Whole-Spine MRI in Children With Suspected Abusive Head Trauma

BACKGROUND. Abusive head trauma (AHT) in children has recently been associated with findings on cervical spine MRI. OBJECTIVE. The purpose of this study was to evaluate whether whole-spine MRI in children with suspected AHT shows additional abnormalities not identified on cervical spine MRI. METHODS. This retrospective study included 256 children younger than 3 years old (170 boys, 86 girls; mean age, 5.9 months) who underwent skeletal survey and head MRI for suspected child abuse from January 2019 to December 2020. Per institutional protocol, children with suspected AHT also underwent whole-spine MRI. AHT diagnoses were established by a combination of clinical information from medical record review and injuries described in reports from skeletal survey, head MRI, and head CT (if performed). Two pediatric neuroradiologists independently reviewed whole-spine MRI examinations for presence and level of intraspinal hemorrhage (classified as subarachnoid, subdural, or epidural), ligamentous injury, spinal cord edema, and vertebral fractures; subdural hematoma, epidural hematoma, ligamentous injury, and fracture unidentified by skeletal survey were considered major findings. Interobserver agreement was assessed; a third radiologist resolved discrepancies. Findings were summarized with attention to injuries isolated to the thoracolumbar spine. RESULTS. A total of 148 of 256 (57.8%) children underwent whole-spine MRI. AHT was diagnosed in 79 of 148 (53.4%) children who underwent whole-spine MRI versus in 2 of 108 (1.9%) who did not undergo whole-spine MRI (p < .001). Interobserver agreement, expressed as kappa coefficient, was 0.90 for intraspinal hemorrhage, 0.69 for ligamentous injury, 0.66 for spinal cord edema, and 0.95 for fracture. A total of 57 of 148 (38.5%) whole-spine MRI examinations showed injuries, and 34 of 148 (23.0%) showed injuries localized to the thoracolumbar spine. A total of 47 of 148 (31.8%) whole-spine MRI examinations showed major findings, of which 24 (51.1%) were localized to the thoracolumbar spine. Isolated thoracolumbar injuries included 23 of 34 spinal subdural hematomas, 2 of 3 spinal epidural hematomas, and 9 of 11 vertebral fractures, including five fractures not identified by skeletal survey. Diagnosis of AHT was more common in children with positive, versus negative, whole-spine MRI examinations (76.8% vs 39.1%; p < .001). CONCLUSION. In children with suspected AHT, whole-spine MRI commonly shows isolated thoracolumbar injuries. CLINICAL IMPACT. The results support performing whole-spine MRI rather than cervical spine MRI in children with suspected AHT.