|Year : 2012 | Volume
| Issue : 4 | Page : 316-320
|Presentation and outcome of traumatic spinal fractures
Ahmed El-Faramawy1, Ayman El-Menyar2, Ahmad Zarour1, Kimball Maull3, Jane Riebe1, Krishna Kumar4, John Mathew5, Ashok Parchani1, Hassan Al-Thani1, Rifat Latifi6
1 Department of Surgery, Section of Trauma Surgery, Hamad General Hospital, Doha, Qatar
2 Department of Surgery, Section of Trauma Surgery, Hamad General Hospital; Department of Clinical Science, Weill Cornell Medical School, Doha, Qatar
3 Department of Surgery, Section of Trauma Surgery, Hamad General Hospital, Doha, Qatar; University of Pittsburgh Medical Center, USA
4 Department of Orthopedic, Hamad General Hospital, Qatar
5 Department of Neurosurgery, Hamad General hospital, Qatar
6 Department of Surgery, Section of Trauma Surgery, Hamad General Hospital; Department of Clinical Science, Weill Cornell Medical School, Doha, Qatar; Department of Surgery, University of Arizona, Tucson, AZ, USA
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|Date of Submission||19-Dec-2011|
|Date of Acceptance||10-Apr-2012|
|Date of Web Publication||15-Oct-2012|
| Abstract|| |
Background: Motor vehicle crashes and falls account for most of the spine fractures with subsequent serious disability. Aim: To define the incidence, causes, and outcome of spinal fractures. Materials and Methods: Data were collected retrospectively from trauma registry database of all traumatic spinal injuries admitted to the section of trauma surgery in Qatar from November 2007 to December 2009. Results: Among 3712 patients who were admitted to the section of trauma surgery, 442 (12%) injured patients had spinal fractures with a mean age of 33.2 ± 12 years. The male to female ratio was 11.6:1. Motor vehicle crashes (36.5%) and falls from height (19.3%) were the leading causes of cervical injury (P = 0.001). The injury severity score ranged between 4 and 75. Nineteen percent of cases with cervical injury had thoracic injury as well (P = 0.04). Lumber injury was associated with thoracic injury in 27% of cases (P < 0.001). Combined thoracic and lumber injuries were associated with cervical injury in 33% of cases (P < 0.001). The total percent of injuries associated with neurological deficit was 5.4%. Fifty-three cases were managed surgically for spine fractures; 14 of them had associated neurological deficits. Overall mortalityrate was 5%. Conclusions: Spine fractures are not uncommon in Qatar. Cervical and thoracic spine injuries carry the highest incidence of associated neurological deficit and injuries at other spinal levels. Young males are the most exposed population that deserves more emphasis on injury prevention programs in the working sites and in enforcement of traffic laws.
Keywords: Cord injury, fracture, spine, trauma, Qatar
|How to cite this article:|
El-Faramawy A, El-Menyar A, Zarour A, Maull K, Riebe J, Kumar K, Mathew J, Parchani A, Al-Thani H, Latifi R. Presentation and outcome of traumatic spinal fractures. J Emerg Trauma Shock 2012;5:316-20
|How to cite this URL:|
El-Faramawy A, El-Menyar A, Zarour A, Maull K, Riebe J, Kumar K, Mathew J, Parchani A, Al-Thani H, Latifi R. Presentation and outcome of traumatic spinal fractures. J Emerg Trauma Shock [serial online] 2012 [cited 2019 Jan 15];5:316-20. Available from: http://www.onlinejets.org/text.asp?2012/5/4/316/102381
| Introduction|| |
Traumatic injury to spinal vertebrae may result in isolated spinal column injury (SI) or spinal cord injuries (SCI). Spinal cord injury (SCI) often results in profound and long-term disability that has a devastating effect from the physical, psychological, and socioeconomic point of view. Moreover, these injuries pose an immense burden on society from a public health perspective. In the United States, the estimated cost of treatment of SCI is $9.7 billion per a year.  The Public Health Agency of Canada estimated that in 2000-2001 the hospital costs associated with SI were $61.6 million.  Both SI and SCI are most frequently caused by motor vehicle crashes (MVC), falls and sports or recreational activities. Survival after spinal fractures has been shown to improve along with a greater appreciation of patterns of presentation and complications. , According to the Canadian Paraplegic Association, motor vehicle crashes account for 35% of all SCI.  Approximately 900 Canadians sustain a SCI each year, 80% of whom are male and young with age between 15 and 34 years. ,
The current growth in construction in the state of Qatar as well as the rapid increase in population has led to identification of the mechanism of spine injuries and its impact. Understanding the current epidemiology of acute traumatic SI and SCI in view of different demographics in Qatar is essential for public resource allocation and development of local preventive programs. Herein, we conduct the present study to define the incidence and causes of SI and SCI and its associated neurological deficit and mortality in Qatar. Also, we evaluate the association between fractures at different levels of spine injuries.
