Spinal cord injury in abusive and accidental head injury in children, a neuropathological investigation

The diagnosis of abusive head trauma (AbHT) in children is a challenging one that needs to be differentiated from natural disease and accidental head injury (AcHT). There is increasing evidence from the Neuroradiology field showing spinal cord injury in children subject to AbHT, which has, so far, been poorly investigated pathologically. In this study we retrospectively reviewed the forensic records of 110 paediatric head injury cases over an eight-year-period. The records included detailed circumstances of death and clinical history alongside neuropathology, ophthalmic pathology and osteo-articular pathology. Based on the final multidisciplinary agreement, the 110 case were grouped into AbHT (n = 40), AcHT (n = 9), not clearly accidental or abusive ("undetermined" (UHT) n = 8) and non-traumatic brain injury (NTBI, n = 53). The spinal cord pathology present within each group was compared. Spinal subdural haematoma (SDH) was present in 71% of AbHT and 50% of AcHT cases and were located predominantly at the thoracolumbar level. In AbHT cases without spinal SDH, the suspected mechanism of injury was that of head impact rather than shaking, whilst cases of AcHT with spinal SDH were associated with direct trauma to the spinal cord. Injury of spinal nerve roots in AbHT was almost three times that seen in the accidental head injury group (58% vs. 17%). The study shows that pathological examination of the spinal cord and spinal nerve roots is of high value in investigating AHT and may help in differentiating AbHT from AcHT.