Approximately 50% of adults with SCI have an incomplete injury (10). Approximately 33% of children less than 8 years of age and 50% of adolescents with SCI have an incomplete injury (11).

The mechanism of injury varies with the age of the patient. However, motor vehicle accidents cause the highest percentage of injuries. In children aged birth to 5 years, violence and falls contribute the next highest number of injuries. In the age group 6 to 15 years, sports and violence are major culprits (3). Diving is most commonly associated with cervical spine injury, followed by football, gymnastics, and wrestling (12). In neonates, the leading cause of cervical injury is birth trauma. MacKinnon et al. (13) reported that the injury occurred from C0 to C4 in 64% of patients. Other etiologies of SCI in children and adolescents include child abuse and transverse myelitis (14, 15 and 16).

In 1982, Pang and Wilberger popularized the acronym SCIWORA for “SCI without radiographic abnormality” (17). These children sustain traumatic myelopathy with no radiographic evidence of bony injury. Four mechanisms of injury have been clearly implicated in the pathogenesis of SCIWORA: hyperextension, hyperflexion, distraction, and ischemia. The incidence of SCIWORA varies widely in the literature, from 5% to 67% (17, 18, 19 and 20). The wide variability is partly explained by inconsistent definitions of SCIWORA employed in the literature. At the time of the original report by Pang in 1982 (17), magnetic resonance imaging (MRI) was not widely available, and the definition relied solely on normal plain films and computed tomography (CT). Recently, with the widespread use of MRI, some authors have questioned the relevance of the term SCIWORA (19,21) (Fig. 34.1). Some, including ourselves,
are promoting the term “SCIWONIA”—SCI without neuroimaging abnormality.

The pediatric spine demonstrates numerous properties that make it susceptible to SCI without bony pathology. The high water content of the intervertebral disks and annulus allows for marked stretching. The neck muscles and uncinate processes are underdeveloped. The vertebral bodies are wedged ventrally, allowing for enhanced forward slippage. The facet joints are shallow with a horizontal orientation, rather than oblique as found in adults, which allows translational mobility both laterally and in flexion/extension. In addition, the ligaments and facet capsules permit significant stretching (22, 23, 24 and 25). This explains the phenomenon in young children of pseudosubluxation, or seemingly excessive angulation between C2 and C3 (26). These factors in combination with a high head-to-torso ratio increase the chances of injuring the inelastic spinal cord without obvious bony injury.

Delayed onset of neurologic deficit following SCIWORA has been reported (18,27, 28, 29 and 30). This usually occurs within 48 hours of injury and may be preceded by transient weakness or sensory impairment. Postulated mechanisms remain speculative and include occult spinal instability leading to repeated spinal cord trauma (28) or an ischemic etiology (31). Recurrent SCIWORA has also been reported in the literature (17,18,27,32,33), although some suggest the incidence may not be as high as first thought (19). Pollack et al. (32) reported that 8 of 18 patients sustained a more severe recurrent SCIWORA. The majority of the patients had a mild initial SCIWORA. Subsequently, four of the eight patients sustained permanent neurologic deficits. They attributed this recurrent SCIWORA to occult spinal instability and recommended a hard cervical collar for 3 months following the initial injury. Bosch et al. (19) in a follow-up report on the experience at the University of Pittsburgh suggest the rate of recurrent SCIWORA is lower than initially reported.

MRI findings correlate with recovery potential following SCIWORA (18,28,34). MRI evaluates the extraneural elements such as ligaments, disks, and soft tissue, as well as the spinal cord. A normal MRI portends an excellent recovery, whereas, increasing magnitude of spinal cord edema and hemorrhage implies more severe SCI. A study by Liao et al. (35) showed that imaging patterns on MRI correlated with neurologic recovery in children less than 8 years of age.

As with any trauma, maintaining strict adherence to Advanced Trauma Life Support protocol is vital for a successful outcome. A trauma patient is assumed to have an SCI until proven otherwise; this is particularly true in the pediatric patient in whom neurologic assessment may be difficult. Thus, the patient must be immediately immobilized and transported carefully to avoid exacerbating neurologic injury. The head-to-chest ratio for young children is high, and transportation on a regular backboard induces cervical kyphosis (36, 37 and 38). At age 8 years, the chest attains 50% of its adult size, and this discrepancy normalizes. Until then, a blanket or a 2 to 3-inch pad placed under the chest area or an occipital recess in the transport board help maintain cervical alignment.⁹⁹ The use of tape and sandbags provides superior immobilization of the cervical spine compared with a hard collar. In patients wearing a helmet, removal ideally occurs in the emergency department while the head is manually stabilized. One must always be cognizant of the basic principles of emergency care, particularly because many children with cervical level injury have compromised respiratory function. Route of intubation, either orotracheal or nasotracheal, does not appear to cause neurologic injury when performed in a controlled manner (39).

The role of steroids in the pediatric population remains unclear. Bracken et al. reported that methylprednisolone improved spinal cord recovery up to five motor points if administered within 8 hours of injury. Most treating physicians use methylprednisolone in children, although only 15% of patients in the study were between 13 and 19 years old (40).

The injured child should undergo an expedited, yet thorough, history and physical evaluation, as the incidence of associated injuries is very high (41). Cardiac, abdominal, renal, and bladder injuries are often detected after the initial trauma evaluation. Patients with upper cervical injury may have cardiopulmonary arrest. Head injury occurs with SCI in 25% to 50% of patients (7,36). On palpation of the spine, one must assess spinous process step-off and tenderness, as these may indicate underlying injury. Torticollis is another indication of cervical spine injury. The neurologic examination must be repeated at short, regular intervals to ensure the rapid detection of deterioration. It is important to determine the presence of transient neurologic symptoms. At the time of examination, the patient
may not manifest any deficits; however, these patients may have occult instability, which if not detected may have catastrophic consequences.