Working Diagnosis:
1. Spinal Cord Injury without Radiologic Abnormality
2. Concussion

Treatment:
Spinal immobilization with Aspen collar for two weeks.
Physical Therapy

Outcome:
The day after the injury the patient had significant improvement in strength. Our patient continued to wear an Aspen collar for two weeks post-injury. He followed up with neurosurgery. Two months after the injury he regained full range of motion and strength. He was cleared to begin gradual return to sport activities.

Author's Comments:
Spinal cord injury without radiologic abnormality (SCIWORA) is defined as traumatic myelopathy without radiologic evidence of fracture or instability. It is mostly seen in children, often occurring in the cervical spine due to increased mobility, ligamentous laxity, and large head-to-body ratio. Proportion of spinal cord injury diagnosed as SCIWORA in children and adults is reported as 6% - 19% and 9% - 14% respectively. The mechanism of injury is often from hyperextension after direct frontal trauma. The injury to the spinal cord is usually caused by a contusion or ischemia due to temporary occlusion of vertebral arteries followed by return of the spine to its original position. The onset of symptoms may be immediate or delayed for up to 48 hours after trauma. The two main predictors of prognosis are the initial neurological status and MRI findings. Absence of pathology in MRI is predictive of good outcomes. External immobilization and avoiding increased-risk activities are the most common treatments.

Editor's Comments:
Spinal cord injury without radiologic abnormality was originally defined considering plain radiograph and computed tomography findings. Magnetic resonance (MR) imaging may demonstrate intrinsic cord signal abnormalities, and as the case authors note, MR findings can have prognostic significance. Symptoms of the condition persist beyond 48 hours, which helps differentiate it from other transient neuropraxias that may occur during sports participation.

As highlighted by the working diagnoses, when cervical spine injury in present, concomitant concussion should be considered.

Specific return to play guidance is limited, but some note it may be up to 6 months before return to sport.

This case also reminds the physician and healthcare team of the importance of having an emergency action plan, and considering responses to scenarios at various locations on the field of play.

References:
Atesok K, Tanaka N, O'Brien A, et al. Posttraumatic Spinal Cord Injury without Radiographic Abnormality. Adv Orthop. 2018 Jan 4.

Copley PC, Tilliridou V, Kirby A, Jones J, Kandasamy J. Management of cervical spine trauma in children. Eur J Trauma Emerg Surg. 2019 Oct;45(5):777-789.

DeVivo, M. J., & Kartus, P. L. (1999). Spinal cord injury: a guide for patients and families. Demos Medical Publishing.

NINDS SCIWORA Information Page. (2021, March 12). National Institute of Neurological Disorders and Stroke. www.ninds.nih.gov/Disorders/All-Disorders/SCIWORA

Rosenfeld, JV, Bell, RS (2006). Injuries of the spine and spinal cord: Neurosurgical principles and practice. Saunders Elsevier.

Vaccaro, AR, Hulbert, RJ, Patel, AA, Fisher, C, Dvorak, M, Lehman, RA, & Anderson, P. (2013). The decision to return to play after cervical spine injuries. Journal of sports medicine and physical fitness, 53(3), 305-312.

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