Abstract
Background
Though spine trauma contributes to great functional, psychological, and economic loss, research regarding the demographic profile of patients according to different regions of our country are lacking.This study aims to identify the demographic pattern and clinical profile of patients with spinal fracture in the Sub-Himalayan region.
Method
Patients with acute or subacute spine trauma presenting within 8weeks and involving fracture of cervical, dorsal, or lumbar vertebra, from July 2017 to December 2019 were included prospectively. Patients with osteoporotic or metastatic collapse, isolated transverse or spinous process fracture, penetrating trauma or ballistic injuries were excluded.
Results
Out of 280 enrolled patients, 180 were males and 100 were females. The maximum number of spine trauma patients was in 16–30 years age group. The most common mechanism of injury was fall from height (FFH, 42.5%)> road traffic accident (RTA, 38.6%). RTA was more common among males and FFH among females (p < 0.0001). Most common location of injury was at thoracolumbar junction (D10-L2) (37.5%) followed by cervical spine (25.3%). 58.2% of patients had AO type A facture morphology followed by AO types C (36.1%) and AO type B (5.7%). Spinal Cord Injury (SCI) was seen in 82.1% spine trauma patients with statistically significant association with male gender (p- 0.045). Complete paralysis was seen maximum in patients with cervical spine injury (67.3%, p < 0.0001). Complete neurological deficit (ASIA grade A) was seen maximum in AO type C fracture morphology (74.25%, p < 0.001) followed by AO type A4 (29.6%). Seasonal distribution showed increased incidence during summer and monsoon season.
Conclusion
Young aged males in age group of 16–30 yrs were most commonly affected with fall from height as the most common mechanism of trauma. Association was found between gender and mechanism of injury (RTA in males and FFH in females). Most common vertebral injury level was thoracolumbar junction. AO type A was the most common fracture morphology. SCI seen in 82.1% of spine trauma. Statistically significant association was found between Complete SCI with Location of Injury (Cervical) and Fracture morphology (AO type C).
Keywords: Spine trauma, Epidemiology, Spinal cord injury, Sub-himalayan region
1. Introduction
Spinal Cord Injury (SCI) is associated with permanent disability and decreased life expectancy especially in low and middle-income countries.1,2 The etiology of spine trauma varies with country and the results of the epidemiological study from developed countries do not apply to developing countries.3,4 Worldwide, the incidence of spine trauma lies between 10.4 and 83 million inhabitants per year.4 The incidence rates of SCI in developed countries are reported to be 13.1 to 163.4 per million people while rates in non-developed countries varied from 13.0 to 220.0 per million people.5 Worldwide, the most common mechanism of spine trauma is Road traffic accidents but in India, fall from height is the most common mechanism of spine trauma.2,6
Epidemiological studies are of great importance in understanding the underlying etiology, social, cultural environmental factors, regional differences in the incidence and prevalence of a particular disease or trauma, and its resulting socioeconomic impact.7,8 Data describing the distribution and determinants of injury are vital for the development of strategies to mitigate its effects. Though spine trauma contributes to great functional, psychological, and economic loss, research done regarding its epidemiological data and change in the demographic profile of patients according to different regions of our country are lacking. The current study was undertaken to identify the demographic pattern and clinical profile of patients with spine fracture in the Sub-Himalayan region so that better prevention strategies can be formulated to decrease the socioeconomic burden due to SCI.
2. Materials and method
In this Prospective observational study, we included 280 patients who presented to tertiary care Centre from July 2017 to December 2019 with acute or subacute spine trauma presenting within 8weeks and involving fracture of cervical, dorsal or lumbar vertebra. Patients with osteoporotic collapse, metastatic collapse, isolated spinous process or transverse process fracture, and penetrating trauma or ballistic injuries were excluded. Approval by the ethics committee of our institution was obtained before conducting our study. All the patients underwent meticulous workup, which included a detailed history, physical examination, neurological assessment using ASIA Impairment scale/ISCoS International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI)9 and functional assessment using VAS, ODI and SCIM scale. Supine plain radiograph (AP & lateral view), computed tomography (NCCT), and magnetic resonance imaging (MRI) were done for all patients. Data that was recorded consisted of the demographic profile of patients (age, sex, occupation, and socioeconomic status), mechanism of injury, vertebral level of injury, vertebral fracture type, neurological status, seasonal distribution, and associated injuries.
