Cervical spinal cord injury following near-hanging without associated cervical fracture: a case report

Introduction

Hanging is a prevalent method of suicide worldwide and remains a major public health concern. Epidemiological studies report that hanging accounts for a substantial proportion of self-inflicted deaths in many regions (1,2).

The mechanisms of injury in hanging are traditionally related to compression of cervical vessels leading to cerebral hypoxia, neurogenic reflex mechanisms, and less commonly airway obstruction (3,4). Hypoxic-ischemic brain injury should be regarded as an outcome rather than a primary injury mechanism. Neurological manifestations in survivors are therefore most often attributed to cerebral hypoxia rather than direct spinal cord involvement.

Spinal cord injury after hanging is extremely rare and is usually associated with cervical fractures or dislocations. When no bony abnormality is present, such cases resemble spinal cord injury without radiographic abnormality (SCIWORA), a phenomenon initially described in children and later recognized in adults (5,6). Although adult SCIWORA is uncommon, it may result in severe and permanent neurological deficits (7).

We present an additional case of cervical spinal cord injury following near-hanging in an elderly patient, highlighting clinical features, imaging findings, and pathophysiological considerations. We present this article in accordance with the CARE reporting checklist (available at https://jss.amegroups.com/article/view/10.21037/jss-2025-aw-197/rc).

Case presentation

A 70-year-old man with no history of psychiatric illness and previously active in managing his business was found suspended by a rope inside a vinyl greenhouse storage area. According to family and emergency medical service reports, the knot was positioned at the posterior cervical region, and the body was partially supported by the ground, consistent with incomplete (near) hanging. No fall or high-energy trauma was reported.

Cardiopulmonary resuscitation (CPR) was initiated immediately by his spouse and continued by his son until emergency medical services arrived. The estimated duration of pulselessness was approximately 10 minutes before return of spontaneous circulation. On arrival at the emergency department, one additional cycle of CPR was required. Initial vital signs were stable. Pupils were bilaterally non-reactive, and the patient was semicomatous (Glasgow Coma Scale score 8) with quadriparesis (muscle strength grade I in all extremities).

Arterial blood gas analysis revealed mixed acidosis (pH 7.207, PaCO₂ 52.7 mmHg, PaO₂ 115.0 mmHg, lactate 5.1 mmol/L). No petechial hemorrhage or other classical asphyxial signs were documented, and toxicological screening was negative.

Plain radiographs and computed tomography (CT) scans of the cervical spine showed no fracture or dislocation, or prevertebral swelling (Figure 1). Magnetic resonance imaging (MRI) performed within 24 hours demonstrated diffuse T2-hyperintense intramedullary edema of the cervical cord without fracture, bone marrow edema, ligamentous disruption, or facet joint injury. Only mild age-related cervical spondylotic changes without canal stenosis were noted (Figure 2).

Figure 1 CT scans of the cervical spine showed no fracture, dislocation, or prevertebral swelling. CT, computed tomography.

Figure 2 Sagittal T2-weighted MRI of the cervical spine demonstrating diffuse intramedullary hyperintense cord edema (arrows), without evidence of recent fracture line, bone-marrow edema, ligamentous disruption, or facet joint injury. MRI, magnetic resonance imaging.

The patient was treated with rigid cervical immobilization and admitted to the intensive care unit. High-dose corticosteroids were administered according to institutional protocol. Despite supportive care, no meaningful neurological recovery was observed during hospitalization, and severe quadriparesis persisted as a permanent neurological sequela.

All procedures performed in this case were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Helsinki Declaration and its subsequent amendments. Written informed consent for publication of this case report and accompanying images was obtained from the patient’s legal guardian. A copy of the written consent is available for review by the editorial office of this journal.

Discussion

Spinal cord injury following hanging is exceptionally rare. Large clinical series have demonstrated that neurological morbidity in hanging survivors is predominantly due to cerebral hypoxia and vascular compromise rather than direct spinal cord injury (8,9). In a prospective study of 101 patients with suicidal hanging, no cases of cervical cord injury were identified (8).

Nevertheless, isolated case reports have documented spinal cord involvement after hanging. Adult SCIWORA cases demonstrating cervical cord edema on MRI despite normal radiographs have been reported (10,11). A systematic review by Boese and Lechler identified only a limited number of adult SCIWORA cases, underscoring the rarity of this condition (7). Compared with previously reported cases, the advanced age of our patient may have contributed to poorer neurological recovery.

Pathophysiological considerations

The mechanisms underlying cervical spinal cord injury in hanging are multifactorial. While hypoxic-ischemic encephalopathy results from vascular compression and impaired cerebral perfusion, direct spinal cord injury requires mechanical forces such as hyperextension, hyperflexion, or axial traction (12). Ligature position and incomplete hanging may still generate sufficient cervical loading to injure the cord.

In elderly patients, degenerative changes reduce spinal canal reserve and increase vulnerability to stretch-related injury (13). Vascular factors, including venous congestion and ischemia, may further exacerbate intramedullary edema (14). In the present case, diffuse cord edema without fracture supports a distraction- and vascular-related injury mechanism rather than direct contusion.