| Materials and Methods|| |
In this retrospective descriptive study, data were collected from the database registry in the section of trauma surgery at Hamad General Hospital (HGH) between November 2007 and December 2009. HGH is a tertiary hospital with level 1 trauma center in the state of Qatar. We recruited all patients who presented with spinal trauma that required hospitalization. Patients who died at the scene or declared dead in the accident and emergency department were excluded. On arrival, all patients underwent thorough clinical assessment and resuscitation according to Advanced Trauma Life Support (ATLS) guidelines. Collected data included age, sex, nationality, mechanism of injury, protective measures used, radiological imaging, Injury Severity Scores (ISS), and location of spinal trauma (i.e., cervical, thoracic, lumbar and sacral vertebrae). The presence or absence of associated SCI with each type of injury was reported. Association among cervical, thoracic and lumbar injuries and acute interventions were recorded. In the emergency room, spinal cord injuries were assessed by careful inspection, testing for sensory function and movement including NEXUS criteria.  If the injured person complained of neck pain, was not fully conscious, or had obvious signs of weakness or neurological injury, emergency diagnostic tests were requested such as plain X-rays and computerized tomography (CT) scan. Pan CT scan was occasionally requested in certain circumstances (deterioration of conscious level, mechanism of injury and multiple injuries). The outcomes included presence of neurologic deficit and hospital all-cause mortality.
Data were presented as proportions, medians, or mean ± SD as appropriate. Differences in categorical variables between respective comparison groups were analyzed using the χ2 test or Fisher's exact test. The continuous variables were analyzed using student t test when applicable. P values of < 0.05 were considered significant. All data analyses were carried out using the Statistical Package for Social Sciences version 18 (SPSS Inc. USA).
| Results|| |
Among 3712 patients who were admitted to the section of trauma surgery at HGH between November 2007 and December 2009, 442 (12%) injured patients were found to have spinal fractures. Age ranged between 4 and 87 years with a mean age of 33.2 ± 12 years. The incidence of spinal fractures varied among different age groups. The number of cases in age group (1-20 years), (21-40 years), (41-60 years), and (above 60 years) were 47 (7.7%), 278 (65.5%), 92 (20.8%), and 25 (5.7%) cases, respectively. The male to female ratio was 11.6:1 (407 males and 35 females) and the number of Qataris patients was 88 (20%), while non-Qatari patients was 354 (80%) [Table 1].
Mechanism of injury
The majority of spinal fractures were related to MVC (38.5%), fall (30.5%), and pedestrian injuries (13%). [Table 2] shows the causes of trauma to the spine. MVC was the most frequent mechanism of injury in patients with cervical and thoracic injury (36.5% and 38.2%, respectively, P = 0.001 for each). Fall from height was more evident cause of lumber injuries (55.6%), P = 0.02, while sacral injuries were more frequently observed in pedestrian injuries (37.5%), P = 0.001.
|Table 2: Causes of spine fractures and neurologic deficits at different levels|
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Injury severity score
The injury severity score (ISS) ranged between 4 to75 with a mean of 17 ± 10 and median of 14. Minor cases (ISS = 1-9) were reported in144 cases (33%), moderate cases (ISS = 10-15) in 87 cases (20%), severe cases (ISS = 16-25) in 142 cases (33%), and critical cases (ISS = 26-75) in 69 cases (15%).
