Abstract
Purpose
Spine injury is one of the leading causes of death and mortality worldwide. The objective of this study was to determine the incidence, pattern and outcome of trauma patients with spine injury referred to the largest trauma center in southern Iran during the last 3 years.
Methods
This is a cross-sectional study conducted between March 2018 and June 2021 in the largest trauma center in the southern Iran. The data collection form included the age, sex, injury location (cervical, thoracic, and lumbar), cause of injury (traffic accidents, falls, and assaults), length of hospital stay, injured segment of spine injury, severity of injury, and outcome. Statistical analyzes were performed using SPSS software version 24.
Results
Totally 776 cases of spine injury were identified. The spine injury rate was 17.0%, and the mortality rate was 15.5%. Cervical spine injury (20.4%) more often occulted in motorcycle accident, and thoracic spine injury (20.1%) occulted in falls. The highest and lowest rates of spine injurys were related to lumbar spine injury (30.2%) and cervical spine injury (21.5%), respectively. There was a statistically significant relationship between the mechanism of injury and the location of spine injury (p < 0.001). And patients with lumbar spine injury had the highest mortality rate (16.7%). Injury severity score (OR= 1.041, p < 0.001) and length of stay (OR = 1.018, p < 0.001) were strong predictors of mortality in trauma patients with spine injury.
Conclusion
The results of the study showed that the incidence of traumatic spine injury rate was approximately 17.0% in southern of Iran. Road traffic injury and falls are the common mechanism of injury to spine. It is important to improve the safety of roads, and passengers, as well as work environment, and improve the quality of cars. Also, paying attention to the pattern of spine injury may assist to prevent the missing diagnosis of spine injury in multiple trauma patients.
Keywords: Trauma, Spinal cord, Injury, Incidence, Pattern
Introduction
Spine injury is one of the most common causes referral to trauma care centers, which may lead to permanent disability, dysfunction, and complete paralysis of the patients.1,2 Spine injury is the leading cause of mortality and disability worldwide.3 For example, about 14,000 Americans suffer spine injuries each year and 4 billion dollars are spent on caring and compensating for spine injuries.4
The incidence of spine injury varies around the world, and the rate of spine injury is higher in low- and middle-income countries (LMICs) than that in high-income countries.3 The incidence of spine injury is 39 per million people in developed countries. It was 16 cases per million in Australia and 15 cases per million in eastern Europe.5,6 The prevalence of spine injury in Iran is estimated at 318.45 per million.7 Also, the incidence of spine injury in Tehran was 10 per million.8 On the other hand, the severe disability extremely reduces their quality of life. For example, the disability adjusted life years due to spine injury is 3772 years in Tehran.9 And for the severely injured people with complete spine injury above the cervical C3, the survival rate was 35%.10 The results of similar studies have shown that, in Iran, the frequency of damage to the lumbar spine is higher than other areas of the spine.11 Men were more likely to suffer from spine injuries than women. Workers, farmers and unemployed have been risk factors for spine injuries.12 Most of spine injuries occults in young people, and road traffic injuries have been the most common mechanism of spine injuries.11 Complications following spine injury include brady arrhythmias and low blood pressure, unstable temperature, pain, and autonomic dysreflexia.13
Awareness of the incidence, severity, site, and pattern is essential in the management of trauma patients with spine injury, especially patients with impaired consciousness. It is also necessary to compare risk factors between patients with or without spine injury. Meanwhile, trauma is the main cause of mortality and disability among young population in Iran.14 Fars province, the 4th most populous province of Iran, located in the southern of the country, has the most road traffic injuries among the southern provinces,15 and ranks the first in the country in terms of the number of people death caused by road traffic injury.16 The city of Shiraz, as the center of Fars province, has the largest trauma center in the south of Iran, and most of the trauma patients in the south are transferred to this center.14, 15, 16 Nevertheless, there is insufficient local information about spine injury in the last 3 years referred to the largest trauma center in southern Iran. Therefore, the objective of this study was to discuss the incidence, pattern and outcome of spine injury patients referred to the largest trauma center in southern Iran.