MRI findings and prognosis

MRI is indispensable when CT findings are normal. T2-hyperintense intramedullary edema is a typical finding in SCIWORA and correlates with neurological outcome (7,10,11). In our patient, brain MRI demonstrated diffuse cortical and deep gray matter signal changes consistent with global hypoxic-ischemic encephalopathy, which likely contributed substantially to the poor neurological outcome.

Management and clinical implications

Management remains controversial. Although high-dose corticosteroids were historically used, evidence supporting their benefit is limited, and current guidelines recommend individualized decision-making (15,16). In the absence of instability or compression, conservative management is appropriate.

From a forensic and clinical perspective, awareness that cervical spinal cord injury can occur after near hanging without fracture is essential, as neurological deficits may otherwise be incorrectly attributed solely to cerebral hypoxia.

Conclusions

Cervical spinal cord injury following near-hanging, even in the absence of bony abnormalities, is a rare but clinically significant entity. The injury mechanism is more consistent with distraction forces and vascular compromise than with direct contusion. Early MRI evaluation is essential for accurate diagnosis and prognostic assessment.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the CARE reporting checklist. Available at https://jss.amegroups.com/article/view/10.21037/jss-2025-aw-197/rc

Peer Review File: Available at https://jss.amegroups.com/article/view/10.21037/jss-2025-aw-197/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jss.amegroups.com/article/view/10.21037/jss-2025-aw-197/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All procedures performed in this case were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Helsinki Declaration and its subsequent amendments. Written informed consent for publication of this case report and accompanying images was obtained from the patient’s legal guardian. A copy of the written consent is available for review by the editorial office of this journal.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

References

1. Gunnell D, Bennewith O, Hawton K, et al. The epidemiology and prevention of suicide by hanging: a systematic review. Int J Epidemiol 2005;34:433-42. [Crossref] [PubMed]
2. Bennewith O, Gunnell D, Kapur N, et al. Suicide by hanging: multicentre study based on coroners' records in England. Br J Psychiatry 2005;186:260-1. [Crossref] [PubMed]
3. Iserson KV. Strangulation: a review of ligature, manual, and postural neck compression injuries. Ann Emerg Med 1984;13:179-85. [Crossref] [PubMed]
4. Sauvageau A, Boghossian E. Classification of asphyxia: the need for standardization. J Forensic Sci 2010;55:1259-67. [Crossref] [PubMed]
5. Pang D, Wilberger JE Jr. Spinal cord injury without radiographic abnormalities in children. J Neurosurg 1982;57:114-29. [Crossref] [PubMed]
6. Gupta SK, Rajeev K, Khosla VK, et al. Spinal cord injury without radiographic abnormality in adults. Spinal Cord 1999;37:726-9. [Crossref] [PubMed]
7. Boese CK, Lechler P. Spinal cord injury without radiologic abnormalities in adults: a systematic review. J Trauma Acute Care Surg 2013;75:320-30. [Crossref] [PubMed]
8. Jawaid MT, Amalnath SD, Subrahmanyam DKS. Neurological Outcomes Following Suicidal Hanging: A Prospective Study of 101 Patients. Ann Indian Acad Neurol 2017;20:106-8. [Crossref] [PubMed]
9. Vander Krol L, Wolfe R. The emergency department management of near-hanging victims. J Emerg Med 1994;12:285-92. [Crossref] [PubMed]
10. Hana H, Gnena H, Safia O, et al. Delayed presentation of spinal cord injury without radiographic abnormality (SCIWORA): a case report. Pan Afr Med J 2023;45:160. [Crossref] [PubMed]
11. Bonfanti L, Donelli V, Lunian M, et al. Adult Spinal Cord Injury Without Radiographic Abnormality (SCIWORA). Two case reports and a narrative review. Acta Biomed 2019;89:593-8. [PubMed]
12. Shkrum MJ, Ramsay DA. Forensic Pathology of Trauma: Common Problems for the Pathologist. Totowa, NJ: Humana Press; 2007.
13. Thompson K, Travers H, Ngan A, et al. Updates in current concepts in degenerative cervical myelopathy: a systematic review. J Spine Surg. 2024;10:313-26. [Crossref] [PubMed]
14. Galeiras Vázquez R, Ferreiro Velasco ME, Mourelo Fariña M, et al. Update on traumatic acute spinal cord injury. Part 1. Actualización en lesión medular aguda postraumática. Parte 1. Med Intensiva 2017;41:237-47. [Crossref] [PubMed]
15. Bracken MB. Steroids for acute spinal cord injury. Cochrane Database Syst Rev 2012;1:CD001046. [Crossref] [PubMed]
16. Fehlings MG, Tetreault LA, Wilson JR, et al. A clinical practice guideline for the management of acute spinal cord injury: introduction, rationale, and scope. Global Spine J 2017;7:84S-94S. [Crossref] [PubMed]