ABSTRACT
Background:
Spinal cord injury is a devastating condition to an individual and his/her family imposing an economic burden on the family, society, and the country. Finding out the demographic and morbidity profile of cervical spine injuries is essential for formulating means and ways for its prevention and treatment.
Aim:
This study aimed at assessing the clinico-radiological and socio-demographic profile of cervical spine injury patients and their association with short-term clinical outcomes.
Methods:
This was a prospective observational study that included 120 patients with cervical spine/cord injury. Social, demographic, clinical, and radiological parameters of the study participants were recorded. Improvement, worsening, and neurological stability at 2 weeks follow-ups were considered as a short-term outcome. The association of neurological outcomes with clinico-radiological profile and socio-demographic characteristics was analyzed to study the level of significance.
Results:
The study found that nearly 81% of the study participants were involved in heavy physical activity, and 45% of the cases sustained cervical spine injury because of falls from height. About 37% and 55% of patients had complete and incomplete cord injury, respectively. Computerized tomography of the spine injury patients showed a fracture, subluxation, and locked facets. Magnetic resonance imaging showed disco-ligamentous injury and cord contusion in these patients. Nearly 29% of patients showed motor improvement, and around 4% of patients had a worsening of their neurological status after 2 weeks.
Conclusion:
Most of the people who sustain cervical spine injuries are involved in heavy physical work. Female gender, incomplete cord injury, and unilateral locked facet in subluxation are associated with good neurological outcomes. This study will form a preliminary base to build a larger database on spinal cord injury at the regional and national levels.
Keywords: Cervical spine injury, clinico-radiological profile, neurological outcome socio-demographic factors
Introduction
The morbidity caused by cervical spine injuries not only paralyzes the patient but also creates an economic and social burden on the family and the society in which the individual stays.[1] Cervical spine injury as a cause of morbidity and losses to the social and economic productivity of a nation cannot be underestimated. The expenses that are incurred by the family of the patient and the government authorities to deal with these patients are significant.[2,3] The incidence of spinal cord injury in developing countries ranges from 2.1 to 130.7 million/year.[4] A family of Indian origin belonging to lower socio-economic strata cannot take the burden of this kind of injury without causing distress to their daily life sustenance.
Although the urbanization and industrialization in India are increasing at a rapid pace, the Indian health system lacks a proper database for cervical spine injuries that are more common than assumed. With rapid urbanization, the type of occupations that involve heavy work and rapid transportation is increasing. The chances of an individual experiencing a RTA or a fall from height are also increasing.[5,6]
Information on the demographic and morbidity profile of patients with cervical spine injury is limited with reference to the Indian scenario. This study is an attempt to start a database for the same at an institutional level that will grow to a regional level and then might be to a national level.
Materials and Methods
This was a prospective observational study conducted in the department of neurosurgery, at a tertiary care hospital in south India, from July 2016 to June 2017. The study was approved by the institute’s research and ethics committee (No. JIP/IEC/SC/2016/30/955). Patients with cervical spine injury who attended the emergency medical services were included in the study. However, unconscious patients because of the severe head injury and polytrauma patients with poor hemodynamic status were excluded from the study. Informed consent was obtained from all the study participants and their attenders before enrolling them in the study.
Methodology
All patients were subjected to emergency cervical spine X-ray and spiral computerized tomography (CT) of the cervical spine as per the department protocol. Patients who did not have any bony injury but had a stable neurological weakness were subjected to magnetic resonance imaging (MRI). Those who had fractures and instability of the spine were subjected to surgical procedures if they were considered fit for the same.
Patients with complete motor paralysis, absence of perianal sensations, and loss of anal sphincter tone were grouped under the complete cord injury category. The motor power following 2 weeks of follow-up was compared with that at the time of admission. An increase in motor power even by one point in any of the limbs was considered to be an improvement. Based on the outcome with respect to neurological status, patients were categorized as (a) No change, (b) Improved, and (c) Worsened.
The variables included in the study were the following:
-
1)
Independent variables such as age, sex, mode of injury, socio-demographic characteristics (education, occupation, etc.), and vital parameters (blood pressure, respiratory rate, and pulse rate).
-
2)
Clinico-radiological profile in the form of type of injury – complete or incomplete cord injury, CT findings, and MRI findings.
