Preditores no quadro SCIWORA do adulto

coluna Coluna/Columna Coluna/Columna 1808-1851 2177-014X Sociedade Brasileira de Coluna São Paulo, SP, Brazil OBJETIVOS: Análise cinemática, reconhecer apresentação clínica, descrever imagens, considerar as possibilidades terapêuticas e avaliar a evolução. MÉTODO: Análise de 13 pacientes do sexo masculino com SCIWORA (em ingles Spinal cord injury without radiographic abnormality) entre 2005 e 2012. Avalia-se quadro clínico, tratamento, complicações e resultado. RESULTADOS: Dez pacientes com mais de 45 anos apresentaram sinais de espondiloartrose com sintomas mínimos. Dos três pacientes com menos de 45 anos, apenas um tinha estenose de canal constitucional assintomática. Todos haviam sofrido trauma de baixa energia. Na ressonância magnética prevaleceu hematoma intramedular e clinicamente todos os pacientes com mais de 45 anos tinham síndrome medular central grave (ASIA A-B). Sete pacientes foram inicialmente tratados de forma conservadora; um paciente piorou e teve que ser submetido a cirurgia 18 meses depois e outro morreu nas primeiras horas, o restante teve bom desempenho. Seis pacientes necessitaram de cirurgia (laminoplastia) nos primeiros 10 dias; três morreram e os pacientes restantes melhoraram pelo menos um nível ASIA. CONCLUSÕES: A idade mais baixa, os casos não graves e o edema intramedular são bons fatores prognósticos e são favorecidos pelo tratamento conservador. A idade mais elevada, a espondiloartrose e os quadros graves ou progressivos, são fatores de mau prognóstico e podem necessitar de tratamento cirúrgico. ARTÍCULO ORIGINAL ARTIGO ORIGINAL ORIGINAL ARTICLE Predictores en el cuadro SCIWORA del adulto Preditores no quadro SCIWORA do adulto Pedro Luis Bazán; Alvaro Enrique Borri; Martín Medina HIGA - San Martín de La Plata y Hospital Italiano de La Plata, Argentina Correspondencia RESUMEN OBJETIVOS: Analizar cinemática, reconocer cuadro clínico de presentación, describir imágenes, considerar posibilidades terapéuticas y evaluar evolución. MÉTODO: Se analizan 13 pacientes del sexo masculino que presentaron SCIWORA (en inglés Spinal cord injury without radiographic abnormality) entre el 2005 al 2012. Se evalúan cuadro clínico, tratamiento, complicaciones y evolución. RESULTADOS: 10 pacientes mayores de 45 años presentaban signos de espondiloartrosis con mínimos síntomas. De los tres menores de esta edad solo uno presentaba estenosis de canal constitucional asintomática. Todos sufrieron trauma de baja energía. En la resonancia magnética prevaleció el hematoma intramedular y clínicamente todos los pacientes presentaban un síndrome medular central, con cuadro severo (ASIA A-B) en los mayores de 45 años. Siete pacientes fueron tratados inicialmente en forma conservadora; un paciente empeoró y tuvo que ser sometido a intervención quirúrgica 18 meses después y otro falleció en las primeras horas, el resto de los pacientes tuvieron buena evolución. Seis pacientes requirieron cirugía (laminoplastía) en los primeros 10 días; tres fallecieron y el resto mejoro por lo menos un nivel ASIA. CONCLUSIONES: La menor edad, los cuadros leves y el edema intramedular son factores de buen pronóstico y se ven favorecidos con el tratamiento conservador. La mayor edad, la espondiloartrosis y los cuadros severos o progresivos, son factores de mal pronóstico y puede ser necesario su tratamiento quirúrgico. Descriptores: Síndrome del cordón central; Tratamiento; Traumatismos de la médula espinal. RESUMO OBJETIVOS: Análise cinemática, reconhecer apresentação clínica, descrever imagens, considerar as possibilidades terapêuticas e avaliar a evolução. MÉTODO: Análise de 13 pacientes do sexo masculino com SCIWORA (em ingles Spinal cord injury without radiographic abnormality) entre 2005 e 2012. Avalia-se quadro clínico, tratamento, complicações e resultado. RESULTADOS: Dez pacientes com mais de 45 anos apresentaram sinais de espondiloartrose com sintomas mínimos. Dos três pacientes com menos de 45 anos, apenas um tinha estenose de canal constitucional assintomática. Todos haviam sofrido trauma de baixa energia. Na ressonância magnética prevaleceu hematoma intramedular e