Spinal Subdural Effusion – An Additional Sonographic Sign of Child Abuse

Zusammenfassung

Ziel: Es wurde die Aussagekraft des spinalen Ultraschalls zur Detektion von spinalen Subduralergüssen bei Säuglingen mit Schütteltrauma untersucht. Material und Methoden: Sechs stationär aufgenommene Säuglinge (mittleres Alter ± SD 3,3 ± 1,5 Monate) mit Verdacht auf Kindesmisshandlung wurden mittels Ultraschall, CT und/oder MRI und Skelettröntgen untersucht. Zwölf gesunde Säuglinge (mittleres Alter ± SD 2,5 ± 1,4 Monate), bei welchen ein spinaler Ultraschall zum Ausschluss des Vorliegens von spinalen Dysrhaphien durchgeführt wurde, dienten als Kontrollgruppe. Ergebnisse: Bei allen sechs Säuglingen, die ein Schütteltrauma erlitten hatten, wurde mittels Ultraschall und CT oder MRI ein kraniales subdurales Hämatom festgestellt. Mittels spinalem Ultraschall konnte bei allen sechs Säuglingen eine spinale subdurale echogene Flüssigkeitsansammlung mit beweglichen Partikeln dargestellt werden, welche die undulierende Arachnoidea von der Dura mater spinalis separierte. Die spinalen subduralen Ergüsse zeigten eine unterschiedliche kraniokaudale Ausdehnung und variable Tiefe in der Axialebene. Die Dura und Arachnoidea mater spinalis konnten sonografisch identifiziert werden und bestätigten die subdurale Lokalisation des Hämatoms. Keiner der Säuglinge der Kontrollgruppe zeigte eine spinale subdurale Flüssigkeitsansammlung. Schlussfolgerung: Das Vorhandensein eines spinalen Subduralergusses ist ein wertvolles zusätzliches Zeichen der Kindesmisshandlung, welches rasch mittels spinalem Ultraschall ohne die Notwendigkeit einer Sedierung festgestellt werden kann. Der spinale Ultraschall sollte daher zusätzlicher Bestandteil der bildgebenden Diagnostik bei Verdacht auf Kindesmisshandlung sein.

Abstract

Purpose: To assess the suitability of spinal ultrasound for the detection of spinal subdural hematoma in infants with sustained non-accidental trauma. Materials and Methods: Six infants (mean age ± SD 3.3 ± 1.5 months) admitted to our hospital because of suspected non-accidental trauma were examined radiologically with ultrasound, CT and/or MRI and skeletal radiography. Twelve healthy infants (mean age ± SD 2.5 ± 1.4 months) in whom an ultrasound of the spine was performed to exclude spinal dysraphism served as controls. Results: All six patients with non-accidental trauma (NAT) presented with cranial subdural hematoma visualized by ultrasound and CT scan or MRI. Spinal ultrasound detected echogenic effusions with floating particles that displaced the undulating arachnoidea from the dura mater spinalis in all six patients with NAT. The size of the spinal subdural hematoma varied and extended from the cervical spine to the cauda equina. The anatomic landmarks (dura mater spinalis, arachnoidea spinalis) were identified and confirmed the subdural location. All spinal subdural hematomas were asymptomatic and detected by diagnostic ultrasound. None of the infants had a pre-existing neurological or hemorrhagic disorder. The plain X-rays of the spine in these infants showed no osseous lesion. Spinal subdural hematoma was not observed in any of the controls. Conclusion: The presence of spinal subdural hematoma is a valuable sign of sustained non-accidental trauma in infants that can be quickly and easily detected using spinal ultrasound without the need for sedation or general anesthesia. Thus, spinal ultrasound should be part of the imaging examinations performed in infants with suspected abuse.