-
3)
Short-term clinical outcome at 2 weeks follow-up as to whether the neurological status had improved, worsened, or no change.
Statistical analysis
The distributions of categorical data such as clinic-radiological factors, socio-demographic factors, outcomes, etc., are expressed as frequency and percentages. The continuous data such as blood pressure, respiratory rate, and pulse rate are expressed as median with range.
The association of the clinical outcomes with clinico-radiological profile and socio-demographic characteristics was carried out using the Chi-square test. The comparison of the continuous data between the outcomes was carried out by using Mann–Whitney U-test or Kruskal–Wallis test. All statistical analysis was carried out at a 5% level of significance and a P value of less than 0.05 was considered significant.
Results
Age and sex distribution
In this study, the majority of spine trauma victims were in the age group of 45–65 years (47.5%). About 45.8% of patients were between 18 and 44 years and around 6.7% of patients were more than 65 years [Table 1; Figure 1]. Out of the total 120 patients, 91.7% were male and only 8.3% were female [Table 1; Figure 2].
Table 1.
Distribution of socio-demographic characteristics
| Variables | Category | Frequency | Percentage |
|---|---|---|---|
| Age (years) | 0-17 | 0 | 0 |
| 18-44 | 55 | 45.8 | |
| 45-65 | 57 | 47.5 | |
| >65 | 8 | 6.7 | |
| Gender | Male | 110 | 91.7 |
| Female | 10 | 8.3 | |
| Education | Uneducated | 31 | 25.8 |
| Matriculation or below | 76 | 63.3 | |
| Above matriculation | 13 | 10.8 | |
| Occupation | Heavy physical work | 97 | 80.8 |
| Light physical work | 19 | 15.8 | |
| Unemployed | 4 | 3.3 | |
| Mode of injury | RTA | 47 | 39.2 |
| Fall from height | 54 | 45 | |
| Others* | 19 | 15.8 |
RTA=road traffic accident. *Include slip and fall (n=11), assault (n=1), heavy object fell over head (n=3), hit by a bull (n=2), fall from a moving train (n=1), diving in water (n=1)
Figure 1.
Age distribution (in years)
Figure 2.
Sex distribution
Education and occupation
On analyzing the educational level of the patients, it was found that 25.8% were uneducated, 63.3% of them had completed at least matriculation, and only 10.8% were educated above matriculation [Table 1; Figure 3]. Nearly 81% of the study participants were farmers, daily wage workers, carpenters, drivers, fishermen, or masons and were grouped under heavy physical activity. Around 15.8% of participants were involved in light physical work as their occupation included teachers, shopkeepers, peons, businessmen, and a security guard. About 3.3% of the patients were unemployed [Table 1; Figure 4].
Figure 3.
Educational level
Figure 4.
Type of occupation
Mode of injury
About 45% of the cases with cervical spine injury were because of falls from height, 39.2% were because of RTAs, and 15.8% of cases were because of other reasons, such as slip and fall (n = 11), fall of a heavy object overhead (n = 4), assault (n = 1), hit by a bull (n = 2), fall from a moving train (n = 1), and diving into water (n = 1) [Table 1; Figure 5].
Figure 5.
Mode of cervical spine injury
Clinico-radiological characteristics
Of the 120 patients with a cervical spine injury, 55% had a complete cord injury, 37% had an incomplete cord injury, and 7.5% had no neurological deficits on presentation. About 8.3% of the study group had an associated injury such as head injury, long bone fracture, and chest injury [Table 2].
Table 2.
