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Joseph Junewick, MD FACR
over 10 years ago
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Nonaccidental Trauma - Spinal Extraaxial Hemorrhage

Case Detail

Anatomy: Brain-Spine
Joseph Junewick, MD FACR
Diagnostic Category: Trauma
Created: over 10 years ago
Updated: over 10 years ago
Tags: PEDS
Modality/Study Types: MR
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2 month old male with rib fractures and intracranial hemorrhage.

Case Images


Nonaccidental Trauma – Spinal Extraaxial Hemorrhage


MR – Sagittal fat-suppressed T1 and T2 images show extraaxial hemorrhage near the cervicothoracic junction predominantly posteriorly. No osseous, ligamentous or soft tissue injury is identified.


The cervical spine and the thoracolumbar junction are the most prone sites for injury in child abuse. In the cervical region these are largely nonosseous injuries. Craniocervical injuries may be masked by respiratory symptoms and/or neurologic depression. Multiple autopsy studies have shown cervical extraaxial hemorrhage in nonaccidental trauma.

The etiology of the cervical extraaxial hemorrhage is uncertain. Hemorrhage may occur as a result of injury of the epidural venous plexus; the bleeding may occur from traumatic disruption and/or transient venous hypertension. Intracranial hemorrhage may migrate with gravity into the spinal extraaxial space.

In this case, an epidural or subdural location cannot be determined with certainty, although it is likely the subdural space. The existence of the spinal subdural space however is controversial. The arachnoid mater had two portions: a compact laminar portion covering the dural sac internal surface and a trabecular portion extending like a spider web around the pia mater. The interface between the laminar arachnoid and the internal layer of the dura is variable; in some the interface is tightly adherent whereas in others there are fissures in between the neurothelial cells that extended throughout the interface leading to a potential subdural space.


Reina MA, De Leon Casasola O, López A, De Andrés JA, Mora M, Fernández A. The origin of the spinal subdural space: ultrastructure findings. Anesth Analg. 2002 Apr;94(4):991-5.

Junewick JJ. Cervical Spine Injuries in Pediatrics: Are children small adults or not? Pediatric Radiology 2010; 40(4):493-498.

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