Sample Review
Physical Abuse

Prevalence of cervical spine injury in infants with head trauma. Joel S Katz, Chima O Oluigbo, C Corbett Wilkinson, Sean McNatt, Michael H Handler. J Neurosurg Pediatrics 2010;5:470-473. (from Aurora, CO)

Review from Autumn 2010 issue

The authors reviewed the Children’s Hospital trauma database in Colorado from 1993 to 2007, searching for infants less than one year old with head trauma. They identified 905 patients with a mean age of 4.3 months. Those who were the victims of motor vehicle events or falls of more than ten feet were excluded.

Fifty-four percent of the study sample had been injured in falls, 39% were the victims of child abuse, 2.5% were struck by an object, and 2.8% had other causes of injury. Thirty percent had dedicated spine X-rays, 49% had skeletal surveys, 3% had spinal CTs and 1% had spinal MRIs. In all, 62% had the spine evaluated by some form of imaging; the diagnosis was cleared clinically in the rest.

Only two children had recognized cervical spinal injury. One, a six-month-old infant with a pneumomediastinum extending into the neck, had a small ventral epidural hemorrhage at autopsy. A two-month-old had a unilateral laminar fracture of C-4. Neither child had symptomatic cervical injury or required intervention for the spinal injury. Both children had been abused.

The prevalence of cervical spine injury was 0.2% in the entire series, 0.5% among abused infants, and 3% among the 33 fatalities. On follow-up, no additional spinal injuries were found.

   Reviewed by Kenneth Feldman, M.D.

 

Reviewer’s Note:
Although defense witnesses continue to assert that abusive head injury from whiplash events MUST also cause cervical injury, this is an additional series that belies this assertion. Not only is clinically apparent cervical injury rare in abuse, but the authors did not see it in the context of any other form of head trauma in infants. No falls less than ten feet caused cervical injury. Shorter falls have been reported to cause cervical cord injury1 but it is unclear how carefully abuse was excluded. In their review of spinal injury in abuse, Kemp et al.2 also noted the rarity of documented cervical spinal injuries and the high percentage of abuse among those children. Seventy-seven percent had multiple fractures and 50% had abusive head injuries. In my clinical series of cervical cord injuries, I estimated that 1% of the children with abusive head injury I have seen sustained clinical cervical cord injury.3

This series included few cases evaluated with the more detailed imaging techniques of CT or MRI scans. As such, it probably underestimates the rate of cervical injuries that are not apparent clinically. Brennan4 also observed that autopsy evidence of cervical injury in abused, head-injured infants is much more common (71%) than is clinically apparent.

It would behoove us to look more closely for clinical evidence of cervical injury and to use the most specific imaging. When possible, we should use CT for bony injury and MRI for cord and soft tissue injury.

References:

  1. Chen LS, Blau ME. Acute central cervical cord syndrome caused by minor trauma. J Pediatr 1986;108:96-97.
  2. Kemp AM, Joshi AH, Mann M et al. What are the clinical and radiological characteristics of spinal injuries from physical abuse: A systematic review. Arch Dis Child 2010;95:355-360.
  3. Feldman KW et al. Cervical spinal cord injury in abused children. Ped Emerg Care 2008;24:222-227.
  4. Brennan LK, Rubin D, Christian CW et al. Neck injuries in young pediatric homicide victims. J Neurosurg Pediatr 2009;3:232-239.