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

AbstractAbusive 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.

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Neck injuries in young pediatric homicide victims

Journal of Neurosurgery Pediatrics ◽

10.3171/2008.11.peds0835 ◽

2009 ◽

Vol 3 (3) ◽

pp. 232-239 ◽

Cited By ~ 42

Author(s):

Laura K. Brennan ◽

David Rubin ◽

Cindy W. Christian ◽

Ann-Christine Duhaime ◽

Haresh G. Mirchandani ◽

...

Keyword(s):

Spinal Cord ◽

Soft Tissue ◽

Head Trauma ◽

Cerebral Edema ◽

Cervical Spinal Cord ◽

Abusive Head Trauma ◽

Cervical Cord ◽

Neck Injuries ◽

Cord Injury ◽

Hypoxia Ischemia

Object 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. Methods 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. Results 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. Conclusions 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.

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Factors Which Facilitate or Impede Interpersonal Interactions and Relationships after Spinal Cord Injury: A Scoping Review with Suggestions for Rehabilitation

Rehabilitation Research and Practice ◽

10.1155/2016/9373786 ◽

2016 ◽

Vol 2016 ◽

pp. 1-13 ◽

Cited By ~ 2

Author(s):

Delena Amsters ◽

Sarita Schuurs ◽

Kiley Pershouse ◽

Bettina Power ◽

Yvonne Harestad ◽

...

Keyword(s):

Spinal Cord ◽

Spinal Cord Injury ◽

Scoping Review ◽

English Language ◽

International Classification Of Functioning ◽

Interpersonal Interactions ◽

Self Image ◽

Language Studies ◽

Cord Injury ◽

Review Question

Interpersonal interactions and relationships can influence an individual’s perceptions of health and quality of life in the presence of disability. In the case of people with spinal cord injury (SCI), positive interpersonal interactions and relationships have been shown to contribute to resilience and adaptability. Understanding factors which facilitate or impede the development and maintenance of relationships after SCI may form the basis for proactive relationship support for people with SCI. To gain a broad insight into these factors, a scoping review was undertaken. Databases were searched for English language studies published between 2000 and 2015 that informed the review question. Sixty-two (62) studies were identified. Thematic analysis was conducted on data extracted from the studies and 51 factors which may facilitate relationships and 38 factors which may impede relationships after SCI were noted. The majority of factors could be categorized as environmental or personal according to the domains of the International Classification of Functioning, Disability, and Health (ICF). The facilitating factors included partner and social support, reciprocity in relationships, and presenting oneself positively. Impeding factors included physical environmental barriers, real and perceived social biases, and poor self-image. Factors identified may inform the provision of supportive, holistic rehabilitation for people with SCI.

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Treatment of posttraumatic syringomyelia: evidence from a systematic review

Acta Neurochirurgica ◽

10.1007/s00701-020-04529-w ◽

2020 ◽

Vol 162 (10) ◽

pp. 2541-2556

Author(s):

Andrea Kleindienst ◽

Francisco Marin Laut ◽

Verena Roeckelein ◽

Michael Buchfelder ◽

Frank Dodoo-Schittko

Keyword(s):

Spinal Cord ◽

English Language ◽

Spinal Cord Injuries ◽

Case Reports ◽

Treatment Options ◽

Sensory Function ◽

Time Interval ◽

Eligibility Criteria ◽

Cord Injury ◽

Posttraumatic Syringomyelia

Abstract Background Following spinal cord injury (SCI), the routine use of magnetic resonance imaging (MRI) resulted in an incremental diagnosis of posttraumatic syringomyelia (PTS). However, facing four decades of preferred surgical treatment of PTS, no clear consensus on the recommended treatment exists. We review the literature on PTS regarding therapeutic strategies, outcomes, and complications. Methods We performed a systematic bibliographic search on (“spinal cord injuries” [Mesh] AND “syringomyelia” [Mesh]). English language literature published between 1980 and 2020 was gathered, and case reports and articles examining syrinx due to other causes were excluded. The type of study, interval injury to symptoms, severity and level of injury, therapeutic procedure, duration of follow-up, complications, and outcome were recorded. Results Forty-three observational studies including 1803 individuals met the eligibility criteria. The time interval from SCI to the diagnosis of PTS varied between 42 and 264 months. Eighty-nine percent of patients were treated surgically (n = 1605) with a complication rate of 26%. Symptoms improved in 43% of patients postoperatively and in 2% treated conservatively. Stable disease was documented in 50% of patients postoperatively and in 88% treated conservatively. The percentage of deterioration was similar (surgery 16%, 0.8% dead; conservative 10%). Detailed analysis of surgical outcome with regard to symptoms revealed that pain, motor, and sensory function could be improved in 43 to 55% of patients while motor function deteriorated in around 25%. The preferred methods of surgery were arachnoid lysis (48%) and syrinx drainage (31%). Conclusion Even diagnosing PTS early in its evolution with MRI, to date, no satisfactory standard treatment exists, and the present literature review shows similar outcomes, regardless of the treatment modality. Therefore, PTS remains a neurosurgical challenge. Additional research is required using appropriate study designs for improving treatment options.

