Traumatic Death in Ankylosing Spondylitis

Abstract: Ankylosing spondylitis (AS) is a chronic rheumatic disease that causes spinal rigidity with an increased risk of spinal fractures. We present a case report where a middle‐aged man, in apparent good health, died following a fall from his bike. Postmortem computed tomography (CT) showed several fractures in the cervical and thoracic spine, with displacement into the spinal canal as well as spinal changes consistent with AS. The cause of death was determined to be upper spinal cord injury caused by cervical spinal fractures that were facilitated by spinal rigidity from AS. Further investigation into the medical records revealed that the decedent had previously been treated for AS. This case report illustrates the importance of obtaining a detailed medical history when investigating deaths, including nonfatal conditions, such as AS. Furthermore, it shows the value of CT in the evaluation of the mechanism and manner of death.     

Road crash cervical injuries. A radiological study of fatalities

A lateral radiograph of the cervical spine was obtained for 174 of the 207 persons killed in road crashes in Adelaide, South Australia, during the 12-month period of June 1, 1987 to May 31, 1988. Of the total of 57 cases of cervical injury, routine postmortem examination identified 30 cases (52.6%), and the radiographic examinations identified 51 cases (89.5%). In the cases where it was performed, radiography identified 96.2% of injuries. One-half of injuries of level C3 and above were not reported at postmortem examination, compared with 22% of those occurring below this level. This finding correlates with the physical difficulties of examining the upper part of the cervical spine. This study has shown that lateral cervical radiography is a simple and effective method of more accurately identifying significant cervical spinal injuries, thus improving greatly the value of postmortem examinations in determining the patterns and mechanisms of these injuries.     

Morphologic changes in spinal cord of patients with spinal injuries who died in hospital

Morphologic changes in the spine have been investigated in patients with spinal injuries who died in hospital. The incidence of injuries has been evaluated as 9.3% of mechanical injuries. Purposeful search for possible injuries increased the rate of detection of injuries of the spine and the cord. Spinal cord can be impaired without involving the osseous formations and spinal ligaments. Edema of the cord tissue develops during the early period of injury and prevents the detection of injuries, persisting for a long time after the injury. Edemas are detected even in subjects who died at the site of accident.     

Spinal epidural haematoma after blunt trauma to the neck and hyperflection of the cervical spine

Spinal epidural haematomas (sEDH) can be regarded as rare events, in principle a spontaneous and a traumatic aetiology can be distinguished. Spontaneous spinal epidural haematomas can arise, e.g. from vascular malformations, coagulopathies, etc. On the other hand, traumatic sEDH are related to, e.g. spinal trauma or intraoperative vascular injuries. With regard to clinical significance, spinal epidural haematomas accompanied by transient mild neurological symptoms up to lethal outcomes have been observed. We report on a 53-year-old male alcoholic who was found in the kitchen of his asylum in a grotesquely fixed body position, with his head and cervical spine in a maximum anteflected position. A general practitioner had ruled for a non-natural manner of death due to "broken neck" and alcohol intoxication, therefore, the prosecution authorities called for a medicolegal autopsy. At autopsy, paravertebral soft tissue haemorrhage in between the shoulder blades was disclosed. Furthermore, a spinal epidural haematoma, extending from the foramen magnum down to the middle portion of the thoracic spine was found. No fractures of vertebrae nor lesions of spine ligaments or bleedings of intervertebral discs were found. Blood alcohol concentration was determined 1.92 g/l and urine alcohol concentration was 1.76 g/l. Further morphological findings were cerebral oedema and cardiac hypertrophy; the urinary bladder was found filled to bursting. Neuropathological investigations confirmed the presence of the spinal epidural haematoma and assigned lethal significance to this finding. There were no histological signs of axonal injury. Reconstruction revealed that when sitting on a chair in a drunk condition, the individual's upper part of the body had fallen backwards in the corner and subsequently got stuck with maximum anteflection of the head and cervical spine, causing rupture of vessels and spinal epidural haematoma. Acute respiratory failure caused by impairment of the phrenic nerve following spinal epidural haematoma with potential synergism of alcohol intoxication was ascertained as the cause of death.     

