural course of neurological change after injury, particularly of the American Spinal Injury Association (ASIA) Impairment Scale (AIS), within the first year after traumatic SCI. Data were derived from a multicenter cohort at five fixed time points after injury: within the first 15 days and at one, three, six and twelve months post injury. About 72% of the SCI subjects, who were classified within the first 15 days as AIS A were still classified as AIS A at 6 months. While 16% of the AIS A subjects converted (changed) to AIS B, only a few became motor incomplete. In contrast, only a quarter of the AIS B subjects remained AIS B, and most of them converted to AIS C and D. Over 70% of the AIS C subjects converted to AIS D, while almost 90% of the AIS D did not convert. The natural rate of neurological change that occurs in the first year in patients treated with standard therapies needs to be considered when planning clinical trials as well as when assessing the effectiveness of new regeneration-inducing therapies. Spiess MR, Mueller RM, Rupp R, et al. J Neurotrauma. 2009 May 20 .

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• Case Report
• Published: 16 April 2024

Bilateral tibial fractures associated with powered exoskeleton use in complete spinal cord injury – a case report & literature review

• John Mahon   ORCID: orcid.org/0000-0002-9450-7798 1 ,
• Lily Nolan 1 ,
• David O’Sullivan 1 ,
• Mark Curtin 1 ,
• Aiden Devitt 1 &
• Colin G. Murphy 1  

Spinal Cord Series and Cases volume  10 , Article number:  22 ( 2024 ) Cite this article

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• Adverse effects
• Fracture repair
• Rehabilitation
• Risk factors

Introduction

Powered robotic exoskeleton (PRE) physiotherapy programmes are a relatively novel frontier which allow patients with reduced mobility to engage in supported walking. Research is ongoing regarding their utility, risks, and benefits. This article describes the case of two fractures occurring in one patient using a PRE.

We report the case of a 54 year old man who sustained bilateral tibial fractures while using a PRE, on a background of T10 AIS A SCI. The initial session was discontinued due to acute severe bilateral knee swelling after approximately 15 min. The patient attended their local hospital the following day, where radiographs demonstrated bilateral proximal tibial fractures. The patient was treated with manipulation under anaesthetic and long-leg casting for five weeks, at which point he was stepped down to hinged knee braces which were weaned gradually while he remained non-weight bearing for 12 weeks. The patient was investigated with DEXA scan and was diagnosed with osteoporosis. He was liaised with rheumatology services and bone protection was initiated. Fracture healing was achieved and weight-bearing precautions were discontinued, however this period of immobilisation led to significant spasticity. The patient was discharged from orthopaedic services, with ongoing rehabilitation and physiotherapy follow-up.

PRE assisted physiotherapy programmes are a promising concept in terms of rehabilitation and independence, however they are not without risk and it is important that both providers and patients are aware of this. Furthermore, SCI patients are at increased risk for osteoporosis and should be monitored and considered for bone protection.

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Case Report: Description of two fractures during the use of a powered exoskeleton

Surgical outcome of upper extremity fractures in patients with Parkinson’s disease

Evaluation of safety and performance of the self balancing walking system Atalante in patients with complete motor spinal cord injury

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Information generated and analysed during the writing of this paper can be found within the text itself and referenced articles.

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Acknowledgements

The authors would like to acknowledge the contributions of Dr. Cara McDonagh and her team in the National Rehabilitation Hospital, and Dr. Kieran Kelliher of Turloughmore Medical Centre for their ongoing care of the patient in this case. We would also like to acknowledge the staff at the Dublin City University Exoskeleton Programme for their assistance and expertise in the subject matter.

This project did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

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John Mahon, Lily Nolan, David O’Sullivan, Mark Curtin, Aiden Devitt & Colin G. Murphy

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JM was the main author, and was responsible for data collection and liaison with the patient, review of the literature, and writing the manuscript. LN contributed to review of the literature, data collection, and contributed to writing the manuscript. DOS and MC were involved in initial literature search, and contributed to review and feedback on the manuscript. AD and CGM are senior authors who provided feedback and final approval of the manuscript.

