Blunt Traumatic Cervical Spine Fractures in Iran

doi:10.4236/ss.2011.28089

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Surgical Science, 2011, 2, 407-413

doi:10.4236/ss.2011.28089 Published Online October 2011 (http://www.SciRP.org/journal/ss)

Blunt Traumatic Cervical Spine Fractures in Iran

Soheil Saadat1, Aliashraf Eghbali1, Alexander R. Vaccaro2, Mahdi Sharif-Alhoseini1,

Vafa Rahimi-Movaghar1,3

1Sina Trauma and Surgery Research Center, Tehran University of Medical Sciences, Tehran, Iran

2Department of Orthopaedic Surgery, Thomas Jefferson University and Rothman Institute, Philadelphia, USA

3Research Centre for Neural Repair, University of Tehran, Tehran, Iran

E-mail: [email protected]

Received April 4, 2011; revised Augu st 25, 2011; accepted September 26, 2011

Abstract

Background: Blunt traumatic cervical spine fractures (TCSF) are serious injuries which may be associated

with considerable mortality and morbidity. We describe the epidemiology of blunt traumatic cervical spine

fracture in Iran over a definable time period. Methods: in a cross-sectional study, the data including the dis-

tribution of TCSF, demographics, mechanisms, abbreviated injury scale (AIS), spinal cord associated inju-

ries and final outcome of patients, was extracted from the Iranian national trauma registry database in target

hospitals in eight major cities of Iran from 1999 to 2004. The Chi square test was used to compare mortality

and one-way ANOVA was used to compare ISS amongst th e cate gorie s of TCSF. Results: T CSF was identi-

fied in 120 cases, of these 70.8% were male. Their mean age was 36.6 ± 17.2 years. The overall incidence of

TCSF among all trauma patients was 0.7% (95%CI: 0.61% - 0.88%). The TCSF incidence among all spine

fractured patients was 19.38% (95%CI: 16.34% - 22.72%). The most common mechanism of TCSF was a

motor vehicle collision (66.7%). The overall percentage of in-hospital death for TCSF was 12.6%. There

were no statistically significant difference in death and injury severity scores (ISS) among TCSF categories

(p > 0.05). Spinal cord and root injuries occurred in 34.9% and 2.4% of TCSF, respectively. Conclusions:

preventive strategies need to be developed in order to reduce the number and severity of TCSF in the general

Iranian population.

Keywords: Cervical Spine, Fractures, Iran, Motor Vehicle Crash, Trauma

1. Introduction

Injuries to the cervical spine are of critical importance

given the potential risk of damage to the spinal cord

leading to paralysis and life long consequences [1].

Studies of cervical spinal injury report prevalences rang-

ing from 1% to 14% [2]. Blunt traumatic cervical spine

fractures (TCSF) accounts for 1% to 3% of trauma pa-

tients [3,4] but the resulting loss of neurologic function,

i.e. incomplete/complete quadriplegia following cervical

spinal cord injuries are an important source of mortality

and morbidity [5]. TCSF is seen in 19.2% - 20.8% of

blunt traumatic spine fractures [6-8]. It most frequently

occurs in male patients [9]. The cervical spine is vulner-

able to injuries resulting from high-energy motor vehicle

collisions and falls [10]. TCSF can be potentially devas-

tating, with delayed diagnosis and neurologic damage

resulting in death and disability [11-13]. Prompt immo-

bilization and timely diagnosis are essential for optimal

therapy. Delayed, missed, or inaccurate diagnosis can

result in life-long devastating i mplicatio ns [14].

Among patients undergoing emergency department

cervical spine radiography following blunt trauma, cer-

vical spine injuries were found to be more common

among the young male patients [8,15] and the C1 - C2

was the most common location of inj ury [4].

The Injury severity score (ISS) is an anatomically

based ordinal scale, with a range from 1 to 75. To com-

pute the ISS, the nine abbreviated injury scale (AIS)

body regions are grouped into six: head or neck, face,

chest, abdominal or pelvic contents, extremities or pelvic

girdle, and external. The ISS is then calculated as the

sum of t he sq uar es of the high e st AIS sc or es fo r the t hre e

most severely injured body regions [16].

So far, there has been no reliable investigation of dis-

tribution of TCSF among hospitalized traumatic patients

S. SAADAT ET AL.

408

in Iran. The purpose of this study is to describe blunt

TCSF in traumatic patients ad mitted to general hospitals

in Iran by using a cross-sectional study and to determine

the incidence, demographics, etiology, severity, associ-

ated injuries and final outcomes.