clinicamente todos os pacientes com mais de 45 anos tinham síndrome medular central grave (ASIA A-B). Sete pacientes foram inicialmente tratados de forma conservadora; um paciente piorou e teve que ser submetido a cirurgia 18 meses depois e outro morreu nas primeiras horas, o restante teve bom desempenho. Seis pacientes necessitaram de cirurgia (laminoplastia) nos primeiros 10 dias; três morreram e os pacientes restantes melhoraram pelo menos um nível ASIA. CONCLUSÕES: A idade mais baixa, os casos não graves e o edema intramedular são bons fatores prognósticos e são favorecidos pelo tratamento conservador. A idade mais elevada, a espondiloartrose e os quadros graves ou progressivos, são fatores de mau prognóstico e podem necessitar de tratamento cirúrgico. Descritores: Síndrome medular central; Tratamento; Traumatismos da medula espinal. INTRODUCCIÓN El término SCIWORA (Spinal Cord Injury without Radiologic Abnormality) describe a la lesión de la médula espinal demostrable a través de la resonancia magnética, pero que no evidencia lesión ósea en estudios completarios como las radiografías y/o tomografía.1-8 La incidencia de lesión medular en un trauma cervical oscila entre un 0,9 a 6%,5,9,10 aumentando del 2 al 27% cuando se asocian a otras lesiones en el contexto de un politraumatizado.9,11 La presencia de compromiso neurológica sin lesión traumática ósea en adultos, puede variar entre un 0,08 a un 15%.8,12-15 Las lesiones medulares tienen consecuencias catastróficas tanto para el paciente como para su entorno social. Se identificaron factores que influyen significativamente en la sobrevida de un paciente con trauma raquimedular, estos son la edad, el nivel comprometido, el grado de injuria primaria7,14,16,17y la lesión secundaria.7,18,19 La mortalidad de estos pacientes puede variar de un 4 a 11% y las causas están directamente relacionadas con el trauma o sus complicaciones como las urinarias, cardiopulmonares e infecciosas.5,17 Loyd en 1907 apud Fermín20 e Launay et al.21 fue el primero en describir el cuadro, Pang y Wilberger22 en 1982 describen este síndrome en la población pediátrica con afectación principal en menores de 8 años, pero autores como Hendey et al.13 mencionan la aparición de SCIWORA en la edad adulta y su relación directa con la patología degenerativa. Pueden describirse cuatro grupos etarios que están predispuestos a sufrir este síndrome: el primer grupo al nacer, principalmente la tracción longitudinales la causante del cuadro; el segundo corresponde a menores de 16 años, donde el mecanismo de distracción prevalece debido a la elasticidad ligamentaria; el tercer grupo va desde los 16 a 45 años en este rango etario es raro tener lesión medular sin lesión ósea y/o ligamentaria, salvo en canal cervical constitucionalmente estrecho; y por ultimo el cuarto grupo, mayores de 45 años, aquí prevalece la degeneración espondiloartrósica y el mecanismo principal es la hiper extensión.22-24 La mayoría de los autores coinciden en que las poblaciones menores de 8 años y los mayores de 60 debido a diferencias anatómicas y biomecánicas son los que mayor predisposición presentan.8,24 Si bien el cuadro neurológico puede ser variable el que prevalece en estos casos es el Síndrome Medular Central (SMC)5,11,13,14,16,25-27 principalmente en el trauma de baja energía,24 como son caída sentado desde su propia altura (43%), accidentes automovilísticos (33%) y caída de altura (12%)23,28 La Resonancia Magnética ha pasado a ser el método de elección para evaluar estos pacientes.7,8,14,29 En esta se pueden identificar las causas que ocasionaron el síndrome y de esta manera dividirlas en extramedulares (hernia de disco, estenosis de canal, lesión de ligamento vertebral común anterior o complejo ligamentario posterior y hematoma intra canal) e intramedulares (edema, contusión y hemorragia).7,15,30-32 La presencia de hemorragia dentro de la médula es un signo de mal pronóstico en la evolución del paciente.5,7,16,19,32,33 Con respecto al tratamiento los pacientes jóvenes con cuadros neurológicos estables pueden ser tratados en forma conservadora con inmovilizacon y corticoterapia; y los ancianos o con déficit