Methods
This is a cross-sectional study that analyzes the pattern and risk factors for mortality in patients with spine injury. The study population included all trauma victims who had referred to the largest trauma center in southern Iran, (Shiraz, Iran) between March 2018 and June 2021. The injured patients under the age of 15 years were excluded from the study.
Data were extracted from patients' records using a case report form, which includes the age, sex, location of spine injury (cervical, thoracic, lumbar), mechanism of injury (motorcycle rider, pedestrian, car driver, car passenger, falls, motorcycle passenger, assault, intentional self-harm, and gunshot), length of hospitalization, injured segment of spine, severity, and outcome. Injury severity score (ISS) was calculated according to the researchers' previous article.17 Spine injuries were diagnosed by a trained specialist based on CT scan findings. The first values of systolic blood pressure, diastolic blood pressure, pulse rate, respiratory rate, and Glasgow coma scale (GCS) were collected by the trained specialist when the patient was admitted to the hospital.
Number with percentage is presented in categorical variables and mean with standard deviation is presented in continuous variables. Chi-square and quantitative independent t-test data were used to analyze the qualitative data. Logistic regression was used to determine the risk factors for death in injured people with spine injuries. Analyzes were performed using SPSS software.
Results
There were total 776 cases of spine injury for analysis. The incidence of spine injury in trauma patients referred to the largest trauma center in southern Iran is 17%. The mortality rate in patients with different segments of spine injury ranged from 14.8% to 16.7%, and patients with lumbar spine injury had the highest mortality rate (16.7%). Most people with spine injury were men (78.7%). The ISS score was significantly higher in casualties with spine injury than in non-injured casualties (p < 0.001).
Most drivers suffered spinal injuries (20.6%). Systolic blood pressure in patients with spine injury was significantly lower than that in patients without spine injury (p < 0.001) and pulse rate in patients with spine injury was significantly higher than that in patients without spine injury (p < 0.001). Most people with spine injury (65.5%) had GCS between 13 and 15. The median length of hospital stay was significantly longer in patients with spine injury than in those without spine injury (12 days vs. 6 days) (p < 0.001). And 15.5% of patients with spine injury died (Table 1).
Table 1.
Descriptive traumatic patients with and without spine injury data set over the 3 years.
| Variables | Without spine injury (n = 3801) | With spine injury (n = 776) | Total (n = 4577) | p value |
|---|---|---|---|---|
| Sex, n (%) | <0.0001 | |||
| Male | 3236 (85.1) | 611 (78.7) | 3847 (84.1) | |
| Female | 565 (14.9) | 165 (21.3) | 730 (15.9) | |
| Age (year), mean (SD) | 37.1 (18.5) | 38 (17.6) | 37.1 (18.3) | 0.200 |
| ISS, mean (SD) | 18.01(17.32) | 21.49 (10.29) | 18.60 (16.39) | <0.001 |
| ISS, median (IQR) | 14 (19) | 21 (15) | 14 (16) | <0.001 |
| Cause of injury, n (%) | <0.001 | |||
| Motorcycle rider | 681 (17.9) | 122 (15.7) | 803 (17.5) | |
| Pedestrian | 561 (14.8) | 125 (16.1) | 686 (15) | |
| Car driver | 450 (11.8) | 160 (20.6) | 610 (13.3) | |
| Car passenger | 361 (9.5) | 137 (17.7) | 498 (10.9) | |
| Falls | 566 (14.9) | 156 (20.1) | 722 (15.8) | |
| Assault | 663 (17.4) | 15 (1.9) | 678 (14.8) | |
| Motorcycle passenger | 132 (3.5) | 23 (3) | 155 (3.4) | |
| Gunshot | 93 (2.4) | 5 (0.6) | 98 (2.1) | |
| Intentional self-harm | 98 (2.6) | 6 (0.8) | 104 (2.3) | |
| Other | 196 (5.2) | 27 (3.5) | 223 (4.9) | |
| Vital signs (on arrival), mean (SD) | ||||
| SBP | 124.8 (23.6) | 121.7 (23.7) | 124.5 (23.4) | 0.001 |
| DBP | 78.3 (15.7) | 77.2 (16.5) | 78.1 (15.9) | 0.095 |
| PR | 97.9 (22.7) | 102.4 (23.9) | 98.7 (22.5) | <0.001 |
| RR | 32.3 (32.5) | 30.3 (30.1) | 29.4 (27.4) | 0.856 |
| GCS, n (%) | 0.411 | |||
| 3 – 8 | 793 (22.3) | 181 (24.3) | 974 (22.6) | |
| 9 – 12 | 400 (11.2) | 76 (10.2) | 476 (11.1) | |
| 13 – 15 | 2365 (66.5) | 488 (65.5) | 2853 (66.3) | |
| Length of stay (day), median (IQR) | 6 (10) | 12 (16) | 7 (12) | <0.001 |
| In hospital mortality, n (%) | <0.001 | |||
| Survival | 3150 (82.9) | 656 (84.5) | 3806 (83.2) | |
| Dead | 651 (17.1) | 120 (15.5) | 771 (16.8) | |
SD: standard deviation; ISS: injury severity score; IQR: inter-quartile range; SBP: systolic blood pressure; DBP: diastolic blood pressure; PR: pulse rate; RR: respiratory rate; GCS: Glasgow coma scale.
