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

Abstract

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.

Keywords: Abusive head trauma; Forensic investigation; Spinal cord injury; Spinal nerve roots; Spinal subdural haemorrhage.

Fig. 1

A. Dura (A), brain (B) and spinal cord (C) from a 5 month old female diagnosed with abusive head trauma. (A) multiple patches of thin SDH, underneath dorsal and infratentorial parts of dura; (B) moderately thick film of SAH covering the dorsal surface of the cerebral hemisphere in the parietal lobe and slightly in the occipital lobe and lateral surfaces around right and left Sylvian fissure extending to the anterior and inferior surfaces of temporal lobes; (C) dusky discolouration of outer surfaces of spinal cord consistent with SAH or SDH haemorrhage

Fig. 2

A: Haematoxylin and eosin-stained histological sections of cortex showing generalised recent ischaemic damage in the brain (vacuolation, shrunken neurones). B: βAPP deposition in the brain forming ill-defined areas with faint granular and filamentous deposits consistent with ischaemic disruption of axons. Scale bar represents 100 μm (a), 75 μm (b)

Fig. 3

Macro (A) and micro (B,C) representation of spinal cord. A) material with reddish /dusky discolouration between the dura and the spinal cord consistent with SAH and SDH haemorrhages; B) histological examination shows recent haemorrhages in the subdural and subarachnoid spaces composed of well preserved red blood cells C) in the cervical segment, the βAPP staining shows multiple small rounded to oval-shaped accumulated deposit in the spinal cord’s white matter tracts extending to the subpial areas consistent with recent axonal injury. Scale bar represents 100 μm

Fig. 4

βAPP deposition indicating axonal injury in the spinal nerve roots. Scale bar represents 75 μm