Table 1.

Spinal cord AHT pathological findings: evidence from neuroradiology (case series)

Study	Cases	Spinal cord level	Spinal cord injuries	Muscolo-skeletal spinal injuries	Imaging technique	Author’s statement
Rabbitt et al., 2020 [41]	47 AHT and 29 accidental head trauma (mean age and age interval are not given)	All levels	Spinal SDH was the only finding associated with a combination of RH (p = 0.001), non-contact head injury (p = 0.008) and AHT diagnosis (p < 0.05).	42% of AHT had ligament injury.	MRI	Spinal injury is seen in most AHT children and might be clinically and forensically valuable.
Jauregui et al., 2019 [42]	116 abused and 22,076 non abused (ma 2.1 and 13.9, respectively)	All levels	No increased risk of spinal cord injury in abused compared with non-abused (OR = 1.51).	Abused have increased risk of vertebral fractures at thoraco (OR = 2.97) and lumbar (OR = 1.67) level.	Not reported	Abused with spinal cord/vertebral injury are less likely to be admitted with cervical vertebra column fractures compared with non-abused children (OR = 0.51)
Henry et al., 2018 [43]	74 AHT and 14 accidental head trauma (<2 y)	Cervical	23% of AHT and 1.3% of accidental head trauma had spinal extra-axial haemorrhage.	9% of AHT and 6% of accidental head trauma had ligamentous injury.	CT MRI	AHT are at increased risk of cervical injuries.
Oh et al., 2017 [44]	91 abusive trauma (<9 y, ma 6 mo)	Cervical	2/91 had SDH, 4 had spinal cord injuries.	13/91 had ligamentous injuries, 22/91 had soft-tissue injuries.	MRI	In abused children, the rate of positive cervical MRI is up to 31%.
Baerg et al.,2017 [45]	53 AHT (<36 mo, ma 5 mo)	Cervical	1 case of cord injury with cord EDH and a case of an isolated cord EDH.	Ligamentous, vertebral artery shear injuries, atlantoccipital dissociation.	CT MRI	Small children with inflicted trauma had cervical spine injuries in around 15.1% of cases. Evaluation of them should include cervical spine imaging.
Jacob et al.,2016 [46]	89 AHT (<5 y, ma 9.1 mo)	Cervical	18% had SDH.	67% ligamentous 32% vertebral joint swelling.	MRI	The prevalence of cervical spine injuries in AHT children is high.
Kadom et al., 2014 [16]	38 AHT and 26 accidental head trauma and 10 undefined-head trauma (0.6–22.6 mo, ma 5.5 mo)	Cervical	2 children had spinal cord injuries.	27/74 had cervical soft-tissue injuries (data for single categories are not reported).	MRI	Spinal MRI does not discriminate AHT from accidental head trauma MRI can be helpful to distinguish traumatic from non-traumatic (but non-traumatic cases were not included in the study).
Choudhary et al., 2014 [47]	67 AHT and 46 accidental head trauma and 70 non-traumatic (all <48 months, ma 4 mo, 15 mo, 14 mo, respectively)	All levels	48% of AHT vs 2% of accidental head trauma had SDH (all in association with intracranial SDH). None of the non-traumatic had SDH.	78% of AHT vs 46% of accidental head trauma had ligamentous injuries. Nearly none (1%) of the abusive had MSSI	MRI	The statistically proven correlation between occipitocervical ligamentous injuries and intracranial findings (brain ischaemia) suggest upper occipitocervical spinal cord injuries leads to hypoxic-ischaemic encephalopathy.
Choudhary et al., 2012 [48]	67 AHT and 70 accidental head trauma (between 0 to 2 yo) who underwent CT/MRI of head and spinal cord	All levels	46% of AHT had SDH as compared with 1% of accidental head trauma. SDH finding is more frequent at thoracolumbar than cervical levels (63% vs 34%) (all in association with intracranial SDH).	Not mentioned.	CT MRI	Spinal SDH is statistically (p < 0.001) related to AHT.
Edelbauer et al., 2012 [49]	6 AHT and 12 non-traumatic (ma 3.3 and 2.5 mo, respectively)	All levels	Spinal SDH was seen in all AHT children from the cervical to the cauda equine.	No vertebral fractures.	US CT MRI RX	Spinal US should be part of the imaging examinations in case of suspected abuse.
Kemp et al.,2011 [35]	25 AHT with spinal injuries (1–48 mo)	All levels	Central cord injuries, compression, transection. Stroke, contusion, tethering.	10/12 of those with cervical lesions and 11/12 of those with thoracolumbar lesions had MSSI, the majority in association with spinal cord injuries.	RX CT MRI	Cervical spinal injuries are more frequent between younger infants (ma 5 mo). Thoracolumbar injuries are mainly seen in older children (13.5 mo). One of the cause of the delayed diagnosis are the unrecognized thoracolumbar injuries.
Koumellis et al., 2009 [50]	18 AHT (1–12 mo, ma 3 mo)	All levels	8/18 (44%) had spinal SDH (all had the same intensity of posterior fossa SDH and in 2 cases spinal collections were in continuity with intracranial collection).	2/18 spinal fractures on plan radiography.	CT MRI	There is a high incidence of unsuspected spinal SDH in AHT children. The location of it is commonly thoracolumbar rather than cervical.
Feldman et al., 1997 [40]	12 AHT (mean age and age interval are not given) 5/12 deceased (1.3–34.1 mo, ma 5.8 mo)	Cervical	MRI showed no cervical spinal cord injuries 4/5 had cervical spine bleeding at PM.	Not mentioned.	MRI	Routine cervical MRI is not convenient to identify cervical spinal cord injuries as well as to recognize abused babies.

AHT abusive head trauma, CT computed tomography, yo years old, ma mean age, mo months, MRI magnetic resonance, MSSI muscoloskeletal spinal injury, PM post mortem, RH retinal haemorrhages, Rx radiography, SC spinal cord, SDH subdural haematoma, US ultrasound scan