Level of significance was p < 0.05.
The results showed that the highest spine injuries were related to lumbar spine injury (30.2%), thoracic spine injury (24.7%), multilevel spine injury (23.6%), and cervical spine injury (21.5%), respectively. There was no statistically significant relationship between the location of spine injury with gender, age, ISS, GCS, length of stay, and mortality. There was only a statistically significant relationship between the mechanism of injury and the location of spine injury (p < 0.001) (Table 2). Only 2 factors, ISS (OR = 1.041, p < 0.001) and length of stay (OR = 1.018, p < 0.001) were predictors of mortality in patients with spine injury by logistic regression (Table 3).
Table 2.
Frequency of spinal injured region according demographic, severity of injury, cuase of injury, and patient outcome.
| Variables | Cervical spine (n = 167) | Thoracic spine (n = 192) | Lumbar spine (n = 234) | Multiple level (n = 183) | Total (n = 776) | p value |
|---|---|---|---|---|---|---|
| Sex | 0.194 | |||||
| Male | 137 (82.0) | 158 (82.3) | 177 (75.6) | 139 (76.0) | 611 (78.7) | |
| Female | 30 (18.0) | 34 (17.7) | 57 (24.4) | 44 (24.0) | 165 (21.3) | |
| Age (year), mean (SD) | 39.9 (18.6) | 35.4 (17.7) | 39.2 (17.9) | 37.3 (15.7) | 38 (17.6) | 0.055 |
| ISS, median (IQR) | 21 (10.5) | 19.4 (10.1) | 22.3 (10.7) | 23.2 (9.4) | 21.5 (10.3) | 0.002 |
| Cause of injury, n (%) | 0.001 | |||||
| Motorcycle rider | 34 (20.4) | 34 (17.7) | 28 (12.0) | 26 (14.2) | 122 (15.7) | |
| Pedestrian | 23 (13.8) | 26 (13.5) | 55 (23.5) | 21 (11.5) | 125 (16.1) | |
| Car driver | 46 (27.5) | 38 (19.8) | 42 (17.9) | 34 (18.6) | 160 (20.6) | |
| Car occupant | 33 (19.7) | 33 (19.8) | 30 (12.8) | 41 (22.4) | 137 (17.7) | |
| Falls | 19 (11.4) | 41 (21.4) | 56 (23.9) | 40 (21.8) | 156 (20.1) | |
| Assault | 3 (1.8) | 7 (3.7) | 5 (2.1) | 0 (0) | 15 (1.9) | |
| Motorcycle occupant | 4 (2.4) | 5 (2.6) | 4 (1.7) | 10 (5.5) | 23 (3.0) | |
| Gunshot | 1 (0.6) | 2 (1.0) | 2 (0.9) | 0 (0) | 5 (0.6) | |
| Intentional self-harm | 1 (0.6) | 0 (0) | 3 (1.3) | 2 (1.1) | 6 (0.8) | |
| Other | 3 (1.8) | 6 (3.1) | 9 (3.9) | 9 (4.9) | 27 (3.5) | |
| On Arrival GCS, n (%) | 0.070 | |||||
| 3 – 8 | 42 (26.8) | 46 (25.4) | 44 (19.1) | 49 (27.9) | 181 (24.3) | |
| 9 – 12 | 22 (14.0) | 11 (6.1) | 25 (10.8) | 18 (10.2) | 76 (10.2) | |
| 13 – 15 | 93 (59.2) | 124 (68.5) | 162 (70.1) | 109 (61.9) | 488 (65.5) | |
| Length of stay (day), n (%) | 18.5 (17.2) | 15 (15.7) | 15.9 (15.4) | 18.6 (15.3) | 16.9 (15.9) | 0.067 |
| In-hospital mortality, n (%) | 0.994 | |||||
| Survival | 142 (85.0) | 163 (84.9) | 195 (83.3) | 156 (85.2) | 656 (84.5) | |
| Dead | 25 (15.0) | 29 (15.1) | 39 (16.7) | 27 (14.8) | 120 (15.5) |
SD: standard deviation; ISS: injury severity score; IQR: inter-quartile range; GCS: Glasgow coma scale.
