SCIWORA — Spinal Cord Injury Without Radiographic Abnormality¶

Definition¶

SCIWORA (Spinal Cord Injury Without Radiographic Abnormality) refers to clinical spinal cord injury in the absence of fracture or dislocation on plain radiographs and CT. Originally described in children by Pang and Wilberger in 1982, the concept has evolved significantly with the widespread use of MRI, which frequently identifies the cause of the neurological deficit.

Pathophysiology¶

SCIWORA occurs because the spinal column (bones and ligaments) can undergo transient deformation during trauma — stretching, flexing, or extending beyond the normal range — before returning to its anatomical position. During this transient deformation, the spinal cord sustains injury even though the bony and ligamentous structures appear normal on post-injury imaging.

Pediatric SCIWORA¶

Children are particularly susceptible due to:

Ligamentous laxity — Greater elasticity of the spinal ligaments
Horizontal facet orientation — Allows greater translational movement
Relatively large head — Creates a longer lever arm at the craniocervical junction
Immature vertebral bodies — Wedge-shaped bodies that allow more motion
Unfused synchondroses — Additional points of flexibility

The pediatric spinal column can stretch up to 5 cm without disruption, while the spinal cord tolerates only 5–6 mm of stretch before injury occurs.

Adult SCIWORA¶

In adults, SCIWORA is most commonly seen in patients with pre-existing cervical spondylosis (narrowed canal, disc osteophyte complexes) who sustain a hyperextension injury. The mechanism is typically central cord syndrome — the cord is compressed between the posterior disc/osteophyte complexes anteriorly and the buckled ligamentum flavum posteriorly during extension, then the canal returns to normal caliber as the spine returns to a neutral position.

Imaging¶

CT¶

By definition, CT (and radiographs) show no fracture or dislocation. However, CT may demonstrate pre-existing spondylosis or congenital canal narrowing that predisposed the patient to cord injury.

MRI¶

MRI is essential and frequently identifies the cause of injury:

Cord edema — High T2/STIR signal within the spinal cord at the level of injury
Cord hemorrhage — Low T2 signal centrally, indicating more severe injury
Disc herniation — Acute traumatic disc herniation compressing the cord
Ligamentous injury — High T2 signal in the posterior ligamentous complex, disc, or anterior longitudinal ligament, indicating transient instability
Pre-existing spondylosis — Disc osteophyte complexes, ligamentum flavum hypertrophy, and canal stenosis

In some cases, MRI may be entirely normal despite clinical spinal cord injury — true "MRI-negative SCIWORA." This is more common in children and may represent transient vascular injury, concussive cord injury, or injury below the resolution of current MRI sequences.

Clinical Pearl

With modern imaging, the term SCIWORA is somewhat misleading — MRI frequently reveals the mechanism of injury (disc herniation, ligamentous instability, cord edema). Some authors prefer the term "Spinal Cord Injury Without Radiographic Evidence of Trauma" (SCIWORET) or simply describe the MRI findings directly. Regardless of terminology, the key clinical point is: a neurological deficit with a normal CT mandates emergent MRI.

Management¶

Immediate spinal immobilization
Emergent MRI to evaluate the cord, discs, and ligaments
If a compressive lesion is identified (disc herniation, epidural hematoma), surgical decompression may be indicated
If MRI shows ligamentous instability, surgical stabilization may be necessary
If MRI is normal, treatment is supportive with close neurological monitoring
Avoidance of high-risk activities during recovery period

Key Points¶

SCIWORA is spinal cord injury without fracture or dislocation on CT/radiographs
More common in children (ligamentous laxity) and adults with pre-existing spondylosis
MRI is mandatory and frequently identifies the cause (disc herniation, cord edema, ligamentous injury)
A neurological deficit with a normal CT always requires emergent MRI
MRI-negative SCIWORA can occur, particularly in children
Management depends on MRI findings — compressive lesions may require surgical decompression

References¶

Pang D, Wilberger JE Jr. Spinal cord injury without radiographic abnormalities in children. J Neurosurg. 1982;57(1):114-129. PubMed
Farrell CA, Hannon M, Lee LK. Pediatric spinal cord injury without radiographic abnormality in the era of advanced imaging. Curr Opin Pediatr. 2017;29(3):286-290. PubMed
Atesok K, Tanaka N, O'Brien A, et al. Posttraumatic spinal cord injury without radiographic abnormality. Adv Orthop. 2018;2018:7060654. PMC
Sharma S, Singh M, Wani IH, Sharma S, Sharma N, Singh D. Adult spinal cord injury without radiographic abnormalities (SCIWORA): clinical and radiological correlations. J Clin Med Res. 2009;1(3):165-172. PMC
Palombi D, Galeazzi M, Brigato P, et al. Redefining pediatric SCIWORA: a systematic review of the literature on clinical patterns, imaging profiles, and management insights. J Clin Med. 2025;14(17):6338. PubMed
Gaillard F, et al. Spinal cord injury without radiographic abnormality (SCIWORA). Radiopaedia.org. Radiopaedia