Birth-Related Injury to the Head and Cervical Spine in Neonates Aylin Tekes, MD a, *, Pedro S. Pinto, MD a , Thierry A.G.M. Huisman, MD, EQNR, FICIS b Birth-related injury is defined as any traumatic/ ischemic event sustained during the process of delivery. In this article the authors focus on perina- tally acquired disease processes secondary to birth-related injury, either traumatic or ischemic in nature. Other diseases of the perinatal time period, including germinal matrix hemorrhages and hypoxic-ischemic encephalopathy (HIE), are beyond the objective of this review. ETIOLOGY Birth-related injury may affect any organ system; however, because the head is the presenting body part in the majority of deliveries, and is one of the largest anatomic structures to pass through the birth canal, and does not tolerate too much molding during delivery, traumatic head injury is the most frequently encountered type of birth-related trauma. In addition, during the delivery hyperextension and shear forces at the craniocervical junction may result in additional cervical spinal cord injury. Although many traumatic head and spine injuries are benign and do not require therapy, some may require rapid diagnosis and treatment to avoid progression, permanent disability, or even death. In addition, hypoxic-ischemic injuries may be superimposed on “purely” mechanical types of injury, which may worsen functional and neurologic outcome. Advancements in obstetric management in the last few decades have significantly decreased the incidence of birth-related deaths. Birth-related injury accounts for fewer than 2% of neonatal deaths. 1 From 1970 to 1985, rates of newborn mortality due to birth-related trauma fell from 64.2 to 7.5 deaths per 100,000 live births, a remarkable decline of 88%. This decrease reflects, in part, the technologic advancements that allow today’s obstetrician to recognize perinatal risk factors using prenatal ultrasonography (US) and fetal monitoring prior to vaginal delivery. The use of potentially injurious instrumentation, such as for- ceps or vacuum delivery, has also declined. 2 Instrumental delivery (forceps, vacuum extraction) may be performed for fetal or maternal indications. The most common indication is a prolonged second stage of labor with fetal distress or presumed fetal compromise whereby any additional delay may result in hypoxic-ischemic neonatal brain injury or fetal death. Maternal indications include severe heart disease or cerebral vascular malformations. 3 Birth trauma should be suspected in cases with difficult delivery, or in the presence of predisposing maternal or neonatal risk factors. Newborn risk factors include macrosomia (>4500 g), perinatal decelerations/depression, shoulder dystocia, ab- normal presentation of the fetus such as breech position, and the use of instruments during delivery. Maternal risk factors include diabetes mellitus, obesity, small pelvis, induced labor, or previous history of a macrosomic neonate. Placental abrup- tion predisposes a significant risk for hypoxic- ischemic injury in newborns. 4 Although many injuries are believed to occur secondary to birth-related a Division of Pediatric Radiology, Department of Radiology and Radiological Science, Johns Hopkins Hospital, Baltimore, MD, USA b Division of Pediatric Radiology, Department of Radiology and Radiological Science, Johns Hopkins Hospital, 600 North Wolfe Street, Nelson, B-173, Baltimore, MD 21287–0842, USA * Corresponding author. Division of Pediatric Radiology, Department of Radiology and Radiological Science, Johns Hopkins Hospital, 600 North Wolfe Street, Nelson Basement, B-172, Baltimore, MD 21287-0842. E-mail address: atekes1@jhmi.edu KEYWORDS  Neonate  Mechanical birth injury  Head and cervical spine Magn Reson Imaging Clin N Am 19 (2011) 777–790 doi:10.1016/j.mric.2011.08.004 1064-9689/11/$ – see front matter Ó 2011 Elsevier Inc. All rights reserved. mri.theclinics.com