Level of significance was p < 0.05.
Table 3.
Logistic regression coefficients and odds ratios for predictors of mortality among spinal injured patients
| Parameters | Ba | OR | 95% CI | p value |
|---|---|---|---|---|
| Age | - 0.006 | 0.994 | 0.989 - 0.999 | 0.015 |
| Mechanism of Injury | < 0.001 | |||
| Motorcycle rider | - 0.512 | 0.600 | 0.234 - 1.538 | 0.287 |
| Pedestrian | - 0.196 | 0.822 | 0.319 - 2.118 | 0.684 |
| Car driver | 0.308 | 1.360 | 0.532 - 3.479 | 0.521 |
| Car occupant | 0.295 | 1.343 | 0.523 - 3.453 | 0.540 |
| Falls | 0.222 | 1.249 | 0.488 - 3.197 | 0.644 |
| Assault | - 2.211 | 0.110 | 0.038 - 0.314 | < 0.001 |
| Other mechanism | - 0.469 | 0.626 | 0.227 - 1.726 | 0.365 |
| Motorcycle occupant | - 0.637 | 0.529 | 0.187 - 1.499 | 0.231 |
| Gunshot | - 1.574 | 0.207 | 0.057 - 0.758 | 0.017 |
| Intentional self-harm | - 19.586 | < 0.001 | < 0.001 | 0.997 |
| ISS | 0.040 | 1.041 | 1.033 - 1.050 | < 0.001 |
| Length of stay | 0.018 | 1.018 | 1.012 - 1.024 | < 0.001 |
| GCS | < 0.001 | |||
| 3 - 8 | - 0.714 | 0.490 | 0.388 - 0.618 | < 0.001 |
| 9 - 12 | - 0.554 | 0.575 | 0.433 - 0.762 | < 0.001 |
| 13 - 15 | – | – | – | < 0.001 |
| Constant | - 1.775 | 0.169 | < 0.001 |
OR: Odds ratio; CI: confidence interval; ISS: injury severity score; GCS: Glasgow coma scale.
Level of significance was p < 0.05.
This is the coefficient for the constant.
Discussion
The main findings of the study showed that the incidence of spine injury in patients referred to the largest trauma center in southern Iran was 17.0%. The mortality rate of spine injuries was 15.5%. Most trauma patients referred to the largest trauma center in southern Iran had damaged lumbar and thoracic vertebrae. The incidence of spine injuries varies around the world. The incidence rate in developed countries is from 13.12 to 163.42 per million people, which is from 13.02 to 220.02 per million people in underdeveloped countries.18 In a review and meta-analysis of Kumar et al.3, the overall global incidence of traumatic spine injury was 10.5 per 100,000 (7.8/100,000 in LMICs and 13.7/100,000 in high-income countries). In previous study of Germany, 30% of patients had spine injury.19 Such a wide range may be related to the extent of development and income status of countries or sampling methods of studies.