2. Methods

This is a cross-sectional study which was performed us-

ing the data from Iran national trauma registry database

from August 1999 to February 2004. This data was col-

lected from target hospitals in eight major cities of Iran.

Information on every patient who was admitted in these

hospitals due to trauma and had a hospital stay of more

than 24 hours was registered into the database. The data

which was extracted from the original database for this

study included patients’ general demographic character-

istics, mechanism of trauma, levels and regions of spinal

injury, associated injuries, AIS, duration of hospital stay,

and final disposition/outcome. The type of TCSF and the

mechanism of accident were coded according to the In-

ternational Classification of Diseases, the 10th revision

(ICD-10). The region of TCSF was divided by ICD-10

diagnostic codes and classified into C1 (S12.0), C2

(S12.1), C3-7(S12.2) and multiple (S12.7), Concussion

and edema of the cervical spine cord (S14.0), Unspeci-

fied injury of the cervical spinal cord (S14.1), Injury of

the cervical nerve root (14.2), Injury of a peripheral up-

per extremity nerve (14.4).

The statistical analysis was conducted using SPSS

15.0 (SPSS Inc, Illinois, USA). The Chi square test was

used to compare mortality and one way analysis of vari-

ance was used to compare ISS amongst the categories of

TCSF.

3. Results

Of 16,321 enrolled patients, 120 (0.74%) (95% CI:

0.61% - 0.88%) had a cervical spine fracture. The overall

incidence of TCSF among all spine fractured patients

was 19.38% (95% CI: 16.34% - 22.72%). Enrollment

rates in all trau ma patients var ied by age ( Figure 1). The

absolute number of TCSF also varied by age and was

greatest in young adults (aged 15 to 45 years) and older

individuals (aged 60 to 64 years) (Figure 2). The distri-

bution of fractures is listed in Table 1. C2 was the most

common site of fracture, accounting for 20.8% of all

fracture, whereas lower cervical spine (C3 to C7) frac-

tures were seen in 65 (54.2%) patients. The characteris-

tics data are presented in Table 2. The majority of the

patients were male (70.8%). Their mean age was 36.6 ±

17.2 years.

Figure 1. Number of enroll ed patients for each age categ ory.

S. SAADAT ET AL.409

Figure 2. Number of traumatic cervical spine fracture for each age categ ory.

Table 1. The distribution of cervical spine fract ures.

Spine Level No. of Fractures % of All Fractures

C1 12 10

C2 25 20.8

C3 14 11.7

C4 12 10

C5 18 15

C6 12 10

C7 9 7.5

Multiple Fractures 18 15

Total 120 100.0

The dominant occupational category in upper cervical

fracture was office workers (33.3%), but in lower cervi-

cal, it was housewife (21.5%) and for multiple fractures,

it was construction wor kers (27.8%).

The most common geographic location of a single

cervical vertebral fracture was the Outer—city highways

with 51 cases (50%). The educational level of patients

was as follows: 19.7% of the cases were illiterate, 29.1%

completed primary school, 21.4% middle school, 23.9%

high school and 5.9% were graduates of college or uni-

versities.

The most common mechanism of a single cervical

vertebral fracture fro m C1 to C7 was motor vehicle crash

(MVC) with 74 cases (72.5%) but in multiple fractures, it

was violence with 7 cases (38.9%) (Table 2). The spe-

cific etiologies of MVC are presented in Table 3. Only

1.7% of the car occupants who were found to have TCSF

had used seat belts and none of motorcycle riders who

had TCSF had used helmet s.

Accidental falls were the second most common me-

chanism of TCSF (21.7%) and these fractures were most

commonly due to falls of less than 4 meters (50% of all

fractures) (Tabl e 4).

The mean of ISS was 13.3 and 13.9 in patients with

fracture of upper and lower cervical spine fracture, re-

spectively. The ISS was 10.3 in patients with multiple

cervical vertebrae fractures. However, the difference in

ISS among all patient groups was not statistically sig-

nificant (p = 0.115).

Spinal cord and root injuries occurred in 34.9% and

2.4% of TCSF, respectively. Neurological deficits in-

cluded concussion and edema of cervical spinal cord in

13.3% of the patients, unspecified injuries of cervical

S. SAADAT ET AL.

410

Table 2. Chara cteristics of pati ents w i th traumatic cervical spine fractures.

