Forensic and neuropathological characteristics of lethal acute blunt traumatic spinal cord injury

Acute traumatic spinal cord injury (TSCI) is a life-altering yet largely preventable neurological disorder with high morbidity and mortality. Clinical registries typically gather comprehensive trauma data from living patients but often exclude autopsy data from scene-of-injury fatalities, leaving the pathology of acute TSCI underexplored. To address this gap, we reviewed autopsy records from the New York City Office of the Chief Medical Examiner spanning a 15-year period (2003-2018) to characterize the demographic, forensic, and neuropathological features of lethal acute blunt TSCI. Cases were excluded if post-injury survival occurred beyond the acute phase, if there was pre-existing spinal disease or if there was a non-blunt trauma mechanism of injury. A total of 220 cases met inclusion criteria, with a mean age of 48.37 years (range 2-96). Most spinal injuries were accidental and resulted from motor vehicle collisions, falls from standing height, or descents from height. Ethanol was present in approximately one-third of cases. Atlanto-axial dislocation occurred in 14.5% of cases, predominantly among younger individuals who were involved in motor vehicle collisions. Lethal spinal injuries were most commonly single-level fractures. Neuropathological data were available for 184 cases, of which 147 (80%) had concomitant acute spinal cord injury, with cord transections, contusions, and parenchymal softening being the most frequent. Extra-axial hemorrhages involving the epidural and subdural spaces were the most common spinal hemorrhages related to blunt trauma.