Cervical Spine Trauma in Child Abuse
Authored by Stephanie Zimmerman, M.D.
The Child Abuse and Neglect Team of The Mayerson Center for Safe and Healthy Children at Cincinnati Children's Hospital Medical Center provides the following clinical update of literature on cervical spine trauma in child abuse.
There are few case reports in the literature concerning cervical spine trauma in cases of child abuse, and only one prospective study was identified. The mechanism of how cervical spine injuries occur with child abuse is not completely understood. Often these findings are missed by conventional radiographs, and in some instances, they are even missed by magnetic resonance spectroscopy, being seen only at autopsy.
Feldman and colleagues prospectively identified 12 children with central nervous system injury who were determined to have suffered intentional injury. All children had conventional radiographs and magnetic resonance imaging of the cervical spine. None of the children in this study had evidence of cervical cord injury on either conventional radiography or magnetic resonance imaging, but four of five children who subsequently died and were autopsied showed subdural or subarachnoid hemorrhages over the cervical cord.
Hadley et al. reviewed 13 cases of non-accidental head injury without evidence of direct cranial trauma. Five of the six patients who died received a complete autopsy and had an epidural or subdural hemorrhage at the cervicomedullary junction; four of the six patients had spinal contusions at high cervical levels.
Swischuck reviewed 7 cases of children with spine or spinal cord injuries who were diagnosed with "battered child syndrome". There is no mention of how this diagnosis was made. One child in this series had a cervical spine fracture and the remainder had thoracic and lumbar injuries.
Rooks et al. discuss two cases of three month old twins with cervical spine fracture-dislocations. The injuries were identified on conventional radiographs and confirmed on MRI. The mechanism for injury is unknown. Piatt and Steinberg present a case of a toddler with presumed intentional injuries who had a cervical cord injury identified only on MRI (conventional radiographs were normal).
McGregory and Fenichel describe a hangman's fracture in an infant who was "forcibly shaken". The fracture was visualized with conventional radiographs. Towbin, in a letter, describes the autopsy results of 4 infants who were given the diagnosis of sudden infant death syndrome. All four infants had epidural hemorrhages in the cervical and upper thoracic spinal cord regions.
Article Summaries
Feldman K, Weinberger E, Milstein J, Fligner C. Cervical spine MRI in abused infants. Child Abuse & Neglect 1997;21:199-205.
Objective
To determine the usefullness of screening with cervical spine magnetic resonance imaging (MRI) to detect unsuspected cervical spine injury in children with inflicted head injury.
Methods
12 children who presented with stable non-accidental head trauma were studied with cervical spine MRI to detect unsuspected cord injury (mean age of children: 5.8 months).
The diagnosis of inflicted head injury was made by the child protection team.
Results
- All children had evidence of central nervous system injury.
- All children had negative cervical spine films (conventional radiography).
- None of the MRI scans showed evidence of cervical cord injury or bleeding around cord.
- 5/12 children died and were autopsied
- 1 child had a diffuse, thin subdural hematoma over upper cervical cord that was continuous with a cranial subdural hematoma
- 3 children had subarachnoid hemorrhages over the cervical cord, all of which were associated with cranial subarachnoid hemorrhages
- No gross or microscopic changes were noted in the spinal cord except for hypoxic neuronal changes seen in one cord.
Conclusions
- In this series of 12 infants with evidence of inflicted head injury, none had evidence of cervical spine injury or bleeding on MRI or conventional radiographs.
- Four of five children who were autopsied in this series showed evidence of cervical spine hemorrhage even though the hemorrhage was not visible on conventional radiographs or MRI.
Hadley M, Sonntag V, Rekate H, Murphy A. The infant whiplash-shake injury syndrome: a clinical and pathological study. Neurosurgery 1989;24:536-39.
Objective
To investigate cases of non-accidental head injury without evidence of direct cranial trauma.
Methods
Thirty-six cases of non-accidental head trauma in infants over a 6 year period were reviewed.
13 cases were determined to be due to a shaking injury alone (no evidence of direct cranial trauma) based on history, interviews, physical examination and radiographs.
Results
- Median age of patients was 3 months
- All of the patients had subdural hemorrhages and/or subarachnoid hemorrhages on CT scan
- 9 patients had cerebral contusions
- 8 patients died:
- 6 patients had complete autopsies
- All had subdural hemorrhages, cerebral contusions, or swelling with herniation
- 1 patient had an extracalvarial contusion
- 5 patients had epidural hematomas and/or subdural hematomas of the spinal cord at the cervicomedullary junction
- 4 patients had evidence of ventral spinal contusions at high cervical levels
Conclusion
- In this series, hemorrhages of the high cervical spinal cord were found in five of six autopsied patients who died after suffering a shaking injury; four of six patients had cervical spinal cord contusions.
Swischuk L. Spine and spinal cord trauma in the battered child syndrome. Radiology 1969;92:733-38.
Objective
To review seven cases of "battered child syndrome" with spine and spinal cord injuries
Methods
- Records of 7 cases of child abuse with spinal injury were reviewed.
- There was no mention of how the diagnoses of child abuse was substantiated in these cases.