Most of injuries occurred at the level of lumber spines (n = 197), followed by thoracic (n = 138), cervical spines (n = 111) and sacral (n = 85). Isolated spine fractures were reported in patients with cervical (62.7%), thoracic (59.8%), lumber (73.4%) and sacral (82%) injury. [Figure 1] demonstrates association among spinal injuries at different levels. Nineteen percent of cases with cervical injury had thoracic injury as well (P = 0.04). Lumber injury was combined with thoracic injury in 27% of cases (P < 0.001). Combined thoracic and lumber injuries were associated with cervical injury in 33% of cases (P < 0.001). [Figure 2] shows examples of traumatic spinal fractures.
|Figure 2: (a) CT cervical spine of a 28-year-old male showing multiple cervical vertebral fractures including transverse process of C5, vertebral body, and posterior column of C6 and comminuted fracture of transverse process of C7, (b) MRI spine cervical and thoracic of 26-year-old female showing fracture dislocation at T6-T7 vertebral levels with left antrolateral displacement and overriding of the body of T6 over T7 vertebral bodies. Evidence of near total transaction of the dorsal spinal cord at the level of the lower end plate of T6 vertebra with intramedullary areas of high intensity in T1-T2-weighted images (hemorrhagic parenchyma contusions). There is also partial vertical compression of T8, T10, and T11 vertebrae|
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Associated traumatic brain injury
Traumatic brain injury (TBI) was associated with cervical, thoracic and lumber spinal injuries in 13%, 9% and 10.4% of cases.
The total number of injuries associated with neurological deficit was reported in 24 out of 442 cases (5.4%). The incidence of cervical spine injuries associated with neurological deficit was 10 out 111 cases (9%). Thoracic spine injuries associated with neurological deficit was 7 out of 138 cases (5%). In lumbar spine injuries, the incidence of deficit was reported in 7 out of 196 cases (3.5%). Causes of trauma in patients with neurological deficit included falls in 12 cases (50%), MVC in 5 cases (20.8%), pedestrian injury in 3 cases (12.5%), and other causes in 4 cases.
Fifty-three cases were managed surgically for spine fractures; 14 of them had associated neurological deficits. Overall mortality was 5% (22 cases).
| Discussion|| |
This study reports on patients who sustained spinal fractures over a 2-year period at HGH, in Qatar. HGH is the only tertiary specialized hospital in Qatar that has a neurosurgery section; therefore, all cases with spinal fractures are referred from other hospitals or primary care facilities. Accordingly, this study can give an overall incidence, causes and outcome of traumatic spinal injuries in Qatar, and subsequently sets the appropriate strategy for local injury prevention programs.
The section of trauma surgery at HGH has its own dedicated registry unit. However, the registry does not include possible spinal injuries in cases brought dead to the hospital or those who died on arrival before full radiologic assessment. The total number of cases included in the study was 442 cases, which constitutes 12% of all trauma patients that had been admitted over a 2-year period. The high percent of spine fractures among non-Qataris (80%) reflects the fact that Qatar is a rapidly developing country, with many expatriates (construction, farm and industrial workers). According to the last census of 2010, population of Qatar were 1,678,568 (1,320,589 were non-Qataris).  In the present study, male to female ratio was 11.6 to 1, which reflects the population pattern in Qatar (1,274,013 males and 404,555 females).