Fatal birth trauma due to an undiagnosed abdominal teratoma: case report and review of the literature

The fetus is subjected to mechanical forces during labor and delivery, which may result in traumatic injuries. Such injuries include intracranial hemorrhage, spinal cord lesions, cephalhematoma, cranial or peripheral nerve palsies, intraabdominal organ rupture, or bony fractures. Risk for perinatal trauma and mortality is increased in primigravidas, multiple gestations, abnormal presentations, maternal-fetal disproportion, oligohydramnios, forceps or vacuum extractions, and internal version maneuvers. Very-low-birth-weight neonates (<1500 g) are at high risk due to ease of deformity of the cranium. Infants with certain congenital anomalies or pathologic processes that distort normal anatomy are also at increased risk, especially when a prenatal diagnosis is lacking. The authors present a case of a term gestation neonate who sustained a cervical spine dislocation fracture of C5-7, with subtotal transection of the spinal cord and resultant paralysis. The fetus was in vertex presentation, and a manual vaginal delivery was attempted. When the infant lodged in the birth canal following a difficult delivery of the head and arms, its enlarged abdomen was palpated, and the delivery was converted to an emergent cesarean section. The infant lived for 3 days and then expired due to neurologic complications of trauma sustained during the attempted vaginal delivery. Autopsy revealed a previously undiagnosed intraabdominal immature teratoma. The pathology of teratomas, the most common neonatal tumor and occasionally implicated in cases of birth trauma, will be addressed, followed by a review of the literature concerning birth trauma.     

A new approach to upper cervical injuries

Severe injuries to the upper cervical region can be the cause of death. Standard autopsy techniques are inadequate for examination of this area. Therefore a technique has been developed that gives excellent visualization and allows removal of the brain and spinal cord in one piece. With the body prone a midline incision is made from the top of the head to the sacrum. The skull is sawed in a circle from one side of the foramen magnum around the top of the skull to the other side of the foramen magnum. The lamina of the neural arches of the vertebral column are sawed. With the removal of the piece of skull and the posterior portions of the neural arches, the posterior half of the cerebral cortex, cerebellum, and entire spinal cord are exposed. The entire brain and spinal cord can be removed as a unit. Cases are selected by history, X-ray examination, or floppy head. Four cases in which this approach has been helpful are briefly mentioned.     

Upper cervical trauma in motor vehicle collisions

Motor vehicle collisions can cause a variety of injuries in pedestrians and vehicle occupants. Fatal and nonfatal trauma to the upper cervical spine, that is, atlanto-occipital junction, atlas and axis, can be part of this spectrum. Certain distinctive injuries (for example, "hangman's fracture") which occur result from the unique anatomic structure of this area and the various disruptive forces such as extension, distraction (tension), compression (axial loading), shear, and inertia generated during collision. Correlation of autopsy findings or radiological information of these cervical injuries or both with scene investigation can be informative not only in the determination of morbidity and mortality, but also in the assessment of injury mechanisms and improvements in occupant protection.     

Sudden Collapse due to Medullary and Cervical Cord Infarction—An Unusual Presentation of Hepatocellular Carcinoma

Hepatocellular carcinoma (HCC) is a common cancer worldwide with a great potential for metastatic spread. Hepatocellular carcinoma often arises in people with underlying viral hepatitides or liver cirrhosis and may present in various ways including abdominal pain, liver mass, and signs of hepatocellular decompensation. Many tumors may have metastasized to other organs such as the lungs, lymph nodes, bone, and adrenal glands at the time of diagnosis. However, it is uncommon for HCC to present purely due to its metastasis, such as spinal cord compression from vertebral metastasis. Here, an unusual presentation of a sudden cardiovascular collapse due to medullary and cervical cord infarction from compression of the cervical cord is presented. The importance of clinical investigations, the usefulness of postmortem computed tomography scans, and the examination of the cervical spine and cervical cord in people with no obvious cause of death after standard autopsy procedures are emphasized.     

