Radiology: Spinal bleeding with brain injury may suggest child abuse

Spinal bleeding is found often in young children who are victims of abusive trauma, according to a study published online Nov. 8 in Radiology. The findings support performing complete spine imaging for children undergoing a brain MRI for moderate or severe traumatic brain injury and suggest a pathway for distinguishing between abusive and accidental injury.

According to the researchers, abusive head trauma is the leading cause of significant traumatic brain injury in infants, with a 20 to 38 percent mortality rate and significant neurological and developmental impairment in 30 to 78 percent of survivors, according to Arabinda Kumar Choudhary, MD, of the department of radiology at Penn State University College of Medicine in Hershey, Pa.

The radiologic features of abusive head trauma include bleeding within the skull and brain injury. Spinal injuries like spinal subdural hemorrhage are another feature of trauma that may be overlooked clinically in non-fatal cases because of coexistent brain injury and traumatic coma.

Choudhary and colleagues sought to compare the relative incidence, distribution and radiologic characteristics of spinal subdural hemorrhage after abusive head trauma in children and aimed to better understand the origin.

“Imaging the whole spine is important in cases of abuse for two reasons,” said Choudhary in a statement. “Most of the spinal injuries in abusive head trauma are clinically silent because of extensive injuries elsewhere and lack of a clinical history suggestive of spinal injury. It is important to rule out any significant injury to the spine and spinal cord. Also, spine imaging allows complications of subdural hemorrhage collecting in the spinal canal to be diagnosed earlier.”

The researchers examined clinical data and imaging records for 252 children aged two years old or younger who underwent treatment for abusive head trauma at the medical center between 1997 and 2009. Imaging results included CT and MRI of the brain, spine, chest, abdomen and pelvis. Choudhary and colleagues compared the imaging results to those from a group of 70 similarly aged children who were treated for accidental trauma between 2003 and 2010.

Spinal canal subdural hemorrhage was evident in more than 60 percent of the children with abusive head trauma who underwent thoracolumbar imaging. In contrast, spinal canal subdural hemorrhage was present in 1 percent of children in the accidental trauma group.

“The diagnosis of abusive head trauma is complex,” Choudhary said. “In most of these cases, the history does not fit with the clinical findings.” Choudhary indicated that more research is needed to improve understanding of the relationship between abusive trauma and spinal bleeding.

He added that it is crucial for radiologists to have all the facts at their disposal to be able to come to a confident diagnosis in possible cases of abusive head trauma.