Distribution of clinico-radiological characteristics
| Variables | Category | Frequency | Percentage |
|---|---|---|---|
| Type of injury (cord injury) | Complete | 45 | 37.5 |
| Incomplete | 66 | 55 | |
| No deficits | 9 | 7.5 | |
| Associated injuries | Present | 10 | 8.3 |
| Absent | 110 | 91.7 | |
| CT findings* (Groups) | 1 | 42 | 35 |
| 2 | 14 | 11.7 | |
| 3 | 32 | 26.7 | |
| 4 | 32 | 26.7 | |
| Locked facets present | Yes | 39 | 32.5 |
| No | 81 | 67.5 | |
| Locked facets type | Unilateral | 18 | 46.2 |
| Bilateral | 21 | 53.8 | |
| MRI findings (56) | Disco-ligamentous injury | 38 | 67.9 |
| Cord contusion | 43 | 76.8 |
CT - Computerized tomography, MRI - Magnetic resonance imaging, OPLL - Ossified posterior longitudinal ligament, NAD - No abnormality detected. *Type of fracture subluxation in CT findings (Groups): Fracture (1), Subluxation (2), Fracture + Subluxation (3), Spondylotic spine + OPLL + NAD (4)
Based on the CT findings, patients were categorized into four groups. Patients with exclusive cervical spine fracture (35%) were included in group 1. Patients (11.7%) with mere subluxation but with no associated fractures were included in group 2. Patients (26.7%) with subluxation and fracture of spinal column elements were included in group 3. Around 26.7% of patients were included in group 4 who did not have a fracture or subluxation, but their spine showed spondylotic changes, ossified posterior longitudinal ligament, or no positive findings in CT spine [Table 2].
During the radiological evaluation of spiral CT of the spine, 46 patients had spine subluxation, and among them, 39 patients had locked facets. Among these 39 patients, 18 patients had unilateral and 21 patients had bilateral locked facets [Table 2].
MRI spine of 56 patients revealed that 43 of them had cord contusion and 38 had a disco-ligamentous injury [Table 2].
Neurological outcome after 2 weeks
After the stipulated follow-up period of 2 weeks, there was no change in the neurological status of 66.7% of the patients. Nearly 29% of patients showed an improvement in the form of improved motor power, whereas there was a worsening of the neurological status in 4.2% of patients [Table 3 and Figure 6].
Table 3.
Association of outcomes with socio-demographic characteristics
| Socio-demographic characteristics | Outcome | Significance* | ||
|---|---|---|---|---|
|
| ||||
| No change (%) | Improved (%) | Worsened (%) | ||
| Age | ||||
| 18-44 | 39 (70.9) | 16 (29.1) | 0 (0) | 0.280 (P>0.05) |
| 45–65 | 36 (63.2) | 17 (29.8) | 4 (7) | |
| >65 | 5 (62.5) | 2 (25) | 1 (12.5) | |
| Gender | ||||
| Male | 77 (70) | 28 (25.5) | 5 (4.5) | 0.012 (P<0.05) |
| Female | 3 (30) | 7 (70) | 0 (0) | |
| Education | ||||
| Uneducated | 22 (71 | 7 (22.6) | 2 (6.5) | 0.788 (P>0.05) |
| Matriculation or below | 49 (64.5) | 24 (31.6) | 3 (3.9) | |
| Above matriculation | 9 (69.2) | 4 (30.8) | 0 (0) | |
| Occupation | ||||
| Heavy physical work | 65 (67) | 27 (27.8) | 5 (5.2) | 0.356 (P>0.05) |
| Light physical work | 11 (57.9) | 8 (42.1) | 0 (0) | |
| Unemployed | 4 (100) | 0 (0) | 0 (0) | |
| Mode of injury | ||||
| RTA | 31 (66) | 16 (34) | 0 (0) | 0.216 (P>0.05) |
| Fall from height | 35 (64.8) | 16 (29.6) | 3 (5.6) | |
| Others# | 14 (73.7) | 3 (15.8) | 2 (10.5) | |
RTA=road traffic accident. *Chi-square test P<0.05. #Include slip and fall (11 Nos.), assault (1), heavy object fell over head (3), hit by a bull (2), fall from a moving train (1), and diving in water (1)
Figure 6.
Neurological outcomes after 2 weeks
Association of neurological outcomes with socio-demographic characteristics
The maximum proportion of the patients who improved after 2 weeks was present in the age group 45–65; there was no statistically significant association between the age and the outcome after 2 weeks. Similarly, the level of education, type of occupation, and mode of injury did not reveal any significant association with the neurological outcome after 2 weeks. However, compared to the male (25.5%) patients, female (70%) patients showed statistically significant neurological improvement after 2 weeks [Table 3].
Association of neurological outcomes with clinico-radiological characteristics
Patients with incomplete cord injury showed a statistically significant improvement in neurological outcome at 2 weeks compared to patients with complete cord injury.