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Evaluation of clinical experience using cell-based therapies in patients with spinal cord injury: a systematic review

Journal of Neurosurgery Spine ◽

10.3171/2012.5.aospine12115 ◽

2012 ◽

Vol 17 (Suppl1) ◽

pp. 230-246 ◽

Cited By ~ 37

Author(s):

James S. Harrop ◽

Robin Hashimoto ◽

Dan Norvell ◽

Annie Raich ◽

Bizhan Aarabi ◽

...

Keyword(s):

Spinal Cord ◽

English Language ◽

Spinal Cord Injuries ◽

Case Reports ◽

A Priori ◽

Level Of Evidence ◽

Hematopoietic Stem ◽

Cellular Therapies ◽

Cord Injury ◽

Current Utilization

Object Using a systematic approach, the authors evaluated the current utilization, safety, and effectiveness of cellular therapies for traumatic spinal cord injuries (SCIs) in humans. Methods A systematic search and critical review of the literature published through mid-January 2012 was performed. Articles included in the search were restricted to the English language, studies with at least 10 patients, and those analyzing cellular therapies for traumatic SCI. Citations were evaluated for relevance using a priori criteria, and those that met the inclusion criteria were critically reviewed. Each article was then designated a level of evidence that was developed by the Oxford Centre for Evidence-Based Medicine. Results The initial literature search identified 651 relevant articles, which decreased to 350 after excluding case reports and reviews. Evaluation of articles at the title/abstract level, and later at the full-text level, limited the final article set to 12 papers. The following cellular therapies employed in humans with SCI are reviewed: bone marrow mesenchymal and hematopoietic stem cells (8 studies), olfactory ensheathing cells (2 studies), Schwann cells (1 study), and fetal neurogenic tissue (1 study). Overall the quality of the literature was very low, with 3 Grade III levels of evidence and 9 Grade IV studies. Conclusions Several different cellular-mediated strategies for adult SCI have been reported to be relatively safe with varying degrees of neurological recovery. However, the literature is of low quality and there is a need for improved preclinical studies and prospective, controlled clinical trials.

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Association of Head Trauma with Cervical Spine Injury, Spinal Cord Injury, or Both

The Journal of Trauma: Injury, Infection, and Critical Care ◽

10.1097/00005373-199903000-00018 ◽

1999 ◽

Vol 46 (3) ◽

pp. 450-452 ◽

Cited By ~ 64

Author(s):

Hideo Iida ◽

Shigekuni Tachibana ◽

Takao Kitahara ◽

Shigeharu Horiike ◽

Takashi Ohwada ◽

...

Keyword(s):

Spinal Cord ◽

Spinal Cord Injury ◽

Cervical Spine ◽

Head Trauma ◽

Cervical Spine Injury ◽

Spine Injury ◽

Cord Injury

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Unilateral hypoxic-ischemic injury in young children from abusive head trauma, lacking craniocervical vascular dissection or cord injury

Yearbook of Diagnostic Radiology ◽

10.1016/s0098-1672(09)79311-7 ◽

2009 ◽

Vol 2009 ◽

pp. 134-135

Author(s):

A.E. Oestreich

Keyword(s):

Young Children ◽

Head Trauma ◽

Ischemic Injury ◽

Abusive Head Trauma ◽

Cord Injury ◽

Hypoxic Ischemic Injury

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Promising neuroprotective strategies for traumatic spinal cord injury with a focus on the differential effects among anatomical levels of injury

F1000Research ◽

10.12688/f1000research.11633.1 ◽

2017 ◽

Vol 6 ◽

pp. 1907 ◽

Cited By ~ 33

Author(s):

Antigona Ulndreaj ◽

Anna Badner ◽

Michael G Fehlings

Keyword(s):

Spinal Cord ◽

Spinal Cord Injury ◽

Treatment Options ◽

Basic Research ◽

Traumatic Spinal Cord Injury ◽

Preclinical Research ◽

Cord Injury ◽

Neuroprotective Strategies ◽

Hypertensive Therapy ◽

Cervical Level

Traumatic spinal cord injury (SCI) is a devastating condition of motor, sensory, and autonomic dysfunction. The significant cost associated with the management and lifetime care of patients with SCI also presents a major economic burden. For these reasons, there is a need to develop and translate strategies that can improve outcomes following SCI. Given the challenges in achieving regeneration of the injured spinal cord, neuroprotection has been at the forefront of clinical translation. Yet, despite many preclinical advances, there has been limited translation into the clinic apart from methylprednisolone (which remains controversial), hypertensive therapy to maintain spinal cord perfusion, and early decompressive surgery. While there are several factors related to the limited translational success, including the clinical and mechanistic heterogeneity of human SCI, the misalignment between animal models of SCI and clinical reality continues to be an important factor. Whereas most clinical cases are at the cervical level, only a small fraction of preclinical research is conducted in cervical models of SCI. Therefore, this review highlights the most promising neuroprotective and neural reparative therapeutic strategies undergoing clinical assessment, including riluzole, hypothermia, granulocyte colony-stimulating factor, glibenclamide, minocycline, Cethrin (VX-210), and anti-Nogo-A antibody, and emphasizes their efficacy in relation to the anatomical level of injury. Our hope is that more basic research will be conducted in clinically relevant cervical SCI models in order to expedite the transition of important laboratory discoveries into meaningful treatment options for patients with SCI.