progresivos deben ser tratados en forma quirúrgica.28 Se realiza el presente estudio con los objetivos siguientes: analizar cinemática, reconocer cuadro clínico de presentación, describir imágenes, considerar posibilidades terapéuticas y evaluar evolución. MATERIAL y MÉTODOS Trece pacientes del sexo masculino, promedio de edad de 56.54 años (rango de 16 a 84), que luego de un trauma ingresan al Servicio de Emergencias con diagnóstico de déficit neurológico sin diagnóstico comprobado de fractura y/o luxación, en un período de desde junio de 2005 a junio de 2012. La evaluación neurológica al ingreso y a los 6 meses se realizo con escala de ASIA y la Escala de la Asociación Japonesa de Ortopedia. Se realiza un seguimiento con las mismas escalas a la mayoría de los pacientes. Desde el punto de vista imagenológico se realizaron al ingreso radiografías y resonancia: en algunos casos se sumo la tomografía. Se evaluó el tratamiento realizado, la presencia de complicaciones y la evolución clínica neurológica. RESULTADOS Los pacientes de mayor edad referían, previamente, sintomatología leve asociada con su espondiloartrosis. Los pacientes menores de 45 años no referían sintomatología alguna previo al trauma. El trauma se vio relacionado con accidentes automovilísticos en ocho oportunidades, dos movilizaciones pasivas (una rotación en situación de robo y una flexo extensión), dos caída de propia altura y un trauma deportivo. Un paciente conformaba un politraumatismo por asociación de trauma de cráneo y tórax. (Tabla 1) En la evaluación de ingreso en los mayores de 45 años, prevaleció el compromiso neurológico severo (3 ASIA A y 3 B). Todos los pacientes presentaron un Síndrome Medular Central y fueron estudiados con radiografías y resonancia y en seis también evaluados con tomografías axiales. Las radiografias demostraron signos de espondiloartrosis en la totalidad de los pacientes mayores a 45 años: por debajo de esta edad solo uno mostro un canal constitucionalmente estrecho. La resonancia mostro edema en tres pacientes, patrón mixto en dos y hematoma en el resto; sin la presencia de hernia de disco ni lesión ligamentaria. (Tabla 2) A todos los pacientes se les realizo tratamiento con metilprednisolona según protocolo NASCISS, Siete pacientes fueron tratados en forma conservadora (Figura 1A,B): uno falleció antes del primer control y otro empeoro su estado neurológico y debió ser intervenido quirúrgicamente con laminoplatia 18 meses después con buen resultado aunque con espasticidad de la marcha (paciente 5), al igual que otro (paciente 10) y uno con disminución de la extensión de la flexión dorsal de muñeca (paciente 13). Seis pacientes fueron intervenidos quirúrgicamente mediante liberación por vía posterior con técnica de laminoplastia en las primeras 72 Hs y uno a los 10 días. (Figura 2A-C) Se observo una neumonía pre quirúrgica (paciente 1), dos post quirúrgicas (pacientes 7 y 8), una infección superficial de herida quirúrgica (paciente 9) y una infección urinaria (paciente 1). Óbito en 4 pacientes. Los pacientes menores de 45 años tratados en forma conservadora (collar y corticoides) evolucionaron favorablemente. Los mayores de esta edad con cuadro neurológico parcial y tratados quirúrgicamente antes de los 10 días mejoraron su estado neurológico, al igual que el operado luego de 18 meses del trauma, con por lo menos un nivel de la escala de ASIA y cinco puntos de JAO. (Tablas 3 y 4) DISCUSIÓN Si bien algunos autores afirman que los cambios degenerativos o la calcificación del ligamento vertebral común posterior producen una excesiva tracción de la médula espinal durante el accidente y podrían influir en el desarrollo del SCIWORA;34 otros desestiman esta relación y consideran que estos cambios no tienen influencia directa con la presencia de un déficit neurológico luego de un trauma de baja energía.35 Para el diagnóstico la resonancia magnética es considerado el método de eleccion15,36 pero cuando esta no es concluyente se podrían utilizar una resonancia con ventana de difusión o la tomografía con emisión de protones (PET) que podría ser útil en aquellos pacientes con resonancia magnética negativa