Results
- All seven patients demonstrated fractures of the lower thoracic spine/upper lumbar spine.
- One patient showed evidence of a cervical spine fracture-dislocation with spontaneous reduction (straightening of the normal vertebral curve (muscle spasm) and marked widening of the prevertebral soft tissues (hemorrhage and edema)).
- This was the only case in which the child was symptomatic (symptoms included neck rigidity, limp extremities, pain upon flexion of the thighs, and urinary incontinence).
- All of the injuries were demonstrated with conventional radiographs and myelograms.
Conclusions
- In these seven cases of child abuse and spinal injury, only one child showed evidence of a c-spine fracture.
- In this review, symptoms of spinal trauma were minimal or absent except for the one case of cervical spine injury.
Rooks VJ, Sisler C, Burton B. Cervical spine injury in child abuse: report of two cases. Pediatric Radiology 1998;28:193-95.
Objective
To present two cases of unsuspected cervical spine injury in twin infants.
Case 1
- A three month old 33 week gestation twin was brought to the emergency department because of fever and upper respiratory symptoms.
- Physical exam was unremarkable except for irritability.
- Chest radiographs performed to look for pneumonia revealed multiple fractures.
- Skeletal survey revealed 20 fractures, including multiple rib fractures, multiple metaphyseal fractures, left radius and ulna fractures, and a sternal depression fracture.
- Cervical spine films showed a C5 compression fracture and anterior subluxation of C4 on C5.
- MRI of the spine demonstrated a cord compression at the site of the fracture-dislocation.
Case 2
- Three month old twin of case 1 was admitted to the hospital for an abuse evaluation the same day as her sibling.
- She had recently been discharged following a 3-day hospitalization for viral meningitis.
- Physical exam was unremarkable.
- Skeletal survey revealed 14 fractures of various ages, including multiple rib fractures and multiple metaphyseal fractures.
- Cervical spine radiographs revealed a fracture-dislocation of C5 on C6.
- MRI confirmed the fracture-dislocation and revealed a mild cord compression.
- The authors postulated the mechanism of injury to be "severe hyperflexion compression insult from violent shaking", but no specific history to explain the mechanism is offered as to the injuries in these infants.
Conclusion
- These case reports demonstrate injuries to the cervical vertebrae and cords in twin infants with presumed inflicted injuries.
Piatt J, Steinberg M. Isolated spinal cord injury as a presentation of child abuse. Pediatrics 1995;96:780-82.
Objective
To present a case report of a child with a cervical spine injury and presumed intentional injuries.
Findings
- A 15 month old infant was transferred from a community hospital ED because of quadriplegia.
- The infant had been alone in mother's boyfriend's care.
- The infant was "found on the floor next to a dented popcorn can" after the boyfriend heard a cry.
- Injuries noted in the emergency department included a tongue laceration, lip abrasion, linear contusions in front of the ear and along the jaw, petechiae to the neck, bilateral ears, jaw, right arm, and upper chest, "old" bruises to bilateral orbits, bilateral arms, and right thigh, and flaccid quadriplegia with complete anesthesia below the neck.
- Cervical spine radiographs were normal; MRI of the cervical spine demonstrated fusiform swelling of the spinal cord in the midcervical region with hematomyelia; a healing clavicle fracture was found on skeletal survey.
- The injuries were attributed to child abuse after the boyfriend's story changed following a failed polygraph test.
- The mechanism of injury was unknown.
Conclusions
- This case report demonstrates a cervical cord injury in an infant with presumed inflicted injury.
- The cervical spine injury was demonstrated on MRI but not on conventional radiographs.
McGrory BE, Fenichel GM. Hangman's fracture subsequent to shaking in an infant. Ann Neurol 1977;2:82
Objective
To present a case report of a 4 month old infant with cervical spine injury and a shaking episode.
Findings
- At 1 month of age the baby was reported as healthy.
- A few days later, the infant stopped breathing during an episode of intense crying and became cyanotic, after which he was "forcibly shaken for 10-15 seconds" and slapped on the back.
- After the episode, the child became irritable upon any manipulation of the head or neck.
- At 4 months of age, cervical spine films performed because the infant had little spontaneous movement of the neck revealed a C-2 fracture (neurologic exam was normal except for unsustained bilateral ankle clonus).
- The authors propose that this cervical spine fracture occurred from a hyperflexion/hyperextension injury.
Towbin A. Sudden infant death (cot death) related to spinal injury. Lancet 1967;2:940. Objective
To describe the autopsy findings of spinal epidural hemorrhages in four cases of infants who were given the diagnosis of sudden infant death syndrome (SIDS).
Letter to the editor
Findings
- 4 cases of sudden infant death syndrome (SIDS) in which the spinal structures were examined at autopsy are discussed (age range of patients: 2 weeks-6 weeks).
- All 4 cases had spinal epidural hemorrhages extending from the cervical to thoracic spine regions.
- No history of trauma was reported but how the diagnosis of SIDS was determined is not discussed.
- The author suggests possible causal factors: "the small infant, having a relatively large head, which is supported on a weak flail neck, is vulnerable to self-injury, in particular, to acute extension-flexion injury of the cervical spine."
