Pediatric spine and spinal cord injury are rare sequelae of intentional trauma. They may easily be overlooked, however, and probably represent an underreported phenomenon. Recent autopsy data analyzed in conjunction with prior case series indicate that injury to the upper cervical spine and brainstem may significantly contribute to the major morbidity, mortality, and neuropathology in shaken infants. The findings in the previous case report illustrate several important points regarding spine and spinal cord injury after intentional trauma. First, the very young are susceptible to severe, higher cervical injury of both spine and spinal cord. Second, spine and spinal cord injury were initially overlooked because of masked neurologic findings with the concomitant head injury and multiple other systemic injuries. Finally, the child's outcome with significant cognitive delay because of global brain injury in conjunction with the focal high cervical cord injury may support the hypothesis that hypoxic damage could have occurred secondary to brainstem and high cervical cord injury. At the authors' institution, a detailed history and vigilant physical examination are stressed. When the mechanism of injury reported in the history is incongruous with the physical or initial radiographic findings and intentional trauma is suspected, a full skeletal survey, ophthalmologic evaluation, and social evaluation is undertaken. MRI and CT scanning are individualized according to the clinical assessment.