y con deterioro neurológico mielopático; como otra opción pueden tenerse en cuenta la utilización de potenciales evocados somato sensitivos.30 El estudio dinámico radiográfico del perfil en flexión y extensión máxima en agudo deben ser contraindicadas por la posibilidad de empeorar el cuadro neurológico.1,36 Existen factores que influyen sobre la posibilidad de recuperación neurológica37 de estos pacientes y se encontraría relacionado en primera instancia con la injuria inicial,44 el diámetro del canal,4,38,39 la edad del paciente, el tamaño de la lesión, presencia de lesión disco-ligamentariaes40,41 y la severidad del cuadro neurológico1, es por eso que la decisión quirúrgica no es el patrón de oro para el tratamiento.11,33 Para Saruhashi et al.28 los pacientes que tenían buena respuesta al tratamiento con corticoides eran pasibles de inmovilización y los que presentaban cuadros severos o progresivos deberían ser intervenidos quirúrgicamente. Bhatoe et al.42 prefieren un tratamiento no quirúrgico en los traumas por hiper flexión, ya que consideran que las lesiones que originan el síndrome son de tipo vascular Otros autores como La Rosa et al.43, también defienden el tratamiento médico por el riesgo de aumento de complicaciones. Por otro lado autores como Dolan44, Chen45, Fehling18 y Lenehan et al.46 apoyan la rápida liberación para evitar daño secundario19 y complicaciones.37 CONCLUSIONES Un trauma de baja energía puede descompensar la relación continente contenido en columnas artrósicas asintomáticas o canales contitucionalmente estrechos, pudiendo ser devastador para el paciente. El déficit neurológico post traumático habiendo descartado lesión ósea en radiografías y/o tomografía realizan el diagnóstico de SCIWORA, cuadro caracterizado principalmente por un síndrome medular central. La resonancia magnética la que hace diagnóstico de partes blandas (disco ligamentarias y medulares). La edad de menos de 45 años, el cuadro neurológico con déficit incompleto moderado o leve y el edema intramedular son factores de buen pronóstico y se ven favorecidos con el tratamiento conservador, con secuelas de baja discapacidad. La edad de más de 45 años, la presencia de conflictos continente contenido previo (espondiloartrosis), los cuadros de déficit neurológico severo o progresivo, son en general factores de mal pronóstico y puede mejorar con laminoplastia ganaron por lo menos un nivel de ASIA. Aunque las posibles complicaciones post operatoria pueden ser graves. Correpondencia: 51 – 1715 (CP 1900). La Plata. Provincia de Buenos Aires. Argentina. [e-mail] Recibido en 28/08/2013, acepto en 05/10/2013. Trabajo realizado en el HIGA - San Martín de La Plata y Hospital Italiano de La Plata, Argentina. Todos los autores declaran que no hay ningún potencial conflicto de intereses con referencia a este artículo. 1. Anglen J, Metzler M, Bunn P, Griffiths H. 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Traumatic central cord syndrome: analysis of factors affecting the outcome. Surg Neurol. 2005;63(2):95-9. Traumatic central cord syndrome: analysis of factors affecting the outcome Surg Neurol 2005 95 9 2 63 Yamazaki T Yanaka K Fujita K Kamezaki T Uemura K Nose T 38. Carlson GD, Gorden CD, Oliff HS, Pillai JJ, LaManna JC. Sustained spinal cord compression: part I: time-dependent effect on long-term pathophysiology. J Bone Joint Surg Am. 2003;85(1):86-94. Sustained spinal cord compression: part I: time-dependent effect on long-term pathophysiology J Bone Joint Surg Am 2003 86 94 1 85 Carlson GD Gorden CD Oliff HS Pillai JJ LaManna JC 39. Pavlov H, Torg JS, Robie B, Jahre C. Cervical spinal stenosis: determination with vertebral body ratio method. Radiology. 1987;164(3):771-5. Cervical spinal stenosis: determination with vertebral body ratio method Radiology 1987 771 5 3 164 Pavlov H Torg JS Robie B Jahre C 40. Machino M, Yukawa Y, Ito K, Nakashima H, Kanbara S, Morita D, et al. Can magnetic resonance imaging reflect the prognosis in patients of cervical spinal cord injury without radiographic abnormality? Spine (Phila Pa 1976). 