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Mahon, J., Nolan, L., O’Sullivan, D. et al. Bilateral tibial fractures associated with powered exoskeleton use in complete spinal cord injury – a case report & literature review. Spinal Cord Ser Cases 10 , 22 (2024). https://doi.org/10.1038/s41394-024-00635-4

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Published : 16 April 2024

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A systematic review of the effects of robotic exoskeleton training on energy expenditure and body composition in adults with spinal cord injury

Affiliations.

• 1 The University of Sydney, Nutrition and Dietetics Group, Susan Wakil School of Nursing and Midwifery, The Charles Perkins Centre.
• 2 Royal Rehab, Sydney, New South Wales, Australia.
• PMID: 38616768
• DOI: 10.1097/MRR.0000000000000626

Metabolic diseases disproportionately affect people with spinal cord injury (SCI). Increasing energy expenditure and remodeling body composition may offset deleterious consequences of SCI to improve cardiometabolic health. Evidence is emerging that robotic exoskeleton use increases physical activity in SCI, but little is known about its effects on energy expenditure and body composition. This study therefore aimed to evaluate the impact of robotic exoskeleton training on body composition and energy expenditure in adults with SCI. A systematic literature review was performed according to the Preferred Reporting Items for Systematic Review and Meta-Analysis guidelines. Five databases were searched to retrieve studies meeting pre-set eligibility criteria: adults with SCI, interventions evaluating the effects of robotic exoskeleton devices on body composition or energy expenditure. The PEDro scale guided quality assessments with findings described narratively. Of 2163 records, 10 studies were included. Robotic exoskeleton training does not significantly improve energy expenditure compared to other exercise interventions. Significant changes ( P < 0.05) in body composition, particularly reduced fat mass, however, were reported. High variability seen with the interventions was coupled with poor quality of the studies. While robotic exoskeleton interventions may propose modest cardiometabolic benefits in adults with SCI, further robust trials in larger samples are needed to strengthen these findings.

Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.

Publication types

• Systematic Review
• Body Composition* / physiology
• Energy Metabolism* / physiology
• Exoskeleton Device*
• Spinal Cord Injuries* / rehabilitation

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Sestrin2 can alleviate endoplasmic reticulum stress to improve traumatic brain injury by activating AMPK/mTORC1 signaling pathway

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Traumatic brain injury (TBI), as a serious central nervous system disease, can result in severe neurological dysfunction or even disability and death of patients. The early and effective intervention of secondary brain injury can improve the prognosis of TBI. Endoplasmic reticulum (ER) stress is one of the main reasons to recover TBI. ER stress inhibition may be beneficial in treating TBI. Sestrin2 is a crucial regulator of ER stress, and its activation can significantly improve TBI. In this paper, we analyze the biological function of sestrin2, the latest findings on ER stress, and the relationship between ER stress and TBI. We elucidate the relationship of sestrin2 inhibiting ER stress via activating the AMP-activated protein kinase (AMPK)/mammalian target of rapamycin complex 1 (MTORC1) signaling. Finally, we elaborate on the possible role of sestrin2 in TBI and explain how its activation potentially improves TBI.

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Endoplasmic reticulum stress and the unfolded protein response: emerging regulators in progression of traumatic brain injury

Crosstalk between endoplasmic reticulum stress, oxidative stress, and autophagy: potential therapeutic targets for acute cns injuries.