Anatomical location

Upper cervical (C1 - C2)Lower cervical (C3 - C7)Multiple Total

Number (%) Number (%) Number (%) Number (%)

Male 27 (73) 45 (69.2) 13 (72.2) 85 (70.8)

Sex Female 10 (27) 20 (30.8) 5 (27.8) 35 (29.2)

Age ± SD 36.8 ± 16.4 37.4 ± 17.8 33.3 ± 17.9 36.6 ± 17.2

MVC* 29 (78.4) 45 (69.2) 6 (33.3) 80 (66.7)

Fall 6 (16.2) 15 (23.1) 5 (27.8) 26 (21.7)

Violence 1 (2.7) 3 (4.6) 7 (38.9) 11 (9.2)

Mech anism of

trauma

Others 0 (0) 1 (1.5) 0 (0) 1 (0.8)

Home 6 (16.2) 7 (11.1) 6 (33.3) 19 (16.1)

Outer –city highways 23 (62.2) 28 (44.4) 4 (22.2) 55 (46.6)

Street 6 (16.2) 20 (31.7) 2 (11.1) 28 (23.7)

At work 0 (0) 4 (6.3) 5 (27.8) 9 (7.6)

Sports or lei s ure facilities 1 (2.7) 1 (1.6 ) 1 (5.6) 3 (2.5)

Place of tra uma

Others 1 (2.7) 3 (4. 8) 0 (0) 4 (3.3)

Yes 4 (10.8) 8 (12.5) 3 (16.7) 15 (12.6)

Death No 33 (89.2) 56 (87.5) 15 (83.3) 104 (87.4)

*Motor vehicle crash.

Table 3. Specifi c etiology of motor ve hicle crash.

Anatomical location

Upper cervical Lower cervical Multiple Total

Number (%) Number (%) Number (%) Number (%)

Car passenger or driver 16 (55.2) 26 (57.8) 3 (50.0) 45 (56.3)

Pedestrian 2 (6.9) 9 (20.0) 0 (0) 11 (13.8

Motorcycle rider 8 (27.6) 9 (20.0) 0 (0) 17 (21.3)

Bicycle rider 1 (3.4) 0 (0) 1 (16.7) 2 (2.5)

Others 2 (6.9) 1 (2.2) 2 (33.3) 5 (6.3)

Total 29 (100) 45 (100) 6 (100) 80 (100)

All data have been demonstrated as percentage of total.

spinal cord in 21.6%, injury of the nerve root of cervical

spine in 0.8% and the injuries of the peripheral nerve of

neck in 1.6% (Figure 3).

None of patients with C1 fractures admitted into the

hospital died. The percentages of in-hospital death in the

upper, lower, and multiple cervical fractures were 10.8,

12.5, and 16.7, respectively. The mortality above rates

difference was not statistically significant (p = 0.135).

4. Discussion

The aim of this investigation was to d escribe blunt TCSF

in Iran. TCSF is an uncommon injury in Iran, as the in-

cidence among all trauma patients was only 0.7%. This is

similar to the rates found in a recent literature review

noting a TCSF rate of 1 to 3% of all trauma cases [3].

Claytor et al. reported 254 CSF in 572 cervical spine T

S. SAADAT ET AL.411

Table 4. Specific mechanism of fall.

Anatomical location

Upper cervical Lower cervical Multiple Total

Number (%) Nu mber (%) Number (%) Number (%)

>4 m heights 0 (0) 6 (40.0) 2 (40.0) 8 (30.8)

<4 m heights 4 (66.7) 8 (53.3) 1 (20.0) 13 (50.0)

Stairs 1 (16.7) 0 (0) 2 (40.0) 3 (11.5)

Falling to the ground 1 (16.7) 6.7 (15) 0 (0) 7.7 (26)

Total 6 (100) 15 (100) 5 (100) 26 (100)

All data have been demonstrated as percentage of total.

MultipleLower CervicalUpper Cervical

Count

Other injuries of spinal cord

No spinal cord injury

Injury of nerve root

Concussion/edema of spinal

cord

Figure 3. The number of spinal cor d a nd root injuries in upper and lower of cervical spine fractures.

injuries (44.4%) [15]. Thus, it seems that less than half of

the patients with cervical spine injuries have an associ-

ated fracture. We showed that the overall incidence of

TCSF among all spine fractured patients was 19.38%. In

95% of the previous 38 reports, the incidence of cervical

spine injury in all trauma patients varies from 1.5% to

9.0% (Figure 4) [2]. In a meta-analysis gathering 65

studies with a total of 281,864 subjects, Milby et al.

demonstrated that the overall incidence of cervical spine

injury among all trauma patients was 3.7% [2]. The

lower incidence of TCSF among all trauma and spine

fractured patients in our series could be due to the fact

that we excluded any nonbony injury such as a ligamen-

tous injury or a dislocation without a fracture.