Suicidal hanging resulting in complete decapitation--forensic, radiological, and anthropological studies: a case report

The authors report a case of complete posthanging decapitation. The decapitated corpse lay against a pillar of a road bridge. The head had rolled 5 m from the trunk. The bridge was 7.2 m above the road level. The rope was 3.6 m long, its lower end was 3.6 m from the ground and its diameter was 10 mm. The noose used was a slip knot. Plain X-rays of the skull and cervical spine were obtained. The skull X-rays showed air in the meningeal spaces, in both lateral and third ventricles. The severance plane of the cervical spine was between the third and the fourth cervical vertebrae. No other cervical vertebral injuries were noted. At autopsy, the brain was macroscopically unremarkable except for air in the meningeal veins. The decapitation injuries of the head and the torso corresponded perfectly, without apparent loss of substance. The severance plane was confirmed. Dry bone study was carried out. Except for fractures of the extremities of the spinous processes of the second and third cervical vertebrae, no other bone injury of the spine was seen. The cervical vertebrae displayed numerous osteoarthritic lesions. The traditional hangman's fracture was not found. To the best of our knowledge, this is the first report of complete posthanging decapitation with a severance plane between the third and fourth cervical vertebrae.     

Neck injuries: II. Atlantoaxial dislocation--a pathologic study of 14 traffic fatalities.

C1-C2 vertebral dislocations have not been commonly recognized at autopsy. Among 66 subjects with neck injuries, drawn from a series of 155 traffic fatalities, were 14 with injuries at the level of the atlantoaxial motion segment, ranging in age from 8 months to 93 years. Thirteen had sprains or lacerations of the atlantoaxial facet joints, and one had a healed C1 fracture. Six of the 14 had odontoid fractures. None had transverse ligament lacerations. Injuries of the alar ligaments and the tectorial membrane were frequent. Only 3 subjects had subaxial cervical injury. All 14 had evidence of impact to the head or neck. Four had fractures of the mandible or facial bones, and 5 had skull fractures. Subdural and subarachnoid hemorrhages were found in 7 and 6, respectively. Brainstem lacerations were not uncommon, but only one had a pontomedullary laceration. Spinomedullary cord injuries occurred in 5. Acute neurogenic shock was the major mechanism of death in 9 of the 14, including 5 with major cardiovascular lacerations. Delayed effects of craniocerebral trauma accounted for the majority of the remainder. The biomechanical mechanisms are discussed.     

Retrospective Analysis of Hanging Deaths in Ontario

Hanging deaths from investigation standpoint are rarely problematic. Unusual circumstances can on occasion raise suspicion of foul play. Associated neck injuries are reported in the literature with variable frequency (from 0% to 76.8%). This study retrospectively analyzed 755 hanging deaths in Ontario (Canada) to evaluate the demographic features and circumstances of hanging fatalities, and the frequency of hanging‐related neck injuries. A number of cases showed unusual/special circumstances (e.g., complex, double suicides, restraints). Among 632 cases with complete autopsies, hyoid and larynx fractures were present in 46 cases (7.3%) with the most common being isolated hyoid fractures. The incidence of cricoid fractures was 0.5% and cervical spine injuries, 1.1%. A higher incidence of neck injuries occurred among males, long drop hangings, and in cases with complete suspension. There was a tendency for the number of fractures to increase with increasing age and weight of the deceased.     

Fatal high cervical spinal cord injury in an automobile accident complicating os odontoideum

We report a case where spinal instability from incomplete fusion of the dens of C2 (os odontoideum) allowed anterior displacement of the skull and first cervical vertebra following right frontal impact against the A pillar in an automobile accident. Resultant crushing and laceration of the spinal cord occurred at the level of C1 and C2. Without either radiographic investigation or detailed examination of the spine, the fatal injury might have been overlooked and death attributed to acute alcoholic poisoning because the blood alcohol level was .613%.     

Contributions from Forensic Imaging to the Investigation of Upper Cervical Fractures

Abstract: Injuries to the upper cervical spine (UCS) are common in traumatic deaths and postmortem computed tomography (PMCT) may contribute to the forensic investigation. This study presents PMCT in comparison with autopsy in the examination of UCS injury. Thirteen consecutive cases with UCS fracture and/or cranio‐cervical dislocation were examined with PMCT and autopsy, and the findings were correlated. Neither of the techniques identified all UCS injuries. Fractures of atlas and axis were best visualized with PMCT whereas cranio‐cervical dislocation was better identified during autopsy. Serious injuries were present after both high‐ and low‐energy trauma. Medico‐legal autopsy in combination with PMCT produced a thorough evaluation of UCS injuries. By combining these procedures detailed investigations, including accident reconstruction and injury pattern analysis, can be performed. This study supports the routine application of PMCT, as a supplement to the medico‐legal autopsy of deaths with UCS injuries.     

