Neck injuries in young pediatric homicide victims

Abstract

In this study, the authors estimate the prevalence of injuries to the soft tissue of the neck, cervical vertebrae, and cervical spinal cord among victims of abusive head trauma to better understand these injuries and their relationship to other pathophysiological findings commonly found in children with fatal abusive head trauma. The population included all homicide victims 2 years of age and younger from the city of Philadelphia, Pennyslvania, who underwent a comprehensive postmortem examination at the Office of the Medical Examiner between 1995 and 2003. A retrospective review of all available postmortem records was performed, and data regarding numerous pathological findings, as well as the patient's clinical history and demographic information, were abstracted. Data were described using means and standard deviations for continuous variables, and frequency and ranges for categorical variables. Chi-square analyses were used to test for the association of neck injuries with different types of brain injury. The sample included 52 children, 41 (79%) of whom died of abusive head trauma. Of these, 29 (71%) had primary cervical cord injuries: in 21 there were parenchymal injuries, in 24 meningeal hemorrhages, and in 16, nerve root avulsion/dorsal root ganglion hemorrhage were evident. Six children with abusive head trauma had no evidence of an impact to the head, and all 6 had primary cervical spinal cord injury (SCI). No child had a spinal fracture. Six of 29 children (21%) with primary cervical SCIs had soft-tissue (ligamentous or muscular) injuries to the neck, and 14 (48%) had brainstem injuries. There was a significant association of primary cervical SCI with cerebral edema (p = 0.036) but not with hypoxia-ischemia, infarction, or herniation. Cervical SCI is a frequent but not universal finding in young children with fatal abusive head trauma. In the present study, parenchymal and/or root injury usually occurred without evidence of muscular or ligamentous damage, or of bone dislocation or fracture. Moreover, associated brainstem injuries were not always seen. Although there was a significant association of primary cervical cord injury with cerebral edema, there was no direct relationship to brainstem herniation, hypoxia-ischemia, or infarction. This suggests that cervical spinal trauma is only 1 factor in the pathogenesis of these lesions.