The majority of spine injury victims were men (78.7%), which is consistent with other studies.10,19, 20, 21 Men, being the main custodian of family finances and income, often employ outdoors in dangerous jobs, and therefore, men are in the high risk of injury than women. Thus, we can say that men more likely to suffer from spine injuries.3,18 On the other hand, although the mean age of trauma patients with spine injury in Brazil, the United States, Germany, Japan, and Italy varied between 44 and 60 years10,20, 21, 22, 23 and estimated to be 40 years in the world,3 in the present study the mean age of spine injury victims was 38 years. Therefore, since traumatic injuries are 1 of the main causes of disability, especially among young people, which has a great impact on the years of life with disability,24 it is necessary to pay attention to preventive measures focusing on young men.
In this study, the most common causes and mechanisms related to spine injuries were road traffic accident (20.6%) followed by falls (20.1%). This result is completely consistent with the other global and national studies. In 2016, road traffic accidents (39.5%) and falls (38.8%) were the main causes of traumatic spine injury in the world.3 And in 2017, motor vehicle accidents and falls were the most common causes of spine injury worldwide.18 Other researchers in their studies in different countries showed that traffic accidents10,20, falls and road injuries25, falls and collisions of motor vehicles26, falls (57.1%) and transport accidents (19.9%)27, car accident (44.0%),21 motor vehicle accident (29.3%), and fall (23.7%)22,23 were cited as the most common cause of spine cord trauma. Car accidents and falls were major causes of traumatic spinal injuries, given the preventable nature, health planners and managers should review traumatic injury trends and identify at-risk groups to implement targeted prevention policies.20 Despite the low number of motor vehicles per capital, a significant proportion of road accident injuries in LMICs may be due to poor road infrastructure and traffic signs, as well as inadequate safety regulations and poor law in these countries.3 In addition, it should be considered to reduce the accidents caused by drunk driving, drug driving, or without wearing a seat belt, which still exist in many countries.18 Elderly people are more likely to fall to the ground, while younger people are more likely to fall from buildings and work accidents.28 There seems to be a need to increase attention to the “Health in All Policies”, including to improve the safely of road, workplace safety and vehicle quality.
In this study, the highest spine injuries were related to lumbar spine injury (30.2%), thoracic spine injury (24.7%), multilevel spine injury (23.6%), and cervical spine injury (21.5%), respectively. And the same as the study of Häske et al.19, lumbar spine injury (43.4%), thoracic spine injury (40.1%), and cervical spine injury (25.4%) were the most common injuries among patients with spine injury, respectively. However, in a number of studies, cervical spine injuries accounted for a higher percentage of injuries.20,21 The elderly population strongly influences the epidemiology of cervical spine injury in high- and middle-income countries. But in LMICs, the epidemiology of cervical spine injury has been affected by trauma, as well as lacking of medical resources, general poverty, and poor patient care.29 The location of the injury is variable depending on the cause of the injury, gender, degree of injury and even race. Understanding these factors can help in early detection of injuries, prevention of complications, rapid mobilization of facilities, and improvement of rehabilitation outcomes.18 The ratio of spine injury varies greatly among countries due to different income levels, with a higher proportion of spine injury in LMICs compared to high-income countries. This large difference in ratio could be hardly explained by differences in mechanisms and causes of injury, as road accidents and falls were the most common injury mechanisms in all income classes. However, the severity of injuries caused by these mechanisms may be higher in LMICs due to poor safety standards and regulations, and thus it leads to a higher proportion of spine injuries.3 Therefore, the incidence of spine injuries in different segments like lumbar, cervical, and thoracic has been different in different studies, of which this difference may be partly explained by different patterns of the cause of the injury. It seems that various public health measures aim to improve safer driving conditions which can play a significant role to decrease spine injuries.