Forensic Imaging‐Guided Recovery of Nuclear DNA from the Spinal Cord*,†

Abstract: Our objective is to document the recovery of DNA from the spinal cord or surrounding dura mater in 11 cases of severely burned human remains. Radiographs established that portions of charred tissue contained spine segments. Multidetector computed tomography (MDCT) revealed that each spine specimen contained an intact spinal cord remnant. A full DNA profile was obtained from seven specimens using spinal cord dura mater in six specimens and spinal cord medulla in one specimen. A partial profile was obtained from four specimens (spinal cord dura mater, 2; spinal cord medulla, 2). Bone and muscle surrounding the spinal cord appear to insulate nucleic acid containing tissue from critical thermal degradation. The spinal cord, which is easily identified by MDCT examination of remains and easily recovered at the postmortem examination, can be a source of DNA with extraction yields comparable with other tissue sources. Specimens of dura mater are preferable as processing time is faster than bone.     

The narrow spinal canal - medicolegal aspects (author's transl)]

The constitutional anomayl of a narrow spinal canal was found in a neuroradiological department in 31 cases. The cervical stenosis can be defined in the following way: Inside diameter of cervical canal (anterior-posterior) in relation to diameter of vertebral body. In normal cases the quotient is over 1 - in pathological narrowing under 1. Clinical symptoms mainly appear from 45th year onwards, when reactive-degenerative changes increase the space problem. In wiplash injuries or other adequate cervical trauma 7 cases were seen and described with acute incomplete tetraplegia or/and multilocular lesions of cervical roots, resulting from cervical stenosis combined with degenerative changes in 6 patients. Myelography revealed multilocular deformities of the spinal subarachnoidal space in the abnormal narrow cervical canal. The referred cases were not complicated with forensic aspects. The prognosis quod sanationem was poor. A chronic cervical myelopathy results. Pretraumatic clinical alterations of cervical roots and/or the myelon in the referred cases were absent, existing in other patients. Predominantly men and hard working people with narrow cervical canal became ill. Early symptoms were pain in extremities. Dysesthesia and loss of sensation combined with signs of pyramidal lesion occured later. Defects in nerve roots sometimes overlayed the myelon symptoms. Unspecific CSF-Alterations were common. The EMG showed abnormalities in cases of root involvement. Operative treatment was tried to remove the reactive processes, but could not alter the constitutional anomaly. The resulting immobilisation of myelon and nerve roots involves in the case of trauma a direct mechanical lesion and secondary vascular complications via Arteria vertebralis, spinalis anterior and radicularis, namely in patients with degenerative alterations of the cervical spine, these including a further narrowing behind the constitutional anomaly. Our experience seems to recommend that more attention should be paid a cervical narrow spinal canal in medicolegal implications.     

Abusive Pediatric Thoracolumbar Fracture Due to Forced Hyperextension: Case Report,Biomechanical Considerations,and Review of the Literature

Pediatric thoracolumbar fractures are rare due to the physiological differences which afford greater resilience to the immature spine. Most pediatric thoracolumbar fractures occur as the result of high energy trauma, such as motor vehicle accidents, and modes of reasonable accidental injuries are limited by age and developmental capabilities of the child. These fractures can occur as the result of inflicted blunt force trauma and child abuse, and in most cases, the mechanism of injury to the spine is not known. We report the death of a 29-month-old man due to blunt force trauma to the back and forced hyperextension of the thoracolumbar spine causing fracture of the fourth lumbar (L4) vertebral body. A complete forensic examination revealed a previous healing fracture of the anterior aspect of the L4 vertebral body, with acute disruption of the anterior longitudinal ligament overlying the fracture site, complete fracture of the vertebral body, and fatal retroperitoneal hemorrhage. We present a review of the biomechanical considerations of the pediatric spine, a survey of pediatric spinal fractures, and a review of the literature on pediatric abusive thoracolumbar fractures. In this case, there was never a provided explanation for how the injury occurred; however, understanding the biomechanics of the pediatric spine allowed for the determination of the mechanism, force required to produce this specific pattern of abusive spinal injury, and the manner of death.     