Elevating sestrin2 attenuates endoplasmic reticulum stress and improves functional recovery through autophagy activation after spinal cord injury

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Abbreviations

Traumatic brain injury

Endoplasmic reticulum

AMP-activated protein kinase

Mammalian target of rapamycin complex 1

Tuberous sclerosis complex

p53-activated gene 26

Activating transcription factor 4

Nuclear factor erythroid-2-related factor 2

WD repeat domain 24

GTPase-activating protein activity toward Rags1

RING finger protein 167

STAM-binding-protein-like 1

Unfolded protein response

C/EBP homologous protein

Inositol required kinase 1

Protein kinase R-like endoplasmic reticulum kinase

Mechanistic target of rapamycin

Unc-51 like autophagy activating kinase 1

Ischemia-reperfusion

Nuclear factor kappa B

Reactive oxygen species

Traumatic optic neuropathy

Protein disulfide isomerase A3

DNA J homology subfamily C member 3

TANK-binding kinase 1

Parkinson’s disease

Alzheimer’s disease

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Yu Zhou, Yong Zhang, Benson O.A. Botchway and Min Huang contributed equally to this work.

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Department of Histology and Embryology, School of Medicine, Shaoxing University, Zhejiang, 312000, China

Yu Zhou, Yong Zhang, Min Huang & Xuehong Liu

Bupa Cromwell Hospital, London, UK

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XL designed the study. YZ, YZ, BO.A.B, MH and XL prepared the first draft of the manuscript. YZ, BO.A.B, YZ, MH and XL revised the manuscript. All authors approved the final paper.

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Zhou, Y., Zhang, Y., Botchway, B.O. et al. Sestrin2 can alleviate endoplasmic reticulum stress to improve traumatic brain injury by activating AMPK/mTORC1 signaling pathway. Metab Brain Dis 39 , 439–452 (2024). https://doi.org/10.1007/s11011-023-01323-2

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Received : 25 August 2023

Accepted : 08 November 2023

Published : 04 December 2023

Issue Date : March 2024

DOI : https://doi.org/10.1007/s11011-023-01323-2

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Vol II: Person-Centred Rehabilitation – Theory, Practice and Research

Hope as experienced by people with acquired brain injury in a rehabilitationor recovery process: A qualitative systematic review and thematic synthesis Provisionally Accepted

• 1 Aalborg University, Denmark
• 2 Municipality of Copenhagen, Denmark

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Background: There has been an increasing interest in the concept of hope within the field of brain injury rehabilitation. Existing reviews have nevertheless focused on stroke, leaving out the broad populationgroup of people with acquired brain injury (ABI). Furthermore a just as majority of the included studies in those reviews excluded the subgroup of people with communication difficulties, thus primarily giving voice to a select group of people with ABI. Methods: A qualitative systematic review was conducted with the purpose of systematically reviewing and thematically synthesise findings about hope as experienced by adultspeople with ABI in a rehabilitation or recovery process. The search strategy included peer-reviewed qualitative studies published after 2000 in English or Scandinavian languages. Searches of EBSCO databases incorporating CINAHL, MEDLINE, and PsycINFO were conducted together with SocINDEX, Social Work Abstracts, Eric and Web of Science. Ten qualitative studies were included, and the Critical Appraisal Skills Program (CASP) was used for assessing the quality and relevance of the ten studies. Qualitative findings were synthesized using Thomas and Harden's methodology. data were analysed based on methods for thematic synthesis by Thomas and Harden. Results: Through a thematic synthesis eleven subthemes were identifiedemerged relating to experiences of hope. These were grouped into four analytical themes: (1) Hope a two folded phenomenon; (2) Time and temporality; (3) Progress, goals and visibility and (4) The alliance. Conclusion: This review has shown that even though hope has both a positive and negative side to it, it is necessary as a driving force for people with ABI in terms of supporting them to keep going and not give up. Rehabilitation professionals are advised to embrace the ambiguity of hope, customizing the support of hope to each person with ABI. Attention is needed on how to make progress visible for persons with ABI during their rehabilitation process just as rehabilitation professionals should acknowledge the alliance with the person with ABI as a core component of rehabilitation. This requires a focus on professionals' communication skills if hope promoting relationships between professionals and persons with ABI are to be achieved.

