Reply to the Letter to the Editor by Kawamoto et al.

We sincerely appreciate the comments by Kawamoto et al. and their sharing of an illustrative case related to our article, “Characteristics and Clinical Outcomes of Transition from Conservative Therapy to Surgical Intervention in Older Patients with Cervical Spinal Cord Injury without Major Bone Injury”¹⁾. Their report describes an older patient in whom cervical spinal cord injury (CSCI) without major bone injury was initially misdiagnosed as acute ischemic stroke, which subsequently led to thrombolytic therapy and caused a retropharyngeal hematoma with life-threatening airway obstruction.

This case highlights a crucial diagnostic challenge in older adults, where neurological deficits from CSCI may mimic cerebrovascular disease. As Kawamoto et al. emphasized, cervical pathology should be considered in older patients presenting with acute hemiparesis―particularly when accompanied by neck pain or limited cervical motion―before initiating thrombolytic therapy. We fully agree that a thorough neurological and radiological assessment is indispensable to prevent misdiagnosis and potentially catastrophic complications.

Our nationwide study focused on treatment strategies and outcomes following the transition from conservative to surgical therapy in older patients with CSCI without major bone injury. However, as the case reported by Kawamoto et al. clearly illustrates, the clinical challenges begin at the diagnostic stage. Their report complements our findings by drawing attention to the importance of early recognition and multidisciplinary collaboration among emergency physicians, neurologists, and spine surgeons to ensure timely and appropriate patient management.

In our previous nationwide multicenter study, we found that approximately 40% of older adults with traumatic cervical spine injuries sustained spinal cord injury without bone injury, with most injuries resulting from minor trauma, such as ground-level falls²⁾. Despite the low-energy mechanism, these patients frequently exhibited significant neurological and functional impairment, likely reflecting a combination of spinal degenerative changes and systemic frailty. Such injuries, often resulting from minor trauma, may present without obvious radiographic abnormalities, which can obscure diagnosis and initially lead clinicians to suspect stroke or peripheral neuropathy instead.

Our principal study further revealed that approximately one-fifth of older patients initially managed conservatively required subsequent surgical intervention due to poor neurological recovery or progression of paralysis. The transition to surgery was associated with risk factors, such as ossification of the posterior longitudinal ligament and spinal cord signal changes on magnetic resonance imaging―findings that may not be immediately apparent in the acute phase. These observations indicate that the clinical course of CSCI in older adults is highly variable and that diagnostic vigilance and continuous monitoring are vital, even when conservative management is initially chosen.

Taken together, the case presented by Kawamoto et al. and our nationwide findings highlight two critical phases in the management of CSCI in older adults: first, the need for prompt and accurate diagnosis to prevent iatrogenic harm, and second, the importance of individualized treatment planning and timely surgical decision-making when conservative therapy fails. Both diagnostic and therapeutic challenges stem from the unique vulnerability of the aging spine, where even trivial trauma can cause severe neurological injury.

In conclusion, we are grateful to Kawamoto et al. for presenting a thought-provoking case that underscores the diagnostic pitfalls and clinical complexity of CSCI without major bone injury in older adults. Their report, in conjunction with our findings, collectively emphasizes that, in this vulnerable population, careful diagnostic evaluation, multidisciplinary collaboration, and close clinical observation are key to achieving safe and effective patient care.

Conflicts of Interest: The authors declare that there are no relevant conflicts of interest.