2011;36(24):E1568-72. Can magnetic resonance imaging reflect the prognosis in patients of cervical spinal cord injury without radiographic abnormality Spine (Phila Pa 1976) 2011 E1568 72 24 36 Machino M Yukawa Y Ito K Nakashima H Kanbara S Morita D 41. Maeda T, Ueta T, Mori E, Yugue I, Kawano O, Takao T, et al. Soft-tissue damage and segmental instability in adult patients with cervical spinal cord injury without major bone injury. Spine (Phila Pa 1976). 2012;37(25):E1560-6. Soft-tissue damage and segmental instability in adult patients with cervical spinal cord injury without major bone injury Spine (Phila Pa 1976) 2012 E1560 6 25 37 Maeda T Ueta T Mori E Yugue I Kawano O Takao T 42. Bhatoe HS. Cervical spinal cord injury without radiological abnormality in adults. Neurol India. 2000;48(3):243-8. Cervical spinal cord injury without radiological abnormality in adults Neurol India 2000 243 8 3 48 Bhatoe HS 43. La Rosa G, Conti A, Cardali S, Cacciola F, Tomasello F. Does early decompression improve neurological outcome of spinal cord injured patients? Appraisal of the literature using a meta-analytical approach. Spinal Cord. 2004;42(9):503-12 Does early decompression improve neurological outcome of spinal cord injured patients: Appraisal of the literature using a meta-analytical approach Spinal Cord 2004 503 12 9 42 La Rosa G Conti A Cardali S Cacciola F Tomasello F 44. Dolan EJ, Tator CH, Endrenyi L. The value of decompression for acute experimental spinal cord compression injury. J Neurosurg. 1980;53(6):749-55. The value of decompression for acute experimental spinal cord compression injury J Neurosurg 1980 749 55 6 53 Dolan EJ Tator CH Endrenyi L 45. Chen TY, Dickman CA, Eleraky M, Sonntag VK. The role of decompression for acute incomplete cervical spinal cord injury in cervical spondylosis. Spine (Phila Pa 1976). 1998;23(22):2398-403. The role of decompression for acute incomplete cervical spinal cord injury in cervical spondylosis Spine (Phila Pa 1976) 1998 2398 403 22 23 Chen TY Dickman CA Eleraky M Sonntag VK 46. Lenehan B, Fisher CG, Vaccaro A, Fehlings M, Aarabi B, Dvorak MF. The urgency of surgical decompression in acute central cord injuries with spondylosis and without instability. Spine (Phila Pa 1976). 2010;35(Suppl 21):S180-6. The urgency of surgical decompression in acute central cord injuries with spondylosis and without instability Spine (Phila Pa 1976) 2010 S180 6 35 Lenehan B Fisher CG Vaccaro A Fehlings M Aarabi B Dvorak MF Original Articles Predictors in adult SCIWORA OBJECTIVES: Kinematic analysis, recognize the clinical presentation, describe image tests, consider therapeutic possibilities and assess progress. METHOD: Analysis of 13 male patients with SCIWORA (Spinal cord injury without radiographic abnormality) between 2005 and 2012. Evaluates clinical presentation, treatment, complications and outcome. RESULTS: 10 patients over 45 years showed signs of spondyloarthritis with minimal symptoms. Of the three with less than 45 years, only one had a constitutional asymptomatic stenosis. All had suffered low-energy trauma. In the magnetic resonance prevailed intramedullary haematoma and clinically all patients over 45 years had a central cord syndrome with severe symptoms (ASIA A-B). Seven patients were initially treated conservatively; one patient worsened and had to undergo surgery after 18 months and another died in the early hours; the remaining patients had good performance. Six patients required surgery (laminoplasty) in the first 10 days; three died and the remaining patients improved at least one ASIA level. CONCLUSIONS: The lower age, the mild cases and intramedullary edema are good prognostic factors and are favored by conservative treatment. The higher age, spondyloarthritis and severe or progressive conditions are factors of poor prognosis and may require surgical treatment. Central cord syndrome Treatment Spinal cord injuries ORIGINAL ARTICLE ARTIGO ORIGINAL ARTÍCULO ORIGINAL Predictors in adult SCIWORA Preditores no quadro SCIWORA do adulto Pedro Luis Bazán; Alvaro Enrique Borri; Martín Medina HIGA - San Martín de La Plata y Hospital Italiano de La Plata, Argentina Correspondence ABSTRACT OBJECTIVES: Kinematic analysis, recognize the clinical