Keywords: hope, acquired brain injury, Rehabilitation, Recovery, literature review, qualitative studies, thematic synthesis

Received: 26 Jan 2024; Accepted: 26 Apr 2024.

Copyright: © 2024 Højgaard Nejst and Glintborg. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY) . The use, distribution or reproduction in other forums is permitted, provided the original author(s) or licensor are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

* Correspondence: PhD. Camilla Højgaard Nejst, Aalborg University, Aalborg, Denmark

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• PMC10787207

Real Spinal Cord Injury Without Radiographic Abnormality (SCIWORA) in Pediatrics: A Clinical Case Report and Literature Review

Joao meira goncalves.

1 Neurosurgery, Centro Hospitalar Universitário de São João, Porto, PRT

Sara Carvalho

2 Neuroradiology, Centro Hospitalar Universitário de São João, Porto, PRT

Ana Isabel Silva

3 Physical Medicine and Rehabilitation, Centro Hospitalar Universitário de São João, Porto, PRT

Josué Pereira

Patricia polónia.

Spinal cord injury without radiological abnormality (SCIWORA) was first reported in 1974. The term was used to define “clinical symptoms of traumatic myelopathy without signs of fracture or spine instability on X-ray or CT scan.” With the emergence of MRI, the gold standard method to identify spinal cord injuries, about two-thirds of former SCIWORA cases were found to have pathological findings, and, as such, the term has taken on an ambiguous meaning in the literature.

We describe the clinical case of a 17-year-old boy who was admitted to the emergency department of a tertiary hospital after a fall during a soccer game. He suffered spinal and cranioencephalic trauma. A few minutes later, the boy began to show decreased strength in the right upper limb and lower limbs, as well as changes in sensation in the right hemibody.

On objective examination, the boy presented a Glasgow Coma Scale score of 15 and the American Spinal Injury Association Impairment Scale D, with partial improvement of initial symptoms of monoparesis of the right lower limb. There were no other changes, specifically at the sensory level. The patient underwent a CT and MRI of the spine that showed no fractures, instability, or appreciable medullary signal changes. Electromyography was normal. Based on the clinical history and imaging findings, real SCIWORA was diagnosed. The patient was admitted to an inpatient rehabilitation program. At a follow-up visit two months later, a complete reversal of signs and symptoms was confirmed.

The prognosis of this pathology depends on the extent of the spinal cord injury, as evidenced by MRI. Although neurological improvement when severe deficit is present at initial presentation is unlikely, most patients with incomplete neurological damage show good recovery. The absence of visible changes on MRI is associated with a better prognosis.

Introduction

Spinal cord injury without radiological abnormality (SCIWORA) is often described as the manifestation of acute traumatic myelopathy despite normal X-rays and CT scans [ 1 ]. It predominantly affects the cervical spine [ 2 - 4 ]. The incidence of SCIWORA was found to be 8% to 32% in numerous reports [ 2 ]. With the advent of MRI, the detection of acute herniated discs and ligament injuries, as well as intramedullary and extramedullary injuries in cases previously classified as SCIWORA, has increased [ 3 , 4 ]. In the majority of situations, SCIWORA is caused by hyperextension or hyperflexion injuries because of characteristic anatomic variations such as elasticity and a more deformable spine in children. They might initiate a transient occlusion of the vertebral arteries or the anterior spinal artery, resulting in a spinal infarction [ 3 ]. SCIWORA exhibits a wide range of neurological deficits, ranging from minor and transient injuries to complete spinal cord injuries. Neurological deficits can appear late, hours to days after injury [ 1 ]. We present the case of a patient who was diagnosed with a real SCIWORA along with a review of the literature.

