Abstract
Background
Spinal imaging has been a neglected part of abusive head trauma (AHT) imaging. As most of the radiographs and CT spine are negative in AHT in infants, the cervical spine is assumed to be normal. There is increasing evidence in the role of injury to brainstem and cervical cord in the pathogenesis of AHT. In addition, in courts of law, there is fierce debate about AHT, its mimics and other disparate nontraumatic diagnoses explaining the neuroradiological and skeletal findings. However, this discussion ignores the evidence and significance of spinal injury. We sought to study the cervical spine in an AHT cohort to understand the true prevalence of spinal injuries in AHT and contrast it with cohorts of accidental and nontraumatic groups to give the clinicians a robust diagnostic tool in evaluating AHT.
Objective
The purpose of this study is to compare the relative incidence of spinal ligamentous and soft-tissue abnormalities on spinal MRI among three groups of children ages <48 months: 1) those with AHT, 2) those with accidental trauma, and 3) those with nontraumatic conditions.
Materials and methods
This comparative study included 183 children who underwent spine MRI: 67 with AHT, 46 with accidental trauma and a clinical suspicion of spinal injury, and 70 with nontraumatic conditions. Clinical and radiographic findings were collected in all cases and were analyzed retrospectively to identify MRI evidence of traumatic spinal injuries. The incidence of spinal injuries among the three groups was compared. The incidence of spinal ligamentous injuries was calculated for those with and without radiographic evidence of hypoxic-ischemic encephalopathy. All comparisons were performed using Fisher exact test with P < 0.05 considered statistically significant.
Results
Cervical spine ligamentous injuries (predominantly the nuchal, atlanto-occipital and atlanto-axial ligaments) were present in 78% of the AHT group, 46% of the accidental trauma group and 1% of the nontraumatic group; all of these differences were statistically significant. Among the AHT group, ligamentous injuries were statistically correlated with evidence of brain ischemia.
Conclusion
Injury to the cervical spinal posterior ligamentous complex is common in AHT and even more prevalent than in clinically symptomatic traumatic cases. The high correlation between the radiographic findings of occipitocervical ligamentous injuries and hypoxic-ischemic brain injury is consistent with an interpretation that transient upper occipitocervical spinal cord injury in AHT leads to disordered breathing and results in hypoxic-ischemic encephalopathy. We recommend imaging the entire spine in AHT to properly identify and classify these injuries.
This is a preview of subscription content, log in via an institution to check access.
Similar content being viewed by others
References
Bradford R, Choudhary AK, Dias MS (2013) Serial neuroimaging in infants with abusive head trauma: timing abusive injuries. J Neurosurg Pediatr 12:110–119
Dias MS, Backstrom J, Falk M (1998) Serial radiography in the infant shaken impact syndrome. Pediatr Neurosurg 29:77–85
Geddes JF, Hackshaw AK, Vowles GH et al (2001) Neuropathology of inflicted head injury in children. I. Patterns of brain damage. Brain 124:1290–1298
Brennan LK, Rubin D, Christian CW et al (2009) Neck injuries in young pediatric homicide victims. J Neurosurg Pediatr 3:232–239
Geddes JF, Vowles GH, Hackshaw AK et al (2001) Neuropathology of inflicted head injury in children. II. Microscopic brain injury in infants. Brain 124:1299–1306
Hadley MN, Sonntag VK, Rekate HL et al (1989) The infant whiplash-shake injury syndrome: a clinical and pathological study. Neurosurgery 24:536–540
Johnson DL, Boal D, Baule R (1995) Role of apnea in nonaccidental head injury. Pediatr Neurosurg 23:305–310
Kemp AM, Stoodley N, Cobley C et al (2003) Apnoea and brain swelling in non-accidental head injury. Arch Dis Child 88:472–476