presentation, describe image tests, consider therapeutic possibilities and assess progress. METHOD: Analysis of 13 male patients with SCIWORA (Spinal cord injury without radiographic abnormality) between 2005 and 2012. Evaluates clinical presentation, treatment, complications and outcome. RESULTS: 10 patients over 45 years showed signs of spondyloarthritis with minimal symptoms. Of the three with less than 45 years, only one had a constitutional asymptomatic stenosis. All had suffered low-energy trauma. In the magnetic resonance prevailed intramedullary haematoma and clinically all patients over 45 years had a central cord syndrome with severe symptoms (ASIA A-B). Seven patients were initially treated conservatively; one patient worsened and had to undergo surgery after 18 months and another died in the early hours; the remaining patients had good performance. Six patients required surgery (laminoplasty) in the first 10 days; three died and the remaining patients improved at least one ASIA level. CONCLUSIONS: The lower age, the mild cases and intramedullary edema are good prognostic factors and are favored by conservative treatment. The higher age, spondyloarthritis and severe or progressive conditions are factors of poor prognosis and may require surgical treatment. Keywords: Central cord syndrome; Treatment; Spinal cord injuries. RESUMO OBJETIVOS: Análise cinemática, reconhecer apresentação clínica, descrever imagens, considerar as possibilidades terapêuticas e avaliar a evolução. MÉTODO: Análise de 13 pacientes do sexo masculino com SCIWORA (em ingles Spinal cord injury without radiographic abnormality) entre 2005 e 2012. Avalia-se quadro clínico, tratamento, complicações e resultado. RESULTADOS: Dez pacientes com mais de 45 anos apresentaram sinais de espondiloartrose com sintomas mínimos. Dos três pacientes com menos de 45 anos, apenas um tinha estenose de canal constitucional assintomática. Todos haviam sofrido trauma de baixa energia. Na ressonância magnética prevaleceu hematoma intramedular e clinicamente todos os pacientes com mais de 45 anos tinham síndrome medular central grave (ASIA A-B). Sete pacientes foram inicialmente tratados de forma conservadora; um paciente piorou e teve que ser submetido a cirurgia 18 meses depois e outro morreu nas primeiras horas, o restante teve bom desempenho. Seis pacientes necessitaram de cirurgia (laminoplastia) nos primeiros 10 dias; três morreram e os pacientes restantes melhoraram pelo menos um nível ASIA. CONCLUSÕES: A idade mais baixa, os casos não graves e o edema intramedular são bons fatores prognósticos e são favorecidos pelo tratamento conservador. A idade mais elevada, a espondiloartrose e os quadros graves ou progressivos, são fatores de mau prognóstico e podem necessitar de tratamento cirúrgico. Descritores: Síndrome medular central; Tratamento; Traumatismos da medula espinal. INTRODUCTION The term SCIWORA (Spinal Cord Injury without Radiologic Abnormality) describes spinal cord injury that is demonstrable through magnetic resonance imaging, but that does not demonstrate bone lesion in complementary studies, such as radiographies and/or tomography.1-8 The incidence of spinal cord injury in a cervical trauma ranges from 0.9 to 6%,5,9,10 increasing from 2 to 27% when associated with other injuries in the context of a patient with multiple trauma.9,11 The presence of neurological damage without traumatic bone lesion in adults can range from 0.08 to 15%.8,12-15 Spinal cord injuries have catastrophic consequences, both for the patients and for their social circle. Factors have been identified that significantly influence survival in patients who have suffered a spinal cord trauma, namely, age, extent of the damage, degree of primary injury7,14,16,17 and secondary injury.7,18,19 Mortality in these patients can range from 4 to 11%, and the causes are directly related to the trauma or its complications, including urinary, cardiopulmonary and infectious complications.5,17 Loyd in 1907 apud Fermín20 and Launay et al.21 was the first to describe this syndrome. Pang and Wilberger22 in 1982, described this syndrome in the pediatric population with principal