Case presentation

A 17-year-old male patient, a victim of a fall with traumatic brain injury and spinal trauma aftershock (heading duel) during a soccer game, presented to the emergency department of a tertiary hospital. He had occipital cranioencephalic trauma resulting from dorsal, cervical, and head impact after the fall. He denied loss of consciousness, nausea, or vomiting. A few minutes later, he reported a decrease in strength in the right upper limb and lower limbs, as well as changes in sensation in the right hemibody. He was admitted to the emergency room on a spine board stretcher with a Glasgow Coma Scale score of 15 and scored level D on the American Spinal Injury Association (ASIA) scale. He underwent a detailed neurological examination, which revealed right lower limb monoparesis, with a muscular strength grade of 3/5, without left limb deficits. No sensation or vesico-sphincter changes were reported. The remaining neurological examination was unremarkable. He underwent a CT of the head and spine, followed by an MRI of the dorsal/cervical spine. No abnormalities were found (Figure ​ (Figure1). 1 ). Given the attained deficit, the patient was admitted to the pediatric neurosurgical ward. Based on the clinical history and imaging findings, real SCIWORA was diagnosed. He remained in the hospital for eight days, maintaining the same neurological status. During this period, electromyography was unremarkable. The patient was discharged from the hospital for elective admission to a rehabilitation center. Neuroaxis MRI examination 1.5 months later showed normal findings. At the reassessment consultation two months later, the patient exhibited complete reversal of symptoms, having returned to his normal life without limitations and with former sports activity.

a: T2 sagital. b: short tau inversion recovery sagittal

Since the first description of SCIWORA by Pang and Wilberger in 1982, the definition of this entity has constantly evolved. This change is largely due to the evolution of diagnostic methods, namely, MRI, which began to detect changes that were not previously reported [ 5 ]. Although not yet universally accepted, the literature distinguishes three designations in pediatric patients (Table ​ (Table1) 1 ) [ 6 ].

SCIWORA: spinal cord injury without radiological abnormality; MRI: magnetic resonance imaging

SCIWORA represents a moderately infrequent disease; however, it may be a devastating injury among children. Piatt found that SCIWORA was responsible for nearly 20% of injuries in children under three years old. Between those aged 3-12 and 13-20, an incidence of 9.4% and 5%, respectively, was reported [ 7 ]. Prior reports have verified that SCIWORA in youngsters usually occurs within the higher cervical spine, whereas in adolescents it is more typically seen in the lower cervical and thoracic spine. The severity of the injury is also significantly influenced by the patient’s age, with children below eight years old often sustaining complete and severe neurological deficits [ 8 ].

In our case, the patient presented with an incomplete neurological deficit. At the time of admission, he was showing partial neurological recovery, suggesting a good prognosis.

Knox found that, overall, the most common cause of injury was sports-related. It accounted for 41% of injuries, followed by motor vehicle accidents at 26%, falls at 14%, assault at 4%, and being hit with a falling object at 3% [ 8 ].

There are four supposed mechanisms for SCIWORA, namely, longitudinal distraction, hyperflexion, hyperextension, or ischemic spinal cord injury [ 9 ]. It is believed that SCIWORA is seen less often in adults as a result of age-related changes in bone morphology and a reduction in ligamentous laxity [ 10 ]. Toddlers also have proportionately larger heads with underdeveloped neck muscles. As a result, infants and young children are particularly vulnerable to hyperflexion and hyperextension injuries.

Patients diagnosed with SCIWORA have a wide range of neurological deficits, ranging from mild and transitory symptoms such as paresthesia in the fingers to quadriplegia. In some patients, symptoms appear at the time of injury. However, it should be noted that neurological deficits may not manifest until a few minutes after the injury (they can develop very slowly over time as swelling or bleeding occurs around the injured level).

Initial clinical evaluation and history-taking are more difficult in young patients. Consequently, initial treatment begins with spinal immobilization and clinical assessment.