Causes and Mechanisms of Death in Fatal Water Buffalo Attacks

Deaths due to buffalo attack have not been well described. A 72‐year‐old man was trampled by a water buffalo (Bubalus bubalis) while attempting to move the animal within an enclosed area at an abattoir. At autopsy, there were numerous injuries involving the chest, head, neck, and left upper arm. Blunt force injury had resulted in multiple rib fractures with a flail chest and fracture/dislocation of the mid‐cervical vertebrae caused either by physical crushing by the animal against the walls of the enclosure or by stomping. There was also evidence of crush asphyxia with bilateral conjunctival hemorrhages and petechial hemorrhages. In addition, there was a deep degloving injury of the upper left arm compatible with goring by one of the buffalo horns. While large animal attacks may result in death from multiple injuries, careful dissection and examination of specific injuries at autopsy may clarify the complex interaction of lethal mechanisms.     

Neck injuries caused by automatic two-point seat belts: an analysis of four cases

Although seat belts significantly reduce the extent and severity of injuries sustained by motor vehicle occupants, seat belts are known to be associated with chest and abdominal trauma. Less commonly understood are severe neck injuries caused by the use of two-point automatic shoulder harnesses without concurrent use of a manual lap belt. Such injuries may include cervical spine fractures, craniocervical dislocations and rarely decapitation. Recognizing patterned injuries caused by seat belts and the ability to correlate autopsy findings with the circumstances surrounding the death will allow for correct interpretation of seat-belt related trauma. The four cases described detail fatal neck injuries as a result of improper seat belt use in which an automatic two-point shoulder harness was used without a manual lap restraint. In two of the cases, the victims were decapitated.     

Unusual neck lesion in a pedestrian caused by a road accident

The authors describe a road accident that occurred in the Trieste region of Italy in 1998, wherein a pedestrian experienced a mortal injury. During the on-site examination, the forensic officer in charge noticed, in addition to dispersed abrasions, bruises, and fractures, an unusual position of the head with a highly unusual motility of the cervical rachis and, above all, an apparent whitish fibrous elastic cord, 7-8 cm long, which came out of the mouth. The cord was found to be a segment of the spinal cord, expelled and driven into the mouth cavity by the impact. This represents an interesting case because of the specific dynamics of the accident and the type of lesion involved. This kind of spinal cord injury, in particular, is infrequent among pedestrians involved in road accidents in comparison with other road casualties.     

Was the pedestrian hit in an erect position before being run over?

If a pedestrian was run over by a car, the question can arise whether there was a preceding collision while the pedestrian was in an erect position. From a total of 53 selected autopsy reports, the findings associated with accidents known to involve running over in isolation (n=32) were compared to findings associated with a combined mechanism of a primary impact in an erect position and subsequent running over (n=21). Findings exclusively present in the combined group were wedge-shaped bone fractures ("Messerer"-wedges, 38%), glass fragment injuries (24%), traumatic amputations (10%), traces of car paint on the lower extremities (50%) and abrasions of the shoe soles (17%). These findings can be considered specific for a primary impact in an erect position. Fractures of the cervical and lumbar spine were present in the combined group in 33 and 17%, respectively. In contrast, in the run over group, there was only one case of fracture of the cervical and one of the lumbar spine and both cases involved direct contact with a car wheel. Fractures of the cervical and lumbar spine are, therefore, very indicative for a primary impact. "Bumper injuries", sacroiliac dislocations and fractures of the thoracic spine were approximately 2.5 times more common in the combined group than in the run over group. In the vast majority of cases, a clear differentiation between the two groups is, therefore, possible on the basis of the autopsy findings. This is especially relevant if an inspection of the car cannot be performed after a hit-and-run accident, which occurred in 26% of the cases in this study. In addition, the blood alcohol levels were higher in the run over group (mean=2.14g/l) as compared to the combined group (mean=1.53g/l).