Child Protection Evidence - Head and Spinal Injuries

Child Protection Evidence is a resource available for clinicians across the UK and internationally to inform clinical practice, child protection procedures and professional and expert opinion in the legal system. This systematic review evaluates the literature on abusive and non-abusive head trauma and spinal injuries.

About the review

Abusive head trauma is associated with high levels of morbidity and mortality.

The review seeks to help clinicians by highlighting the areas of the literature which show the features most indicative of abusive head trauma. In addition, newer high quality studies have also allowed further developments in distinguishing abusive from non-abusive head trauma radiologically. The clinical and radiological characteristics of spinal injuries in abusive head trauma (AHT) are also described in this systematic review.

This systematic review evaluates the scientific literature on head and spinal injuries published up until June 2018.

It aims to answer the following clinical questions:

  • What neuroradiological investigations are indicated to identify abusive head trauma in children?
  • What are the distinguishing clinical features of abusive head trauma in children?
  • What neuroradiological features distinguish abusive from non-abusive head trauma?
  • Can you date inflicted intracranial injuries in children neuroradiologically?
  • What are the clinical and radiological characteristics of spinal injury in AHT?

The key evidence statements, research implications, limitations and other useful references are included in the review.

Key findings

  • Clinical guidelines promote a computerised tomography scan (CT) as the preferred first line imaging technique in acutely ill children with suspected AHT abusive head trauma (AHT) in all children < 1 year of age when physical abuse is suspected. 
  • If the initial CT is abnormal, magnetic resonance imaging (MRI) has the capacity to identify further intracranial lesions, particularly parenchymal lesions.
  • Studies describe a number of children with AHT who have a normal initial CT scan but abnormalities were identified on MRI.
  • Advanced MRI techniques have the ability to further delineate the extent and regions of parenchymal damage in terms of abnormal; parenchymal diffusion, cerebral blood flow, haemorrhage. These features can help to inform the full extent of brain injury and inform prognosis.
  • Cranial ultrasound is not an effective diagnostic investigation; whilst it can identify some features, it will miss many others. High resolution ultrasound scans (USS) may have some advantage as a secondary investigation in experienced hands to monitor or follow the development of a lesion already identified on CT or MRI disorders.
  • Certain features (retinal haemorrhage, apnoea) correlate strongly with AHT rather than non-abusive head trauma (nAHT) in children less than three years of age.
  • Other features such as seizures, rib and long-bone fractures show a positive association with AHT that failed to reach statistical significance (once missing data had been accounted for).
  • Skull fractures and bruising to the head and neck were more strongly associated with nAHT but this association failed to reach statistical significance.
  • Subdural haemorrhages (SDH) are statistically significantly associated with AHT, subarachnoid haemorrhages are equally prevalent in AHT and nAHT and extradural haemorrhages are statistically significantly associated with nAHT.
  • Subdural haemorrhages in AHT are significantly more likely to be multiple, occur in the interhemispheric fissure, over the convexities, in the posterior fossa and be bilateral than SDHs in nAHT.
  • Multiple SDH identified on CT scans of different attenuations and those of low attenuation are more commonly seen in AHT than nAHT. Those of mixed attenuation (different attenuation seen in the same SDH) have been reported in both AHT and nAHT.
  • Cerebral oedema, hypoxic ischaemia, diffuse axonal injury and closed head injury were statistically significantly associated with AHT as compared with nAHT. 
  • The time scale of the different appearances of subdural haemorrhages as they resolve, vary and overlap thus CT or MRI findings cannot be used to accurately date SDH. 
  • There is a significant association between spinal injury found on MRI and AHT, particularly in the cervical region. The prevalence of spinal injury in AHT ranges from 13%-78%. 
  • There is growing evidence of an association between ligamentous injury and soft tissue injury to the cervical spine and AHT.
  • Spinal subdural haemorrhages reported in AHT were associated with intracranial SDH. (there is debate as to whether this relates to redistribution of intracranial SDH). 
  • These findings would support consideration of a guideline to include spinal MRI in the assessment of children with AHT to include Short TI Inversion Recover (STIR) sequences.

Disclaimer: This is a summary of the systematic review findings up to the date of our most recent literature search. If you have a specific clinical case, we strongly recommend you read all of the relevant references as cited and look for additional material published outside our search dates

Original reviews and content © Cardiff University, funded by NSPCC
Published by RCPCH August 2019

While the format of each review has been revised to fit the style of the College and amalgamated into a comprehensive document, the content remains unchanged until reviewed and new evidence is identified and added to the evidence-base. Updated content will be indicated on individual review pages.