After the initial management in the field, the diagnostic workup of patients suspected of having spinal cord injury should begin with a detailed medical history, possibly obtained from eyewitnesses, to determine the mechanism of injury. Conventional radiographs are generally performed as a first-line imaging test to exclude fractures or subluxations. CT scans are more accurate in detecting vertebral fractures. MRI is the best modality for direct evaluation of the spinal cord [ 11 , 12 ]. We reviewed the literature and adapted the diagnostic protocol from Atesok et al. (2018) with minor changes (Figure 3). We emphasize the importance of including peripheral nerve pathology in the differential diagnosis. Follow-up MRI at six to nine months should also be considered.

Adapted from Atesok et al. [ 11 ].

SSEP: somatosensory evoked potentials; GRE: gradient echo; STIR: Short tau inversion recovery; AP: anteroposterior; LAT: lateral; CT: computed tomography; MRI: magnetic resonance imaging; SCIWORA: spinal cord injury without radiological abnormality

Spinal cord lesions detected by MRI are important prognostic factors in patients with SCIWORA. Small hematomas (up to one-third of the spinal cord diameter) or edema have a good prognosis and in most cases disappear with time. Anatomic transection of the spinal cord or considerable hematomas (more than half the diameter of the spinal cord) have a poor prognosis and clinically manifest as paresis or paralysis [ 12 ]. Patients with neurological findings consistent with SCIWORA on examination and a normal MRI generally have an excellent prognosis [ 10 ]. Another important factor in predicting prognosis is the neurological status. ASIA is the currently used tool for assessing neurological impairment in patients with SCIWORA. The literature shows that patients with less severe spinal cord injuries are more likely to achieve a full recovery. However, patients with severe injuries were found to have residual or persistent neurological dysfunction at follow-up [ 12 , 13 ].

Based on the current knowledge and past literature, surgical treatment is not recommended in SCIWORA patients with pure or normal intraneural MRI, regardless of neurological status. Clear MRI evidence of ligament injury, spinal cord compression, and instability, along with declining neurological findings, should be indications for surgical decompression with or without fusion [ 11 ]. There is a lack of data supporting the regular use of high-dose intravenous steroids in SCIWORA patients [ 10 ]. The main treatment option for patients with spinal cord injuries is external spinal immobilization for up to 12 weeks. Patients are also advised to avoid high-risk activities for six months to prevent the worsening of symptoms and reduce the risk of further injury [ 12 ]. Physiotherapy can be started as soon as the patient’s general condition allows and can continue throughout the treatment [ 10 ].

Discharging a patient with a motor disability can be a challenge for the family and the patient. In our case, rapid admission to a rehabilitation program and reassurance was fundamental. The post-traumatic stress disorder (PTSD) rate for spinal cord injuries is between 7% and 44%. In this case, the patient in question did not need psychobehavioral therapy, as the deficit had improved completely. In specific cases, we should consider offering reak SCIWORA patients a psychological co-treatment [ 3 ].

Conclusions

In patients with SCIWORA, MRI is crucial and should be done for all patients. Imaging findings are extremely important in predicting outcomes. A better understanding of the disease progression can help the doctor to diagnose accurately and plan management with improved clarification and education for the frustrated patient and their families. This case report emphasizes the good prognosis for patients in whom MRI is normal. Psychological outcomes resulting from neurologic incapacity and trauma are tremendous and psychological care is advisable to prevent PTSD.

The authors have declared that no competing interests exist.

Author Contributions

Concept and design:   Joao Meira Goncalves, Sara Carvalho, Ana Isabel Silva, Josué Pereira, Patricia Polónia

Acquisition, analysis, or interpretation of data:   Joao Meira Goncalves, Sara Carvalho, Ana Isabel Silva, Josué Pereira, Patricia Polónia

Drafting of the manuscript:   Joao Meira Goncalves, Sara Carvalho, Ana Isabel Silva, Josué Pereira, Patricia Polónia

Critical review of the manuscript for important intellectual content:   Joao Meira Goncalves, Sara Carvalho, Ana Isabel Silva, Josué Pereira, Patricia Polónia

Human Ethics

Consent was obtained or waived by all participants in this study