P3.055: Radiographic Spine Imaging Findings as Independent Risk Factors of Motoric Outcomes in Abuse Head Trauma

Background: Abusive head trauma (AHT) is the leading cause of traumatic death in children less than two years, but there is a wide range of neurodevelopmental outcomes in the survivors of abusive head trauma. Many patients have devastating motor, intellectual, and psychological impacts from the abuse, while others make remarkable recoveries. Overall, prognostication remains inadequately understood for this patient population. Identifying distinct, independent risk factors for poor outcomes is important to help identify those patients for whom aggressive, early intervention will mitigate the most harmful and impairing effects. Previous studies have described the various forms of spinal injury associated with AHT, of which ligamentous injury (LI) (50-80%) and subdural hemorrhage (SDH) (45-65%) are the most common. In patients with spinal SDH, thoracolumbar is the most common injury location. In many of these patients, there is underlying brain SDH, and the thoracolumbar SDH is representative of redistribution rather than primary spine injury. The neurodevelopmental consequences of primary spine subdural hemorrhage versus spine findings secondary to redistribution have not been described. This study evaluates the neurodevelopmental outcomes associated with various locations of spinal subdural hemorrhage with and without ligamentous injury to evaluate the impact of primary versus secondary spine injury on neurodevelopmental outcomes in AHT.

Methods: A retrospective patient chart review was conducted on patients less than five-years-old with expert-confirmed diagnosis of AHT at Texas Children’s Hospital from 03/2018 to 08/2024 (n=257). Clinical and radiographic data was collected, including spine imaging via CT and/or MRI (n=170) and longitudinal motor developmental quotients derived from the Gessell Developmental Schedule and the Bayley Scales of Infant and Toddler Development (n=108). The motor quotients were compared by subdural hemorrhage location and presence or absence of ligamentous injury against those with AHT and normal spine imaging.

Results: Regardless of subdural brain bleed size, motor quotients were significantly lower for patients who had SDH involving the cervical spine (p=0.001), ligamentous injury without subdural hemorrhage (p=0.020), and non-cervical subdural hemorrhage with ligamentous injury (p=0.023). Patients with possible or probable secondary spine findings (defined as a thoracolumbar or lumbosacral SDH without ligamentous injury) did not have statistically significant differences in neurodevelopmental outcomes compared to patients with normal spine imaging (p=0.923). Additionally, patients with ligamentous injury with or without spinal SDH demonstrated the greatest variability in motor outcomes longitudinally.

Conclusion: Cervical subdural hemorrhage and ligamentous injuries are independent risk factors for severe motor outcomes in AHT and underscore the critical importance of additional motor screenings and rehabilitation for these patients. Additionally, ligamentous injury with or without SDH, independent of intracranial findings, demonstrates the highest variability in motor outcomes and serves as a population that needs further investigation to improve interventions. Overall, spine neuroimaging and early neurodevelopmental assessment can serve as useful adjuncts for prognostication.