There was no significant association between the neurological outcome at 2 weeks and presence or absence of associated injury, type of CT finding, presence of cord contusion, or disco-ligamentous injury on MRI study of the cervical spine.
The presence or absence of locked facets on CT did not reveal a significant association with neurological outcomes. However, patients with unilateral locked facets showed significant neurological improvement compared to those with bilateral locked facets [Table 4].
Table 4.
Association of outcomes with clinico-radiological characteristics
| Clinico-radiological characteristics | Outcome | Significance* | ||
|---|---|---|---|---|
|
| ||||
| No change (%) | Improved (%) | Worsened (%) | ||
| Type of injury | ||||
| Complete | 40 (88.9) | 4 (8.9) | 1 (2.2) | 0.000 (P<0.05) |
| Incomplete | 31 (47) | 31 (47) | 4 (6.1) | |
| No deficits | 9 (100) | 0 (0) | 0 (0) | |
| Associated injuries | ||||
| Present | 7 (70) | 3 (30) | 0 (0) | 0.788 (P>0.05) |
| Absent | 73 (66.4) | 32 (29.1) | 5 (4.5) | |
| CT findings# (Groups) | ||||
| 1 | 25 (59.5) | 16 (38.1) | 1 (2.4) | 0.707 (P>0.05) |
| 2 | 10 (71.4) | 3 (21.4) | 1 (7.1) | |
| 3 | 24 (75) | 7 (21.9) | 1 (3.1) | |
| 4 | 21 (65.6) | 9 (28.1) | 2 (6.2) | |
| Locked facets present | ||||
| Yes | 29 (74.4) | 8 (20.5) | 2 (5.1) | 0.346 (P>0.05) |
| No | 51 (63) | 27 (33.3) | 3 (3.7) | |
| Bilateral locked facets | ||||
| Yes | 19 (90.5) | 1 (4.8) | 1 (4.8) | 0.028 (P<0.05) |
| No | 10 (55.6) | 7 (38.9) | 1 (5.6) | |
| Disco-ligamentous injury | ||||
| Yes | 17 (44.7) | 18 (47.4) | 3 (7.9) | 0.151 (P>0.05) |
| No | 13 (72.2) | 4 (22.2) | 1 (5.6) | |
| Cord contusion | ||||
| Yes | 23 (53.5) | 18 (30.8) | 2 (4.7) | 0.382 (P>0.05) |
| No | 7 (53.8) | 4 (30.8) | 2 (15.4) | |
CT - Computerized tomography, OPLL - Ossified posterior longitudinal ligament, NAD - No abnormality detected. *Chi-square test P<0.05. #CT findings (Groups): Fracture (1), Subluxation (2), Fracture + Subluxation (3), Spondylotic spine + OPLL + NAD (4)
Comparison of neurological outcome to vital parameters
Vital parameters such as the pulse, systolic blood pressure, and respiratory rate did not show any significant association with the neurological outcome following the 2 weeks of follow-up period [Table 5].
Table 5.
Comparison of vital parameters to the outcome
| Variables | Outcome | Significance* | ||
|---|---|---|---|---|
|
| ||||
| No change [Median (Range)] | Improved [Median (Range)] | Worsened [Median (Range)] | ||
| Pulse rate per minute | 83 (60-120) | 84 (60-114) | 87 (70-100) | 0.533 (P>0.05) |
| Systolic BP (mmHg) | 110 (0-160) | 110 (90-140) | 110 (90-130) | 0.623 (P>0.05) |
| Respiratory rate per minute | 16 (12-35) | 16 (12-22) | 16 (14-18) | 0.923 (P>0.05) |
*Mann-Whitney test P<0.05
Discussion
There are very few studies from India that have studied the socio-demographic and clinico-radiological profiles of cervical spine injury patients and their association with short-term neurological outcomes. As a whole, there is very sparse data on cervical spine injuries from India.
Gender and neurological outcomes in cervical spine injury
A total of 120 patients were included in the analysis, of which 91.7% were male and only 8.3% were female. The proportion of male patients is slightly higher in this study compared to studies by Pandey et al., Lalwani et al., and Obalum et al.[7,8,9] We found that gender was significantly associated with the type of outcome, with male patients having a less chance of improvement after 2 weeks compared to female patients; this may be attributed to the increased possibility of high-velocity injury in males.
