Spinal cord injuries with normal postmortem CT findings: a pitfall of virtual autopsy for detecting traumatic death

The purpose of this study was to assess the incidence of spinal cord injuries without radiographic abnormalities (SCIWORA) on postmortem MDCT studies and to characterize this entity in detail.

Data from consecutive autopsies from October 2009 through December 2012 were searched, yielding 30 cases of cervical spinal cord injuries. Two board-certified radiologists interpreted postmortem MDCT images acquired before autopsy. Cases with normal findings were defined as SCIWORA.

Postmortem MDCT images in 6 of 30 cases (20%; 95% CI, 8-39%) met SCIWORA criteria. In all these cases, traumatic death was not apparent before CT, the highest injury level was below C3, and fractures were not identified at autopsy. All subjects had occult disk injuries and perivertebral hemorrhage. Potentially fatal CT-detectable injuries to other parts of the body were not seen in five of six SCIWORA cases.

A substantial proportion of fatal spinal cord injuries are without radiographic abnormalities at CT. Forensic radiologists and other interpreters of postmortem MDCT images must be aware of this entity to avoid excluding spinal cord injuries solely on the basis of postmortem MDCT findings. Special care is necessary in cases of unknown circumstances of death without abnormal CT findings. MRI may be used for further examination in the future, but until then, MDCT cannot replace autopsy for detecting SCIWORA.