Spinal cord injury as an indicator of abuse in forensic assessment of abusive head trauma (AHT)

Abstract

Abusive head trauma (AHT) in children is notoriously one of the most challenging diagnoses for the forensic pathologist. The pathological “triad”, a combination of intracranial subdural haematoma, cerebral oedema with hypoxic-ischaemic changes and retinal haemorrhages, is frequently argued to be insufficient to support a corroborated verdict of abuse. Data from all available English-language scientific literature involving radiological and neuropathological spinal cord examination is reviewed here in order to assess the contribution of spinal cord changes in differentiating abusive from accidental head trauma. In agreement with the statistically proven association between spinal subdural haemorrhage (SDH) and abuse (Choudhary et al. in Radiology 262:216–223, 2012), spinal blood collection proved to be the most indicative finding related to abusive aetiology. The incidence of spinal blood collection is as much as 44–48% when all the spinal cord levels are analysed as opposed to just 0–18% when the assessment is performed at cervical level only, in agreement with the evidence of the most frequent spinal SDH location at thoracolumbar rather than cervical level. In this review, the source of spinal cord blood collection and how the age of the child relates to the position of spinal cord lesions is also discussed. We concluded that the ante mortem MRI examination and post mortem examination of whole-length spinal cord is of fundamental interest for the assessment of abuse in the forensic setting.

Blood proteome of acute intracranial hemorrhage in infant victims of abusive head trauma

“…Along the same lines, ENPP2 displays the highest CNS expression in the corpus callosum, spinal cord and pigmented layer of the retina [60]. As mentioned above and in line with data in the HPA, F5 is dominantly expressed in the corpus callosum, the pons, and the medulla oblongata, brain regions proximate to the spinal cord, and which frequently report injuries in AHT but not in accidental head trauma in infants [2, 58, 59].…”

“…We observed that the several proteins upregulated in the serum of AHT cases (i.e., ENPP2, BASP1, LCAT) including the highly elevated F5 protein display an overlap of their CNS expression with the anatomical lesions found in the brain of infant victims of AHT, but not accidental head trauma [58, 59].…”

Complex Pathophysiology of Abusive Head Trauma with Poor Neurological Outcome in Infants

“…Upper cervical spinal cord injury is another important non-negligible factor that increases the severity of AHT [ 8 , 9 , 25 ]. To elucidate why CPA occurs, it is necessary to consider the possibility of upper spinal cord injury.…”

Response to Colombari et al. (2021)

“…Colombari et al [1] present a literature review to assess the contribution of spinal cord changes in differentiating abusive from accidental head trauma. This premise itself defies logic.…”