Patterns of fatal cervical spine injuries: A comparative forensic autopsy study of upper and lower cervical trauma

To compare upper and lower cervical spine injuries in fatal cervical spine trauma with respect to injury mechanism, associated traumatic findings, and spinal cord injury, and to investigate whether upper cervical injury is independently associated with spinal cord injury and death at the scene.

This retrospective, single-center study included exclusively fatal adult autopsy cases with cervical vertebral fractures examined at the XXX Group Presidency of the Council of Forensic Medicine between 2025 and 2026. Injuries were classified as upper cervical (occiput-C2) or lower cervical (C3-C7). Demographic characteristics, injury mechanisms, fracture patterns, spinal cord injury, associated traumatic findings, and death at the scene were compared between the two groups. Univariable and multivariable logistic regression analyses were performed to identify factors independently associated with spinal cord injury and death at the scene.

A total of 130 cases were included. Upper cervical injuries were significantly associated with high-energy trauma (p < 0.001), multilevel fractures (p = 0.009), spinal cord injury (p = 0.007), head injury (p < 0.001), and death at the scene (p = 0.003). In the multivariable analysis, no variable remained independently associated with spinal cord injury. However, upper cervical injury remained independently associated with death at the scene (adjusted OR, 4.53; 95% CI, 1.71-11.97; p = 0.002).

Compared with lower cervical injuries, upper cervical injuries were associated with a more severe injury pattern in fatal cervical spine trauma. Although no variable remained independently associated with spinal cord injury, upper cervical injury remained independently associated with death at the scene.