In recent decades, traumatic injuries have been 1 of the leading causes of death (accounting for 10% of all deaths) and disability worldwide.10 Spine injury also caused 9.5 million per year of living with a disability in 2016.25 Mortality of spine injuries ranged from 3.1% to 22.2% in developed countries and from 1.4% to 20.0% in underdeveloped countries.18 In this study, the mortality rate of spine injury victims was 15.5%, and patients with lumbar spine injury had the highest mortality rate (16.7%). In a study of Higashi et al.22, the spine injury mortality rate was 19% in Japan. The variability of mortality rates among countries can be explained in part by differences in the mechanism of injury, demographic characteristics of patients, cultural and lifestyle differences, and the progress of prehospital and inpatient treatments. Elderly patients with traumatic spine injuries are less likely to develop complications and have less potential for rehabilitation than young patients.3,18,30 Therefore, identifying high-risk groups is important to strengthen the nurse and treatment and improve the management of patients' general condition to reduce their mortality.
ISS among patient with traumatic spine injury is higher than patient without spine injury, which is consists with previous studies.31, 32, 33 In this study, ISS (OR = 1.041, p < 0.001) and length of stay (OR = 1.018, p < 0.001) were predictors of mortality in trauma patients with spine injury. In a study conducted by Zhang et al.,27 the International Classification of Diseases-based Injury Severity score less than 0.85 was one of the predictors of nosocomial death in trauma patients. Findings from previous studies showed that age20,22,27,34, gender27,34, head and neck injuries20,27, income and education34,35, health status and underlying diseases18,35, tracheostomy and American Spinal Injury Association impairment scale 22, chronic and non-chronic pressure ulcers36, and infectious and respiratory diseases36 were the predictors of mortality in patients with traumatic spine injuries. Thus, since social economy and public health were widely associated with the causes of trauma-related deaths, intervention strategies may reduce the mortality rate. Assessing mortality predictor variables also improve our ability to identify people at risk of mortality.36,37
This was a 3-year study involving a large number of patients in the largest trauma center in southern Iran. Lacking assessment of pre-hospital information of trauma patients with spine injuries at the time of the accident was 1 of the most important limitations of this study. All data in the study have been collected retrospectively from medical records for last 3 years, but quality of life and disability is not documented routinely in medical record. Thus, only the mortality is investigated related to the outcome of spine injury, while disabilities and quality of life of patients with spine injury were not discussed. There are some previous study in this center showed that quality of life in severe trauma patients is low.38 Therefore, further study of evaluating disabilities, quality of life and burden of patient with spine injury are needed. This study was conducted in single trauma center was another limitation, and further study needs to investigated traumatic spine injury in national and international scale. In addition, for accurate prediction, it is recommended to use data mining algorithms to predict the outcomes of patients with spine injury.39,40
The results of the study showed that the incidence of traumatic spine injury in last 3 years was about 17.0% in southern Iran. Road traffic injury and falls are common causes of spinal injuries, and thus it is important to improve the safety of roads, work environment, and quality of cars. Public health policies should be focused on preventive measures in the young and male population with spine injuries, and appropriate pre- and in-hospital treatment measures in order to reduce spine injury mortality. The associated injury with spine injury was also evaluated in this study. Therefore, paying attention to the spine injury pattern may help assist to prevent the missing diagnosis of spine injury in multiple trauma patients.
Funding
This project was supported by the Shiraz University of Medical Sciences (grant number: 25125). The funding source was not involved in the study design, data collection and analysis, writing a report, and in the decision to submit the paper to this journal.
Ethical statement
This study was approved by Shiraz University of Medical Sciences (approval ID: IR.SUMS.REC.1400.833) in accordance with the guidelines of the National Ethics Committee and COPE regulations.
Declaration of competing interest
The authors declare that there is no confict of interest.
Author contributions
Mahnaz Yadollahi: conceptual and design study, data acquisition, data analysis, drafted and revision paper. Mehrdad Karajizadeh: contributed to conceiving and design of the study, interpretation of data, commented on drafts, and made significant revisions to the paper. Najmeh Bordbar: contributed to the design of the study, interpretation of data, commented on the draft, and made significant revisions to the paper. Zahra Ghahramani: contributed to the design of the study, statistical analysis, commented on drafts, and made significant revisions to the paper.
Acknowledgements
The authors want to thank the Research Vice-Chancellor of Shiraz University of Medical Sciences for financially supporting the research (Grant No. 25125).
Footnotes
Peer review under responsibility of Chinese Medical Association.
References
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