New Insights and Imaging Techniques for Spinal Injury Assessments

Child physical abuse significantly impacts morbidity and mortality within the pediatric population. Recent studies indicate that abusive spinal injuries are increasingly recognized, contradicting historical assumptions that these injuries are rare. The enhanced use of magnetic resonance imaging (MRI) has been crucial in identifying that most abusive spinal injuries involve soft tissues and ligaments, or appear as intrathecal blood products, which typically evade detection through standard radiography or computed tomography (CT). The identification of spinal injuries during evaluations for non-accidental trauma is critical for improving the management of affected children and their siblings.

Research over the past two decades has expanded the understanding of abusive spinal injuries, which are prevalent in children under two years of age. These injuries often lead to longer hospital stays and higher medical costs compared to accidental spinal injuries. Diagnosing these injuries remains complicated due to discrepancies in caregiver accounts, communication barriers with preverbal children, and potentially misleading initial skeletal surveys. The overlap of abusive head trauma (AHT) can further obscure the clinical picture, complicating the diagnosis of spinal injuries.

Spinal injuries in infants and young children can indicate abuse, particularly when the injury history is inadequate. Studies show that many abusive spinal injuries present as soft-tissue and ligamentous injuries, in addition to spinal hemorrhages, rather than bony fractures, which are often missed if appropriate imaging is not conducted. Increased utilization of MRI has helped elucidate the spectrum of inflicted spinal injuries and shed light on common injury patterns; however, variations in imaging practices persist across medical institutions.

Recognizing abusive spinal injuries is imperative since external signs may not always manifest during a clinical examination, especially if coexisting intracranial injuries are present. Imaging often provides the most evident abnormalities. This review focuses on the current imaging literature concerning abusive spinal injuries, identifies patterns that are typically observed, and provides guidance on imaging protocols for assessment.

Historically, instances of abusive spinal injuries were noted as early as the 1950s. Recognition of spinal injuries associated with child abuse has markedly increased, although the exact prevalence remains difficult to ascertain. Skeletal surveys frequently fail to detect spinal fractures, with reported ranges as low as 0 to 3%. In a meta-analysis of 365 skeletal surveys for suspected child abuse, only a small fraction identified spinal fractures. Moreover, reported types of spinal fractures resulting from abuse vary widely, presenting ranging from subtle compression deformities to severe fracture-dislocations resulting in significant neurological consequences.

The increased application of cross-sectional imaging has uncovered additional injury patterns. A systematic review of cases identified significant cervical injuries in nearly half of the subjects, highlighting the necessity for comprehensive imaging that includes the spine when evaluating suspected abuse. Recommendations now advocate for MRI of the total spine in cases of suspected AHT, as evidence continues to correlate abusive spinal injuries with intracranial injuries and other forms of abuse. Detailed understanding and awareness of these injuries are essential for accurate diagnosis, guiding management, and providing strong support for medicolegal investigations.

In cases of AHT, cervical spinal ligamentous injuries are notably prevalent, commonly associated with cranial abnormalities. One study demonstrated that a considerable percentage of children evaluated for abusive head trauma had concurrent cervical injuries, reinforcing the need for thorough imaging evaluations during clinical work-ups for suspected abuse. MRI has become increasingly critical in detecting and characterizing these injuries as they often significantly impact the clinical trajectory.

Recent findings reveal a high incidence of spinal injuries among children evaluated for AHT, with common patterns identified, including ligamentous injuries and soft-tissue edema. Studies indicate strong correlations between the presence of spinal injuries and other traumatic findings such as retinal hemorrhages, suggesting these conditions may coexist in abusive scenarios.

The imaging features indicative of abusive spinal injury include soft tissue edema, hemorrhage, and varying degrees of ligamentous injury. Recognizing the full spectrum of injury patterns is critical for formulating appropriate management strategies. Further, understanding the anatomical differences seen in pediatric populations can inform imaging and clinical decision-making. For instance, unique characteristics of children’s cervical spines can make them particularly susceptible to certain injury mechanisms during abuse, as anatomical structures remain underdeveloped compared to adults.

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