Age distribution in our study showed a mean age of 33.2 years with 278 cases in the young adult age group (21-40 years) representing 65.5% of injured cases. While Qatari patients represented 88 cases (19.9%) of the total number of cases, there were 26 Qataris in the age group 10 to 20 years (59%) and 15 Qatari cases in the age group 41 to 60 years (16%). The mean ISS was 17 with a peak in patients with minor injury (n = 144) and severe injury (n = 142). The high peak in minor injuries is mostly seen in cases with isolated vertebral fractures. This high rate of injuries among young adolescent Qataris deserves further evaluation through the injury prevention programs. Previous data showed the use of a seatbelt can reduce the odds of a spinal cord injury by 60%, while use of a seatbelt and airbag combined can reduce the odds of injury by 80%. ,
Causes of injury at different spinal levels in our study are varying. The leading cause of cervical and thoracic injuries was MVC, while fall was the main cause of lumbar injury. In comparison to lumber and thoracic injuries, cervical injuries were the least in number. However, the latter was associated with the highest rate of cord injury with neurological deficit. The overall incidence of neurological deficits in the current study was 5%. Furthermore, cervical and thoracic spine injuries have the highest incident of being associated with injuries at other spinal levels (37.3% and 40.2% respectively).
Experiences from other countries
Karacan et al.  reported 581 cases with SCI with an annual incidence of 12.7 per million in Turkey. In that study, the main cause of SCI was MVC (49%) and falls (36.5%). Western studies reported an annual incidence of SCI ranging between 15 and 52.5 cases per million with 80% of cases are young males and 5% are children. ,, The associated neurological disability frequently occurred in terms of quadriplegia (53%) and paraplegia (42%). ,, Data from the University of California reported that cervical spine injuries constitute one-third of all spinal fractures and one-half to two-thirds of all spinal cord injuries. Of all spine injuries, 30% involve the thoracic spine and 42.5% the lumbosacral spine.  Another data from USA showed that 250,000 American are SCI injured; 52% are considered paraplegic and 47% quadriplegic.  Almost 12,000 new injuries occur each year; and mainly affect males (82%). The average age of injury is 31 years. Causes of SCI included MVC (37%), violence (28%) and fall (21%). The graduated licensing program showed success in reducing crashes by 20- 30% amongst young drivers in the United States. 
Management of spinal fractures is mainly based on decompression of spinal cord and nerves, and stabilization of the spinal column. [Table 3] shows our current protocol for intervention for decompression injuries. Prevention of neurological deterioration with subsequently improving patients' functional outcome requires early treatment through an experienced, multi- disciplinary, and well-equipped trauma team. 
To minimize the mechanisms of injury
In the present study, 82% of the mechanism of spinal injury could be preventable; this finding highlights the importance of development of local prevention and quality control program in workplaces in addition to enforcement of the traffic laws. [Table 4] shows examples of National traffic legislations from different countries.  Encouraging the graduated licensing, driver education, and training programs may reduce the MVC-related morbidity and mortality in the Middle East. 
A recent data from Qatar reported that during the period 2000- 2006, prior to camera installation, the mean MVC- related death rate per 100,000 was 19.9 ± 4.1. From 2007 to 2010, the mean death rate was lower: 14.7 ± 1.5 (P = 0.03). Non-fatal severe injury rates also declined, but mild injury rates increased.  Furthermore, Qatar established the National Committee of Occupational Health and Safety ("Committee") at the Ministry of Labour comprised of representatives from various ministries, and this may minimize workplace injuries. 
| Conclusion|| |
Spine fractures are not uncommon events in Qatar. Motor vehicle crashes and falls remain the leading cause of spinal injuries in Qatar with an annual incidence around 200 cases and with a consequent spinal cord injury with neurological deficit in around 5% of cases. Young males are the most exposed sector of population that deserves more emphasis on injury prevention programs in the working sites and in enforcement of traffic laws. Cervical and thoracic spine injuries carry the highest incidence of associated neurological deficit and injuries at other levels. Diagnosing spinal injuries at one level should alert the physician to look for possible injuries at other levels.
| Acknowledgments|| |
We thank the staff in the section of Trauma surgery, Hamad General Hospital for their invaluable cooperation. This study was presented in-part in Southeastern Surgical Congress 2011 Annual Scientific Meeting, Feb 12-15, 2011 in Chattanooga, TN (United States). The study has been approved by the Medical Research Center, HMC, Qatar (IRB#10132)
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Department of Surgery, Section of Trauma Surgery, Hamad General Hospital, Doha, Qatar
Source of Support: None, Conflict of Interest: None
[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3], [Table 4]
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