Shannon P, Becker L (2001) Mechanisms of brain injury in infantile child abuse. Lancet 358:686–687
Shannon P, Smith CR, Deck J et al (1998) Axonal injury and the neuropathology of shaken baby syndrome. Acta Neuropathol 95:625–631
Matshes EW, Evans RM, Pinckard JK et al (2011) Shaken infants dies of neck trauma, not of brain trauma. Acad For Path 1:82–91
Bandak FA (2005) Shaken baby syndrome: a biomechanics analysis of injury mechanisms. Forensic Sci Int 151:71–79
Judkins AR, Hood IG, Mirchandani HG et al (2004) Technical communication: rationale and technique for examination of nervous system in suspected infant victims of abuse. Am J Forensic Med Pathol 25:29–32
Choudhary AK, Bradford RK, Dias MS et al (2012) Spinal subdural hemorrhage in abusive head trauma: a retrospective study. Radiology 262:216–223
Katz JS, Oluigbo CO, Wilkinson CC et al (2010) Prevalence of cervical spine injury in infants with head trauma. J Neurosurg Pediatr 5:470–473
Polk-Williams A, Carr BG, Blinman TA et al (2008) Cervical spine injury in young children: a National Trauma Data Bank review. J Pediatr Surg 43:1718–1721
Kemp AM, Joshi AH, Mann M et al (2010) What are the clinical and radiological characteristics of spinal injuries from physical abuse: a systematic review. Arch Dis Child 95:355–360
Mulcahey MJ, Gaughan J, Betz RR et al (2007) The International Standards for Neurological Classification of Spinal Cord Injury: reliability of data when applied to children and youths. Spinal Cord 45:452–459
Anderson RC, Kan P, Vanaman M et al (2010) Utility of a cervical spine clearance protocol after trauma in children between 0 and 3 years of age. J Neurosurg Pediatr 5:292–296
Kadri PA, Al-Mefty O (2007) Anatomy of the nuchal ligament and its surgical applications. Neurosurgery 61:301–304, discussion 4
Takeshita K, Peterson ET, Bylski-Austrow D et al (2004) The nuchal ligament restrains cervical spine flexion. Spine (Phila Pa 1976) 29:E388–E393
Kahkeshani K, Ward PJ (2012) Connection between the spinal dura mater and suboccipital musculature: evidence for the myodural bridge and a route for its dissection–a review. Clin Anat 25:415–422
Nash L, Nicholson H, Lee AS et al (2005) Configuration of the connective tissue in the posterior atlanto-occipital interspace: a sheet plastination and confocal microscopy study. Spine (Phila Pa 1976) 30:1359–1366
Dean NA, Mitchell BS (2002) Anatomic relation between the nuchal ligament (ligamentum nuchae) and the spinal dura mater in the craniocervical region. Clin Anat 15:182–185
Zumpano MP, Hartwell S, Jagos CS (2006) Soft tissue connection between rectus capitus posterior minor and the posterior atlanto-occipital membrane: a cadaveric study. Clin Anat 19:522–527
Hack GD, Koritzer RT, Robinson WL et al (1995) Anatomic relation between the rectus capitis posterior minor muscle and the dura mater. Spine (Phila Pa 1976) 20:2484–2486
Johnson GM, Zhang M, Jones DG (2000) The fine connective tissue architecture of the human ligamentum nuchae. Spine (Phila Pa 1976) 25:5–9
Humphreys BK, Kenin S, Hubbard BB et al (2003) Investigation of connective tissue attachments to the cervical spinal dura mater. Clin Anat 16:152–159
Mitchell BS, Humphreys BK, O’Sullivan E (1998) Attachments of the ligamentum nuchae to cervical posterior spinal dura and the lateral part of the occipital bone. J Manip Physiol Ther 21:145–148
Pontell ME, Scali F, Marshall E et al (2013) The obliquus capitis inferior myodural bridge. Clin Anat 26:450–454
Nicholas DS, Weller RO (1988) The fine anatomy of the human spinal meninges. A light and scanning electron microscopy study. J Neurosurg 69:276–282
Conflicts of interest
None
Author information
Authors and Affiliations
Corresponding author
Rights and permissions
About this article
Cite this article
Choudhary, A.K., Ishak, R., Zacharia, T.T. et al. Imaging of spinal injury in abusive head trauma: a retrospective study. Pediatr Radiol 44, 1130–1140 (2014). https://doi.org/10.1007/s00247-014-2959-3
Received:
Revised:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s00247-014-2959-3