Pediatric Spinal Cord Injury – Accident Or Not

Traumatic Spinal Cord Injury: Accidental Versus Nonaccidental Injury

Patrick D. Barnes, MD,

Michael V. Krasnokutsky,MD

MD, Kenneth L. Monson, PhD,

Janice Ophoven, MD

Abstract:

Nonaccidental injury (NAI) or “shaken baby syndrome”
(SBS) is a diagnosis that is often considered in infants
presenting with an acute life-threatening event. Emergency
physicians, family practitioners, and pediatricians are often
the first to evaluate a child in this situation. Pediatric
neurologists and neuroradiologists are often consulted in
such cases. It has been previously accepted that in the
absence of a history of significant trauma (ie, motor vehicle
accident or 2-story fall), the “triad” of (1) infant encephalopathy,
(2) subdural hemorrhage (SDH) or subarachnoid
hemorrhage (SAH), and (3) retinal hemorrhages (RHs) is
diagnostic of NAI/SBS based on a rotational acceleration deceleration
trauma mechanism. This empirical formula
has been challenged by evidence-based medical and legal
standards.

We present a case of a toddler with a household fall scenario
resulting in “spinal cord injury without radiographic
abnormality” (“SCIWORA”) identified at autopsy. The case
was initially labeled as NAI/SBS

Case Report:

21-month-old boy with steroid-dependent asthma presented to the emergency room withGlascow Coma Score (GCS) 3 and retinal hemorrhages. He was found to have subdural andsubarachnoid hemorrhage on computed tomography plus findings of hypoxic-ischemicencephalopathy (HIE). The caretaker history was thought to be inconsistent with the clinicaland imaging features, and the patient was diagnosed with nonaccidental injury (NAI) and“shaken baby syndrome.” The autopsy revealed a cranial impact site and fatal injury to thecervicomedullary junction. Biomechanical analysis provided further objective support that,although NAI could not be ruled out, the injuries could result from an accidental fall asconsistently described by the caretaker.

Contents

• Clinical Course

• Imaging Evaluation

• Autopsy Findings By Medical Examiner

• Biomechanical Analysis

• Neck And Spinal Cord

• Eyes

• Vertebral Column

• Discussion NAI/SBS

• SCIWORA

• Impact Injury

• SDH And SAH

• Hypoxic Ischemic Versus Traumatic Axonal Injury

• Retinal Hemorrhage

• Thoracic Spinal Injury

• References
  

Conclusion

Physicians have an obligation to completely and timely evaluate
suspected NAI, including its mimics. The imaging findings
alone cannot distinguish NAI from AI or from the medical
mimics. A complete and thorough medical evaluation,
using evidence-based medicine principles, is necessary in
parallel with the child-protection assessment. A multidisciplinary
approach to this evaluation is also important, including
the involvement of qualified specialists. Such an approach
may be the difference between appropriate child
protection versus the improper breakup of a family or a
wrongful indictment and conviction.

Source:

http://www.stanford.edu/~pbarnes/docs/publications/SCIWORASemPedNeurol.pdf