Ans. a. Children (Ref: www.ncbi.nlm.nih.gov/pubmed/17006044 www.orthopaedicsone.com/pages/viewpage action? pageId=27689773)Symptomatic spinal injury without any radiological evidence most commonly found in children.'Following trauma, the commonly used radiological investigations, plain radiographs and computed tomography (CT) studies do nor rule out injury to the spinal cord. This is especially true for children, as an entity known by the acronym SCIWORA (spinal cord injury without radiological abnormality) exists and the changes may be picked up only on magnetic resonance imaging (MRI). Early treatment (within 6 hours) with high dose methylprednisolone improves the outcome.'- www.ncbi.nlm.nih.gov/pubmed/17006044SCIWORA (Spinal Cord Injury Without Radiologic Abnormality)SCIWORA originally referred to spinal cord injury without radiographic or CT evidence of fracture or dislocationQPrognosis of SCIWORA is actually better than patients with spinal cord injury and radiologic evidence of traumatic injuryQ.Defined as 'objective signs of myelopathy as a result of trauma' with no evidence of fracture or ligamentous instability on plain spine radiographs and tomographyQPrevalence:Mostly in pediatric population (range: birth to 16 years old)Inherent elasticity in pediatric cervical spine can allow severe spinal cord injury to occur in absence of X-ray findingsQCommon in cervical and thoracic regionQ; Rare in lumbar regionMechanism of Injury:MVA (motor vehicle accident)FallSports injury: Football, Diving, Wrestling, GymnasticsPathogenesis:Hyperextension injury to spine whose vertebral canal diameter is already compromised by spondylosisQ has a high risk of cord injuryExcessive anterior buckling of ligamentum flavum into canalQ, already compromised by posterior vertebral body osteophytes, probably is the cause of central cord syndromePathophysiologic MechanismsDirect spinal cord injury (traction)Direct spinal cord compression (extreme flexion/ hyperextension)Indirect spinal cord injuryVascular/ischemic injuryDiagnosis:SCIWORA is mainly a diagnosis of exclusion.In children, after trauma, paucity of movement of both legs, inability to bear weight on legs, and inability to pass urine, not able to sit without supportQ.Examination:Gross hypotonia in the lower limbs. 0/5 power and areflexia.Abdominal reflex, cremasteric, and anal reflex are absent.Palpable bladder and urine could be expressed out on abdominal pressure.No meningeal or cerebellar signsWork up:Plain radiographs of the entire spinal column maybe consideredCT scan of suspected level of neurological injuryMRI of the suspected region of neurological injury may show- hemorrhage and edemaQSSEPs (somatosensory evoked potentials):Not used diagnosticallyHelpful for follow up; obtained within 24 hours of admission and compared in follow up analysisTreatmentExternal immobilization of the spinal segment of injury for up to 12 weeksAvoidance of 'high-risk' activities for up to 6 monthsGradually increase range of motion once deficits have resolvedHigh-dose steroids in SCIWORAMethylprednisolone bolus of 30 mg/kg IV within 8 hours of injury, followed by infusion at 5.4 mg/kg/hr for the next 23 hours beneficial in improving the outcomeQOutcome at 6 weeks and 6 months better when drug given over 48 hoursQ, according to recent study.Prognosis:MRl of region of neurologic injury may provide useful prognostic information about neurologic outcome following SCIWORAQ.Poor Prognosis is seen inChildren <8 years old have worse prognosisDelay in onset of neurologic symptomsDeterioration of neurologic symptomsRecurrent injury