occurrence in children aged under 8 years, but authors like Hendey et al.13 mention the appearance of SCIWORA in adult age, and its direct relationship with degenerative pathology. Four age groups can be described, that have a predisposition to this syndrome: the first group is newborn infants, with longitudinal traction being the main cause of the condition; the second is children aged under 16 years, in whom the mechanism of distraction is primarily due to ligament elasticity; the third group is individuals aged between 16 and 14 years; in this age group it is rare for spinal cord injury to occur without bone and/or ligament lesions, except in cases of constitutional stenosis of the cervical canal; and the fourth group consists of individuals aged over 45 years, in whom spondyloarthrosic degeneration is prevalent, with the main mechanism being hyperextesion.22-24 The majority of authors agree that populations aged under 8 years and over 60 years are more predisposed to the condition, due to anatomical and biological differences in these groups.8,24 While neurological symptoms may vary, the prevalent complication in these cases is central cord syndrome (CCS)5,11,13,14,16,25-27 particularly in low-energy traumas,24 such as falling over (43%), traffic accidents (33%), and falling from a height (12%).23,28 Magnetic resonance imaging has become the method of choice for evaluating these patients.7,8,14,29 This technique is used to identify the causes of the syndrome, dividing them into extramedullary (disc hernia, canal stenosis, legion of the anterior common vertebral ligament or posterior ligament complex and intracanal hematoma) and intramedullary (edema, contusion and hemorrhage).7,15,30-32 The presence of hemorrhage in the spine is a sign of poor prognosis in the evolution of the patient.5,7,16,19,32,33 Young patients with stable neurological symptoms can be treated conservatively with immobilization and corticotherapy; while older patients, or those with progressive deficit, should be treated with surgery.28 The objectives of this study are: to analyze the kinematics, recognize clinical symptoms of presentation, describe images, consider therapeutic possibilities, and evaluate evolution. MATERIAL AND METHODS Thirteen male patients, average age of 56.54 years (range 16 to 84) who, following a trauma, were admitted to the Emergency Service with a diagnosis of neurological deficit without proven diagnosis of fracture and/or luxation, between June 2005 and June 2012. The neurological examinations on admission and at 6 months were carried out using the ASIA scale and the Japanese Orthopedic Association Scale. Follow-up was carried out using the same scales for the majority of the patients. In terms of imaging exams, radiographies and MRI were performed on admission: in some cases tomography was also performed. The treatment carried out, the presence of complications, and the neurological clinical evolution were evaluated. RESULTS The older patients reported, previously, mild symptomology associated with their previous spondyloarthrosis. The patients aged under 45 years did not report any symptoms prior to the trauma. The traumas were related to traffic accidents in eight cases, two passive mobilizations (one rotation in situation of robbery and one flexion-extension), two cases of falling over, and one sports trauma. One patient confirmed multiple trauma by association of cranial and thoracic trauma. (Table 1) In the evaluation on admission in the patients aged over 45 years, severe neurological impairment was prevalent (3 ASIA A and 3 B). All the patients presented central cord syndrome and were submitted to radiographies and MRI, and six also underwent axial tomographies. The radiographies showed signs of spondyloarthritis in all the patients over 45 years: below this age, only one patient had constitutional stenosis of the canal. MRI showed edema in three patients, mixed pattern in two, and hematoma in the remainder; without the presence of disc hernia or ligament lesions. (Table 2) All the patients underwent treatment with methylprednisolone, according to the NASCISS protocol. Seven patients