A 12-year-old boy arrives holding his neck stiffly, his football jersey damp with sweat and grass clinging to one shoulder. He collided head-first with another player, stood up, and initially said he was fine; ten minutes later, both hands began to tingle and his legs felt “rubbery.” He can move everything, but his grip is weak and the sensation is not returning to normal. The question is whether a normal first scan will be enough to send him home.

— What’s your move? Read on.

Before you read
  • When is MRI needed despite reassuring radiographs?
  • What are the first preventable secondary insults?

When to Think of It

Think of SCIWORA when trauma is followed by weakness, paresthesias, sensory change, gait difficulty, bowel/bladder symptoms, or transient neurologic deficits despite normal or near-normal radiographs/CT. It is classically pediatric, but adults—especially those with degenerative cervical disease—can have spinal cord injury with a normal CT.

Sick or Not Sick

Any objective or persistent neurologic deficit = spinal cord injury until proven otherwise. The critical call is whether the patient has neurologic symptoms/signs requiring continued immobilization and urgent MRI rather than routine cervical-spine clearance.

The First Fifteen Minutes

  • Maintain inline spinal motion restriction for any neurologic complaint or significant mechanism; movement can worsen occult instability.
  • If hypoxemic or ventilating poorly: oxygen by nasal cannula 2–6 L/min or nonrebreather 10–15 L/min, titrated to adequate oxygenation; hypoxemia worsens secondary cord injury.
  • If hypotensive: establish IV/IO access and give lactated Ringer’s or normal saline 500–1,000 mL IV bolus, reassessing frequently; spinal cord perfusion depends on avoiding hypotension. Use smaller aliquots in children or patients at risk for overload.
  • If pain is limiting examination: fentanyl 25–50 mcg IV, repeat 25 mcg every 5 minutes to effect, or 1 mcg/kg IV in a monitored patient; analgesia reduces movement and sympathetic stress without obscuring a properly documented baseline examination. Check a reference for pediatric dosing and institutional maximums.
  • If respiratory failure or inability to protect the airway: perform controlled airway management with cervical motion restriction; ketamine 1–2 mg/kg IV for induction is commonly useful because it generally preserves blood pressure. Dose selection varies with shock and age—verify with local RSI protocol.
  • Do not give routine methylprednisolone for acute traumatic spinal cord injury; neurologic benefit is unproven and complications are significant.

Definitive Care & Disposition

Obtain thin-cut CT when indicated by mechanism, age, or examination, but a normal CT does not clear a patient with objective neurologic findings. Obtain urgent MRI of the symptomatic spinal region—often the entire cervical spine—to identify cord edema/contusion, epidural hematoma, ligamentous injury, or disc herniation. Consult spine surgery/neurosurgery early. Admit patients with neurologic symptoms, abnormal MRI, persistent midline tenderness with unreliable examination, or significant cord compression to a monitored setting; ICU care is appropriate for evolving deficits, respiratory compromise, or hemodynamic instability. Maintain normoxia, normocapnia, normothermia, and adequate perfusion; avoid prophylactic surgery or steroids without specialist guidance.

How This One Kills

The dangerous error is clearing the cervical spine solely because CT shows no fracture, then allowing ambulation or neck movement while an occult cord contusion, disc herniation, or ligamentous injury is evolving.
The Differential — What Else Looks Like This
  • Transient spinal cord concussion — symptoms resolve completely and MRI is normal; confusing it with ongoing injury risks premature clearance.
  • Peripheral nerve or brachial plexus injury — deficits follow a nerve distribution rather than a cord level; misclassification can delay spinal imaging.
  • Conversion/functional neurologic symptoms — inconsistent examination without an anatomic pattern; labeling trauma-related symptoms as functional too early can miss cord injury.
  • Epidural hematoma — progressive pain and neurologic decline, sometimes with initially normal CT; delay can permanently worsen compression.

The Second-Day Story

Older adults may report hand clumsiness, burning dysesthesias, or difficulty walking rather than dramatic paralysis, particularly after a low-energy fall onto a degenerative cervical spine. Children may transiently improve before deterioration, and a normal neurologic examination between episodes does not erase the history. Repeated examinations, strict motion restriction, and MRI for persistent or objective symptoms preserve the diagnosis when the initial signal is faint.
Back to Our Patient
Back to the 12-year-old football player: his persistent hand paresthesias and weak grip make this a suspected spinal cord injury despite an initially normal CT. He remains in spinal motion restriction, receives a focused repeat neurologic examination and analgesia, and is monitored for respiratory or hemodynamic deterioration. MRI demonstrates cervical cord edema without fracture, confirming SCIWORA; spine surgery is consulted, and he is admitted for neurologic monitoring and specialist-directed management rather than cleared for discharge.
Patient Presentation to Attending
How you’d present this patient on the floor — tight, pertinent positives and negatives, no rambling
“This is a 12-year-old previously healthy boy with neck pain and bilateral hand tingling after a head-first football collision approximately 30 minutes ago. He initially walked but then developed persistent paresthesias and subjective leg weakness without loss of consciousness or vomiting. He is alert, hemodynamically stable, has midline cervical tenderness, bilateral decreased grip strength, and persistent hand sensory symptoms, but no respiratory distress or obvious long-bone injury. CT shows no fracture or dislocation. I’m concerned for spinal cord injury without radiographic abnormality, so I’m maintaining motion restriction, repeating examinations, obtaining urgent MRI, and consulting spine surgery for monitored admission.”

Study Directive

  • Practice a complete motor, sensory, reflex, and rectal examination for suspected cord injury.
  • Memorize the distinction between CT-based cervical clearance and MRI indications.
  • Review pediatric cervical trauma and adult degenerative cervical SCIWORA patterns.
  • Work through three cases: normal CT with persistent deficit, transient symptoms that resolve, and progressive neurologic decline.
  • State aloud your airway, perfusion, immobilization, MRI, and consultation plan in under 60 seconds.

Recent Literature