infants, injuries - ultrasound - spinal canal

References

• 1 Duhaime A C, Christian C W, Rorke L B et al. Nonaccidental head injury in infants – the “shaken-baby syndrome”.  N Engl J Med. 1998;  338 1822-1829
• 2 Keenan H T, Runyan D K, Marshall S W et al. A population-based study of inflicted traumatic brain injury in young children.  JAMA. 2003;  290 621-626
• 3 Ilves P, Lintrop M, Talvik I et al. Predictive value of clinical and radiological findings in inflicted traumatic brain injury.  Acta Paediatr. 2010;  99 1329-1336
• 4 Colbert C A, Holshouser B A, Aaen G S et al. Value of cerebral microhemorrhages detected with susceptibility-weighted MR Imaging for prediction of long-term outcome in children with nonaccidental trauma.  Radiology. 2010;  256 898-905
• 5 Mulpuri K, Slobogean B L, Tredwell S J. The Epidemiology of Nonaccidental Trauma in Children.  Clin Orthop Relat Res. 2011;  469 759-767
• 6 Di Pietro M A, Brody A S, Cassady C I et al. Diagnostic imaging of child abuse.  Pediatrics. 2009;  123 1430-1435
• 7 Offiah A, Rijn R R, Perez-Rossello J M et al. Skeletal imaging of child abuse (non-accidental injury).  Pediatr Radiol. 2009;  39 461-470
• 8 Fernando van S, Obaldo R E, Walsh I R et al. Neuroimaging of nonaccidental head trauma: pitfalls and controversies.  Pediatr Radiol. 2008;  38 827-838
• 9 Chen C Y, Chou T Y, Zimmerman R A et al. Pericerebral fluid collection: differentiation of enlarged subarachnoid spaces from subdural collections with color Doppler US.  Radiology. 1996;  201 389-392
• 10 Feldman K W, Avellino A M, Sugar N F et al. Cervical spinal cord injury in abused children.  Pediatr Emerg Care. 2008;  24 222-227
• 11 Feldman K W, Weinberger E, Milstein J M et al. Cervical spine MRI in abused infants.  Child Abuse Negl. 1997;  21 199-205
• 12 Koumellis P, McConachie N S, Jaspan T. Spinal subdural haematomas in children with non-accidental head injury.  Arch Dis Child. 2009;  94 216-219
• 13 Filippigh P, Clapuyt P, Debauche C et al. Sonographic evaluation of traumatic spinal cord lesions in the newborn infant.  Pediatr Radiol. 1994;  24 245-247
• 14 Fotter R, Sorantin E, Schneider U et al. Ultrasound diagnosis of birth-related spinal cord trauma: neonatal diagnosis and follow-up and correlation with MRI.  Pediatr Radiol. 1994;  24 241-244
• 15 Unsinn K M, Geley T, Freund M C et al. US of the spinal cord in newborns: spectrum of normal findings, variants, congenital anomalies, and acquired diseases.  Radiographics. 2000;  20 923-938
• 16 Dick E A, Patel K, Owens C M et al. Spinal ultrasound in infants.  Br J Radiol. 2002;  75 384-392
• 17 Dick E A, Bruyn de R. Ultrasound of the spinal cord in children: its role.  Eur Radiol. 2003;  13 552-562
• 18 Rohrschneider W K, Forsting M, Darge K et al. Diagnostic value of spinal US: comparative study with MR imaging in pediatric patients.  Radiology. 1996;  200 383-388
• 19 Simanovsky N, Stepensky P, Hiller N. The use of ultrasound for the diagnosis of spinal hemorrhage in a newborn.  Pediatr Neurol. 2004;  31 295-297
• 20 Deeg K H, Lode H M, Gassner I. Spinal sonography in newborns and infants – Part I: method, normal anatomy and indications.  Ultraschall in Med. 2007;  28 507-517
• 21 Carty H, Pierce A. Non-accidental injury: a retrospective analysis of a large cohort.  Eur Radiol. 2002;  12 2919-2925
• 22 Raghavendra B N, Epstein F J, Pinto R S et al. The tethered spinal cord: diagnosis by high-resolution real-time ultrasound.  Radiology. 1983;  149 123-128
• 23 Lundblad M, Lonnqvist P A, Eksborg S et al. Segmental distribution of high-volume caudal anesthesia in neonates, infants, and toddlers as assessed by ultrasonography.  Paediatr Anaesth. 2011;  21 121-127
• 24 Kiechl-Kohlendorfer U, Unsinn K M, Schlenck B et al. Cerebrospinal fluid leakage after lumbar puncture in neonates: incidence and sonographic appearance.  Am J Roentgenol. 2003;  181 231-234
• 25 Yamaguchi S, Kurisu K, Arita K et al. Simultaneous cranial and spinal subdural hematoma.  Neurol Med Chir (Tokyo). 2005;  45 645-649
• 26 Ahn E S, Smith E R. Acute clival and spinal subdural hematoma with spontaneous resolution: clinical and radiographic correlation in support of a proposed pathophysiological mechanism. Case report.  J Neurosurg. 2005;  103 175-179
• 27 Hung K S, Lui C C, Wang C H et al. Traumatic spinal subdural hematoma with spontaneous resolution.  Spine (Phila Pa 1976). 2002;  27 E534-E538
• 28 Bortolotti C, Wang H, Fraser K et al. Subacute spinal subdural hematoma after spontaneous resolution of cranial subdural hematoma: causal relationship or coincidence? Case report.  J Neurosurg. 2004;  100 372-374
• 29 Wong S T, Yuen M K, Fok K F et al. Redistribution of hematoma to spinal subdural space as a mechanism for the rapid spontaneous resolution of posttraumatic intracranial acute subdural hematoma: case report.  Surg Neurol. 2009;  71 99-102, discussion 102
• 30 Lecouvet F E, Annet L, Duprez T P et al. Uncommon magnetic resonance imaging observation of lumbar subdural hematoma with cranial origin.  J Comput Assist Tomogr. 2003;  27 530-533