were treated conservatively (Figure 1A,B): one died before the first follow-up, and another had worsening of the neurological state and had to undergo surgical treatment with laminopathy 18 months afterwards, with good results, although with spasticity of gait (patient 5), the same occurred for another patient (patient 10), and one had decreased range of flexion of the wrist (patient 13). Six patients underwent surgical release of pressure by the laminoplasty technique, by the posterior approach in the first 72 hours, and one at 10 days. (Figure 2A-C) There was one case of pre-surgical pneumonia (patient 1), two post-surgical (patients 7 and 8), one superficial infection of the surgical wound (patient 9), and one urinary infection (patient 1). Four patients died. The patients aged under 45 years treated conservatively (collar and corticoids) evolved favorably. Those over this age with partial neurological compromise, and who were treated surgically before 10 days, showed neurological improvement, as did those who underwent surgery 18 months after the trauma, with improvement of at least one level on the ASIA scale, and five points on the JAO scale. (Tables 3 and 4) DISCUSSION Some authors affirm that degenerative changes or calcification of the posterior common vertebral ligament produce excessive traction of the spinal cord during the accident and can influence the development of SCIWORA;34 while others deny this relationship, and believe these changes have no direct influence on the presence of neurological impairment following low-energy trauma.35 For the diagnosis, MRI is considered the method of choice15,36 but when this is not conclusive; diffusion MRI or proton emission tomography (PET) may be useful in those patients with negative MRI and with myelopathic neurological syndrome. Another option to be considered is the use of somatosensory evoked potentials.30 Radiographic dynamic study of the profile in maximum flexion and extension in acute should be contraindicated, due to the possibility of worsening of the neurological impairment.1,36 There are factors that influence the likelihood of neurological recovery37 in these patients, and these are primarily related to the initial injury,44 the diameter of the canal,4,38,39 the patient's age, the extent of the injury, the presence of disc-ligament lesions40,41 and the severity of the neurological syndrome.1 For this reason, surgery is not the gold standard for treatment.11,33 For Saruhashi et al.28 patients who show good response to treatment with corticoids should be indicated for immobilization, while those with severe or progressive symptoms should be indicated for surgery. Bhatoe et al.42 prefer a non-surgical form of treatment in traumas by hyperflexion, as they believe that injuries originating in the syndrome are of the vascular type. Other authors, like La Rosa et al.,43 also defend medical treatment due to the risk of increased complications. On the other hand, authors like Dolan,44 Chen,45 Fehling18 and Lenehan et al.46 support rapid release to prevent secondary damage19 and complications.37 CONCLUSIONS Low energy trauma can cause an imbalance in the container-content relationship in asymptomatic arthritic spines or spines with constitutional stenosis, and can be devastating for the patient. Post-traumatic neurological deficit after ruling out bone injury in radiographies and/or CT scan perform the diagnosis of SCIWORA, a syndrome characterized mainly by a central spinal cord syndrome. MRI is used for the diagnosis of the soft tissues (ligament and spinal disc). Age under 45 years, neurological compromise with moderate to mild incomplete neurological symptoms and intramedullary edema are factors that suggest a good prognosis and are favored by conservative treatment, with sequelae involving low disability. Age over 45 years, the presence of previous container-content conflicts (spondyloarthritis), and severe or progressive neurological deficit, are generally factors of poor prognosis, and can improve with laminoplasty by at least one level on the ASIA scale. However, the possible postoperative complications can be severe. REFERENCES