We demonstrated the distribution of cervical spine

fractures according to spine level, separately. Based on

that, upper cervical spine fracture accounted for 30.8%

of TCSF, however a literature search notes that injur y to

the upper cervical spine accounts generally for 19 to

32.7% of all cervical spine injuries [3,4]. Fractures of C2

occurred most frequently in our study and this is the

same as noted in the literature.

The majority of the patients were male (70.2%) and

the male/female ratio was 2.4; our data were supported

by previous reported studies [4,12,14,15]. In addition,

the male population, in all age groups, has a higher inci-

dence of cervical fractures than females [1,17]. Of course

Schoenfeld et al. surveyed a large multicultural military

population, but our study was hospital-based [17].

The overall number of TCSF varies with age in a bi-

S. SAADAT ET AL.

412

Figure 4. Incidence of cervical spine injury in trauma pa-

tients in different seri es.

modal fashion. This bimodal distribution was previously

reported in the USA [15]. The first age peak was almost

the same as seen in our study. Mean age for TCSF was

36.6 years in Iran and slightly older in the United States

(42.3 and 43.8 years) [8,18]. The difference may be due

to unsafe driving behavior in young adults and the

younger population in Iran. The second peak in the USA

was in individuals aged 65 to 85 years, which is older

than our patients. This older peak may be due to osteo-

porotic fractures following falls or the longer length of

life in developed countries.

The lower cervical spine is the most frequent location

for spinal trauma. Our study did not show any age-de-

pendent difference in region of TCSF. However, it has

been shown that upper cervical spine injuries are the

most frequent location for the population over 65 years

of age [19].

We demonstrated the mechanisms of accident were

coded according to the ICD-10. The most common

mechanism of TCSF was MVC which has also been re-

ported [4,17,20]. In some other studies, the most com-

mon mechanism was fall [8,21]. In Sweden, transporta-

tion related cervical fractures have dropped since 1991,

leaving fall accidents as the sole largest cause of cervical

trauma [1]. The most common mechanism of our patients

was car occupants (56.6%) in which just 4.4% used seat

belt. In the 20.5% of MVC due to motorcycle accidents,

no one used a safety helmet. Seat belt has been clearly

shown to reduce overall mortality and morbidity in car

accidents [17,22,23] but no association has been shown

between helmet use and the occurrence of cervical spine

injuries in motor cycle collisions [24].

Spinal cord and root injuries occurred in 34.9% and

2.4% of TCSF, respectively. Our results were almost the

same as Sokolwski et al. which found that 31% of pa-

tients with upper cervical injuries and a higher percent-

age of lower cervical injuries had neurologic deficits on

presentation [25]. In the study of Leucht et al., most of

the neurological deficits occurred in response to cervical

spine fractures, followed by thoracic and lumbar spine

fractures and the highest number of complete motor and

sensory neurological deficits was diagnosed in patients

with cervical spine fractures [8].

The mean ISS was 13.3, 13.9 and 10.3 in upper, lower

and multiple cervical spine fractures respectively, which

is near to the median ISS of 14 reports in the literature

[26]. In another study, the ISS was less than 16 in 8 pa-

tients, between 16 and 25 in 60 patients, and more than

26 in 53 patients [6].

The lowest percent of TCSF was at C7 (7.5%) in Iran,

however in the 808 cervical spine injuries in the NEXUS

group study, ther e were 1 9.08% of inj uries invo lving the

C7 level [4]. This difference may be due to probable

missed C7 cases following inadequately performed cer-

vical radiography.

Based on the present study, the overall percentage of

in-hospital death for TCSF was 12.6%. Tolonen et al.

showed that died patients following cervical spine injury

comprised more than 10% of the causes of death in MVC

[27], but Claytor et al. didn’t reveal to rate of TCSF

which lead to death [15].

This study has limitations that the readers should bear

in mind. Providing further information on the anatomic

distribution, location, different parts of each vertebra

fracture, such as odontoid, dislocations by cervical spine

level and radiographic findings would be helpful.

The most common mechanism for TCSF was MVC.

The young in all populations appear to be most affected

which unfortunately is the pro ductive labor force in Iran,

a country more prone to TCSF.

5. Acknowledgement

The database was provided by the Sina Trauma and Sur-

gery Research Center of Tehran University Medical Sci-

ences. The authors thank Mrs. Bita Pourmand for her edit

of the manuscript.

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