Age and neurological outcomes in cervical spine injury
The majority of the cervical spine injury patients were in the age group 44–65 years, followed by 18–44 years. This was in corroboration with reports of other studies from India and the world over.[2,5,9] Hence, it may be inferred that we need to concentrate on the working population to create awareness about cervical spine injury and its implications on an individual and society. Despite the absence of a significant association between age and the short-term neurological outcome, worsening of motor power was more evident with increasing age.
Educational status and neurological outcomes in cervical spine injury
We found out that the majority of the patients were educated less than matriculation (63.3%) or uneducated (25.8%) and were engaged in heavy physical work occupations (80.8%). However, there was no significant association between neurological outcomes and the level of education and type of occupation.
Mode of injury and neurological outcomes in cervical spine injury
Although RTAs are the leading cause of spinal cord injuries in developed countries, falls from height are still the leading cause of cervical spine injury in developing countries such as India.[2,5,6,10,11,12,13,14,15,16,17] This was evident in this study where 45% of the study participants developed cervical spine injury because of falls from height at their workplace. RTA was found to be the second most common cause of spinal cord injury in our patients.
Type of spinal cord injury and neurological outcomes in cervical spine injury
This study showed that 37.5% of patients had a complete injury, 55% of the patients had incomplete cord injury, and 7.5% did not have any deficits. This is in close proximity to the results of the study by Sekhon et al.[18] Patients with incomplete cord injury showed a statistically significant improvement in neurological outcome at 2 weeks compared to patients with complete cord injury.
Associated injuries and neurological outcomes in cervical spine injury
Nearly 8.3% of the patients included in our study had an associated injury that included a head injury, long bone fractures, chest injury, or an axial skeletal fracture. This is less in comparison to the results of a study by Sekhon et al.[18] that reports an incidence of 20–57% associated injuries in patients with spinal cord injury. This might be because of our exclusion criteria of not involving patients with severe head injuries and patients who were in a hemodynamically compromised state. Similarly, there was no significant association between short-term neurological outcome and type of fracture or subluxation.
Radiological findings and neurological outcomes in cervical spine injury
Although 38.9% of the patients with unilateral locked facets improved after 2 weeks, only 4.8% of patients with bilateral locked facets showed neurological improvement. This may be attributed to the force involved in bilateral facetal subluxation that may be more severe to cause more structural injury to the spinal cord than that involved in unilateral locked facet.
In a single-center prospective study published in 2017, Srinivas et al.[19] inferred that incomplete cervical cord injury and those having only edema on MR imaging had a better outcome compared to complete cord injuries and those who showed cord contusion on MRI. In our study, MRI findings were separated into the presence or absence of disco-ligamentous and the presence or absence of cord contusion. The neurological outcome was not significantly associated with these two findings.
This study was an attempt to add data to the national database of traumatic spinal cord injuries. This study is the first of its kind in India to find out the association between the socio-demographic factors, clinico-radiological factors, and short-term (2 weeks) neurological outcomes in patients with a cervical spine injury. This study of ours might prove to be a way for more such studies that can be conducted at different centers for forming a consensus regarding the prognostication of cervical spine injuries.
Limitations
The absence of statistical significance in the above-mentioned variables may be because of the small sample size. Future studies with a large sample size are warranted in this area.
Conclusion
Cervical spine injuries are devastating to the family and the nation’s workforce. In this study, it is observed that the males are more injured than females. Most of the people who sustain cervical spine injuries are involved in heavy physical work. Female gender, incomplete cord injury, and unilateral locked facet in subluxation are associated with good neurological outcomes compared to the male gender, complete cord injury, and bilateral locked facets in subluxation. Although not statistically significant, young age and light physical work are associated with improved neurological outcomes, whereas heavy physical work, disco-ligamentous injury, and cord contusion are associated with poor neurological outcomes.
Trauma care centers that treat patients with cervical spine injuries lack proper databases even at the tertiary care level in India. This study might be a pilot project for more such studies in the field of neuro spinal trauma. This will also help trauma care centers to realize the burden of spinal trauma in the Indian scenario and help us to build a database at the regional and national levels. Having a national database for cervical spine injury might prove to be the first step toward formulating a national policy for the prevention, proper management, and rehabilitation of patients with a cervical spine injury.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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