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Highlighting gaps in spinal cord injury research in activity-based interventions for the upper extremity: A scoping review

Neurorehabilitation ◽

10.3233/nre-210042 ◽

2021 ◽

pp. 1-16

Author(s):

Namrata Grampurohit ◽

Alison Bell ◽

Susan Duff ◽

MJ Mulcahey ◽

Christina Calhoun Thielen ◽

...

Keyword(s):

Spinal Cord ◽

Spinal Cord Injury ◽

Upper Extremity ◽

Scoping Review ◽

Neurological Disorders ◽

High Intensity ◽

English Language ◽

Research Work ◽

Stroke Research ◽

Cord Injury

BACKGROUND: Upper extremity activity-based therapy for neurologic disorders employs high-intensity, high repetition functional training to exploit neuroplasticity and improve function. Research focused on high-intensity upper extremity activity-based therapy for persons with spinal cord injury (SCI) is limited. OBJECTIVE: To summarize high-intensity activity-based interventions used in neurological disorders for their current or potential application to SCI. METHODS: The scoping review included articles from MEDLINE, CINAHL, Cochrane CENTRAL, and OTseeker with the criteria: non-invasive activity-based interventions delivered atleast three times/week for two weeks, upper extremity functional outcomes, 13 years or older, English language, and neurological disorders three months post onset/injury. RESULTS: The search yielded 172 studies. There were seven studies with SCI, all in adults. Activity-based interventions in SCI included task-specific training and gaming, with and without electrical stimulation, and a robotic exoskeleton. The other populations found in the review included studies in stroke, cerebral palsy, and multiple sclerosis. Thirty-four different interventions were reported in other populations. In comparison to the extensive stroke research, work in SCI was not found for high-intensity interventions using virtual reality, brain stimulation, rehabilitation devices, and applications to the home and telerehab settings. CONCLUSION: The results highlight critical gaps within upper extremity high-intensity activity-based research in SCI.

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Magnetic resonance imaging in lumbar gunshot wounds: an absolute contraindication?

Neurosurgical FOCUS ◽

10.3171/2014.7.focus1496 ◽

2014 ◽

Vol 37 (1) ◽

pp. E13 ◽

Cited By ~ 13

Author(s):

Eduardo Martinez-del-Campo ◽

Leonardo Rangel-Castilla ◽

Hector Soriano-Baron ◽

Nicholas Theodore

Keyword(s):

Spinal Cord ◽

Mr Imaging ◽

Spinal Canal ◽

English Language ◽

Spinal Cord Injuries ◽

Gunshot Wounds ◽

Neurological Deficits ◽

Neurological Improvement ◽

Cord Injury

Object Performance of MR imaging in patients with gunshot wounds at or near the lumbar spinal canal is controversial. The authors reviewed the literature on the use of MR imaging in gunshot wounds to the spine. They discuss the results from in vitro and clinical studies, analyze the physical properties of common projectiles, and evaluate the safety and indications for MR imaging when metallic fragments are located near the spinal canal. Methods A review of the English-language literature was performed. Data from 25 articles were analyzed, including 5 in vitro studies of the interaction between 95 projectiles and the MR system's magnetic fields, and the clinical outcomes in 22 patients with metallic fragments at or near the spinal canal who underwent MR imaging. Results Properties of 95 civilian and military projectiles were analyzed at a magnet strength of 1, 1.5, 3, and 7 T. The most common projectiles were bullets with a core of lead, either with a copper jacket or unjacketed (73 [76.8%] of 95). Steel-containing (core or jacket) projectiles comprised 14.7%. No field interaction was evident in 78 (96.3%) of the 81 nonsteel projectiles. All steel projectiles showed at least positive deflection forces, longitudinal migration, or rotation. Heating of the projectiles was clinically insignificant. Image artifact was significant in all 9 steel bullets tested, but was not significant in 39 (88.6%) of the 44 nonsteel bullets tested. Overall, 22 patients with complete (82%) and incomplete (14%) spinal cord injury secondary to a projectile lodged inside the spinal canal underwent MR imaging. Discomfort and further physical or neurological deficits were not reported by any patient. Two patients with spinal cord injuries underwent MR imaging studies before surgical decompression and had subsequent, significant neurological improvement. Conclusions Metallic implants near or at the spinal canal are a relative contraindication for MR imaging. However, safe MR imaging might be feasible when a projectile's properties and a patient's individualized clinical presentation are considered.

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