Sir,

Colombari et al. [1] present a literature review to assess the contribution of spinal cord changes in differentiating abusive from accidental head trauma. This premise itself defies logic. Head trauma is head trauma. How can spinal cord pathology identify the intent of a perpetrator of such injury?

The opening statement “Shaking (with or without impact) has been identified as the leading mechanism resulting in the common AHT features, namely, the “triad” of intracranial subdural haematoma, cerebral oedema with hypoxic ischaemic changes and retinal haemorrhages” cites Squier [2]. Had the authors read even the abstract of that paper they will have seen “research has repeatedly undermined the hypothesis that shaking per se can cause this triad” followed by a discussion of the improbability of the shaking hypothesis concluding that “While shaking is no longer a credible mechanism for NAHI, there remains no doubt that inflicted head injury does occur”. Such egregious misquotation of the first reference in the paper does not inspire confidence in anything that follows. Indeed, Lynøe et al. [3] are miscited, by stating that the triad is not sufficient to confirm abuse. Lynøe et al. were highly specific in addressing the lack of scientific evidence that the triad can be associated with traumatic shaking. They did not use the term abuse. Despite citing this study, Colombari et al. fail to acknowledge one of its main messages; that the child abuse literature is beset by circularity bias, thus invalidating the majority of the publications on which they depend.

The many claims that associations between particular medical findings and abuse have been “statistically proven” indicate that the authors fail to appreciate that medical science depends on observation and is not an exact science like mathematics; hence, it is very difficult to “prove” anything.