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Cervical injuries

The following is a summary of the systematic review findings up to the date of our most recent literature search. If you have a specific clinical case, we strongly recommend you read all of the relevant references as cited and look for additional material published outside our search dates.

 

  • 18 studies described cervical injuries 1-18
  • Age range: 1-48 months 
  • 1 comparative case series of children aged less than 2 years with spinal fracture noted 11 out of 29 were due to abuse.  These injuries were predominantly cervical (8 out of 11) and 3 thoraco-lumbar 12

Presenting features

  • Many of the children presented with respiratory distress 1,2,6-8,11,13-17
  • Altered consciousness and/or neurological deficit were the second most common symptoms 1,2,5-8,11-17 
  • Pain on movement of the neck was noted in 2 cases 8,14
  • 1 child was asymptomatic with a C5-6 fracture dislocation and mild cord compression (diagnosed during investigation after twin was abused) 16
  • Koumellis identified three children with cervical subdural haematoma (SDH) associated with abusive head trauma; in two cases the SDH extended to the sacral region 13
  • In a series of 14 children with spinal fractures to the thoracic, lumbar or sacral spine identified on skeletal survey, Barber reports one child with respiratory arrest, abusive head trauma and rib fractures who had a fracture at C4 identified on CT scan 2
  • Kleinman identified a child with a hangman’s fracture at C2 10

Injuries present

  • Musculoskeletal injury occurred at any point throughout the cervical spine 1,6-8,11,13-18, with upper cervical spine predominantly injured in a case-series (7 out of 8) 12
  • 1 case involved central cord syndrome of C1-7 6
  • 2 cases involved spinal cord injury without musculoskeletal injury 6,14
  • 1 case report of a fatally injured of a 13 month old infant showed a complete tear of the anterior ligament  and diastases of the vertrabral bodies at C5/C6, in conjunction with the lumbar spinal injury and transection of the aorta 5
  • Two case-control studies addressed abnormalities on MRI. One included STIR sequence 4 while one examined T1, T2, DWI and saggital fast-spin echo inversion recovery 9
    • One study identified cervical injury in 36% of children. There was no significant association between these injuries and suspected or confirmed abuse 9. Two infants sustained cervical spinal cord injury, who also had extensive brain injuries and ligamentous injury 9
    • The second study identified nuchal, interspinous, posterior atlanto-axial, posterior atlanto-occiptial and capsule ligamentous injury. While these were not exclusively present among children with abusive head trauma, they were more common in this group. They were not present in non-traumatic cases 4. Only 6% of abusive head trauma cases and 2% of non-abusive head trauma cases had bony injury
  • A comparative case series showed that abusive cervical injuries involved ligamentous injury in 8 out of 8, 7 of these had normal plain films, and 1 child had co-existent thoracic injury. There were no fractures or spinal cord injuries 12
  • Additional injuries included rib and extremity fractures in 3 out of 8 infants 12

Co-existent abusive head trauma

  • Seven cases included a variety of intracranial injuries co-existent with cervical injury 1,6,7,13,14
  • The cervical injuries ranged throughout C1-7 1,6,7,13,14
  • In a large case-control study, amongst those children with abusive head trauma aged 0-2 years with cervical spinal imaging, 7/29 (24%) had cervical subdural haemorrhage versus 0/47 for accidental trauma 3
  • Two case-control studies of children with abusive versus non-abusive head trauma addressed the correlation between intra-cranial and spinal injury 4,9
  • One found no significant association between cervical spine injuries and abusive head trauma (confirmed or suspected) 9
  • The other identified a strong association between cervical ligamentous injury and cerebral ischaemia 4
  • All 8 children with cervical injury had a co-existent intracranial injury 12

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References

  1. Agner C, Weig SG. Arterial dissection and stroke following child abuse: case report and review of the literature. Childs Nervous System. 2005;21(5):416-420 [Pubmed]
  2. Barber I, Perez-Rossello JM, Wilson CR, Silvera MV, Kleinman PK. Prevalence and relevance of pediatric spinal fractures in suspected child abuse. Pediatric Radiology. 2013;43(11):1507-15 [Pubmed]

  3. Choudhary AK, Bradford RK, Dias MS, Moore GJ, Boal DK. Spinal subdural hemorrhage in abusive head trauma: a retrospective study. Radiology. 2012;262(1):216-223. [Pubmed]

  4. Choudhary AK, Ishak R, Zacharia TT, Dias MS. Imaging of spinal injury in abusive head trauma: a retrospective study. Pediatric Radiology. 2014;44(9):1130-1140 [Pubmed]

  5. Dudley MH, Garg M. Fatal child abuse presenting with multiple vertebral and vascular trauma. Journal of Forensic Sciences. 2014;59(2):386-389 [Pubmed]

  6. Feldman KW, Avellino AM, Sugar NF and Ellenbogen RG (2008 ) Cervical spinal cord injury in abused children. Pediatric Emergency Care 24(4):222-227 [Pubmed]
  7. Ghatan S, Ellenbogen RG. Pediatric spine and spinal cord injury after inflicted trauma. Neurosurgery Clinics of North America. 2002;13(2):227-233 [Pubmed]
  8. Gille P, Bonneville JF, Francois JY, Aubert D, Peltre G and Canal JP (1980) Fracture des pédicules de l'axis chez un nourrisson battu (Fracture of the pedicles of the axis in a battered infant). Chirurgie Pediatrique 21(5):343-344
  9. Kadom N, Khademian Z, Vezina G, Shalaby-Rana E, Rice A, Hinds T. Usefulness of MRI detection of cervical spine and brain injuries in the evaluation of abusive head trauma. Pediatric Radiology. 2014;44(7):839-848 [Pubmed]

  10. Kleinman PK, Morris NB, Makris J, Moles RL, Kleinman PL. Yield of radiographic skeletal surveys for detection of hand, foot, and spine fractures in suspected child abuse. American Journal of Roentgenology. 2013;200(3):641-4 [Pubmed]

  11. Kleinman PK and Shelton YA (1997) Hangman's fracture in an abused infant: imaging features. Pediatric Radiology 27:776-777 [Pubmed]
  12. Knox J, Schneider J, Wimberly RL, Riccio AI. Characteristics of spinal injuries secondary to nonaccidental trauma. Journal of Pediatric Orthopedics. 2014;34(4):376-381 [Pubmed]

  13. Koumellis P, McConachie NS, Jaspan T. Spinal subdural haematomas in children with non-accidental head injury. Archives of Disease in Childhood. 2009;94(3):216-219.[Pubmed]
  14. Oral R, Rahhal R, Elshershari H and Menezes AH (2006) Intentional avulsion fracture of the second cervical vertebra in a hypotonic child. Pediatric Emergency Care 22(5):352-354 [Pubmed]
  15. Piatt JH, Jr and Steinberg M (1995) Isolated spinal cord injury as a presentation of child abuse. Pediatrics 96:780-782 [Article]
  16. Rooks VJ, Sisler C and Burton B (1998) Cervical spine injury in child abuse: report of two cases. Pediatric Radiology 28(3):193-195 [Pubmed]
  17. Thomas NH, Robinson L, Evans A, Bullock P. The floppy infant: a new manifestation of nonaccidental injury. Pediatric Neurosurgery. 1995;23(4):188-191 [Pubmed]
  18. Tran B, Silvera M, Newton A and Kleinman PK (2007) Inflicted T12 fracture-dislocation: CT/MRI correlation and mechanistic implications. Pediatric Radiology 37(11):1171-1173 [Pubmed]

 

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