BALTIMORE – Cervical spine injuries may be more prevalent than previously thought among young children who sustain abusive head trauma, results of a 4-year, multicenter, retrospective study presented at the annual meeting of the Pediatric Academic Societies have shown.
Of children with abusive head trauma (AHT) who received cervical CT or MRI scans, 31% had abnormal findings. The most common cervical spine injuries were hemorrhagic (23.7%), with ligamentous abnormalities less common (8.7%).
This study helps fill a gap in the existing literature on the risk for cervical spine injuries for children who have suffered abusive head trauma, said Kate Henry, MD, in presenting the results of the study, conducted with her colleagues at the Center for Pediatric Clinical Effectiveness at the Children’s Hospital of Philadelphia.
Previous research in the area has concentrated on older children and on motor vehicle crashes, but “young children are different. They are preverbal, and the physical exam can be difficult. Also, the developing spine has a unique anatomy” that can change injury patterns and make imaging interpretation challenging, said Dr. Henry. Motor vehicle crashes make up less than 15% of the cases of traumatic brain injury (TBI) in young children, with falls being responsible for about half, and AHT accounting for 19%-25%, she said.
The study included patients younger than 2 years with an ICD-9 code for TBI associated with a hospital admission or emergency department visit. For final inclusion, patients also had to have MRI or CT confirmation of an intracranial injury. Patients who sustained a motor vehicle collision, were readmitted for complications of a prior injury, or were hospitalized following birth were excluded.
The retrospective chart review of records from four urban children’s hospitals found 3,170 patients who met all criteria except positive intracranial imaging findings; a stratified random sampling reduced the number to 664 charts eligible for review. The final TBI cohort included 329 patients who met the imaging criteria and were not excluded for other reasons.
For these 329 records, Dr. Henry and her colleagues collected physical exam findings, radiology reports of abnormal imaging findings, and the care team’s documentation of their assessment of the etiology of the injury.
The medical team’s assessment, together with the assessment of the child protection team (if it was engaged) were used to classify patients as having either “AHT” or “accidental TBI.”
The trauma-related cervical spine injuries considered as positive findings included ligamentous or soft tissue injury, spinal cord injury, vertebral dislocation or fracture, and extra-axial hemorrhage. “We had a high threshold for inclusion,” said Dr. Henry, explaining that only cervical, not high thoracic, findings were included. Additionally, she and her colleagues excluded radiologist interpretation of injuries as “nonspecific soft tissue findings” or a “possible” injury.
Overall, vertebral fractures or dislocations were seen in just 1.1% of patients with imaged AHT. Cord injuries were slightly more common, at 5.5%. Soft tissue or muscular findings were seen in 0.6% of patients. Some patients had multiple findings, so the overall 31.3% of patients with image-confirmed cervical injuries includes the 23.7% of patients with extra-axial bleed and the 8.7% with ligamentous injury.
Dr. Henry noted that the study was predicated on a certain “circularity of reasoning,” in that the results of spinal imaging could have an influence on the clinician assessment of etiology. The percentage of children diagnosed with AHT who received imaging of any kind was higher than for the all-cause TBI group, as well as for the subgroups of those with accidental TBI or indeterminate etiology. And Dr. Henry said there’s an inherent selection bias in including only those cases where imaging was performed: “The decision to image is unlikely to be random,” she said. However, if all AHT patients who did not receive imaging within the study period were considered to have normal findings, then 9.7% of AHT cases, or about 1 in 10, would still have abnormal findings.
These findings are important because currently, “There are no guidelines for use of cervical CT or MRI” for children with abusive head trauma, said Dr. Henry, and previous research in this area was based on a single-center study. Next steps should go beyond retrospective chart reviews, she said. “Prospective studies are needed to inform cervical imaging recommendations.”
Dr. Henry reported no relevant disclosures.
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