Patients were categorized into age groups of 0–15, 16–30, 31–45, 46–60, 61 years and above. Vocational status of patients before trauma was classified as agriculture workers, labourers, private/government professional jobs, students, homemakers, unemployed, and other occupations. The injury mechanism was categorized into five groups. Fall from height (FFH) included fall from buildings, trees, or hills. Road traffic accident (RTA) victims included both subjects who were traveling in a vehicle and pedestrian hit by a vehicle. Spine trauma arising out of physical violence was classified as Assault. Sports injury included injury while playing football, basketball, performing gymnastics, or weightlifting. Miscellaneous causes like fall of weight on head or crush injuries were classified as Others. Associated injuries with spine trauma were divided into head, chest, extremity, and visceral injuries. Level of injury was categorized as Cervical (C0–C7), Thoracic (T1-T9), Thoracolumbar (T10-L2), and Lumbar Fractures (below L2). Fracture type was classified according to AO classification – AO type A (Vertebral body fracture), AO type B (Tension band injury), and type C (Displacement/Dislocation). Neurological status was graded by ASIA impairment Scale as ASIA grade A, B, C, D, and E.9 Severity of injury was classified on basis of completeness of lesion. In case of loss of both motor and sensory function in Sacral segments S4–S5, the injury was classified as complete. The injury was classified as incomplete when either of the sensations was present.
Statistical analysis - Descriptive statistics such as mean, standard deviations, percentages, graphs, and cross-tabulations were used to present study results. Chi-square test was used to estimate the significance of the association between categorical variables. P < 0.05 was considered statistically significant and all the tests were performed by SPSS 17.0.
3. Results
A total of 280 patients of spine trauma were enrolled for an epidemiology study. Out of 280 patients,64.3% were males (n = 180) and 35.7% were females (n = 100) with male: female ratio of 1.8:1.The mean age for males was 34.77 ± 16.8 years and that for females was 33.5 ± 15.04 years. Vocational status of patients before trauma included agriculture workers (35%), labourers (20%), private/government professional jobs (18%), students (10%), homemaker (5%) unemployed (3%) and rest 9% in other occupations. The maximum number of spine trauma patients (47.8%) were in-between age group 16–30 years followed by 31–45 yrs age group (20.35%) (Fig. 1). In our study, the most common mechanism of injury was fall from height (42.5%,n = 119), followed by road traffic accident (38.6%,n = 108) (Table 1). Road traffic accident was the most common mechanism of injury among males (86/180, 47.8%) while females sustained spine trauma mainly due to falling from height (64/100, 64%) and this association was statistically significant (p-value <0.0001). Most common vertebral level of injury was at thoracolumbar junction (D10-L2) (37.5%, n = 105) followed by cervical spine (C0–C7) (25.3%, n = 71) (Fig. 2). Among all these spine trauma patients, 105/280 (37.5%) sustained associated injuries in which head trauma was the most common associated injury (52.3%, n = 55) followed by chest trauma (33.3%, n = 35), extremity trauma and visceral injuries accounted for 9.5% (n = 10) and 4.8% (n = 5) respectively. Out of 280 patients, a total of 163 (58.2%) patients had AO type A fracture morphology, 101 (36.1%) patients had AO types C fracture morphology and only 16 (5.7%) patients had AO type B fracture morphology.
Fig. 1.
Age wise distribution of spine trauma patients (n = 280).
Table 1.
Mechanism of injury in spine trauma patients.
| Mechanism of injury | Male(n), % | Female (n), % | Total (n), % |
|---|---|---|---|
| Fall from height | 55,30.5% | 64, 64% | 119, 42.5% |
| Road traffic accident | 86,47.8% | 22, 22% | 108, 38.6% |
| Assault | 16,8.9% | 4, 4% | 20, 7.1% |
| Sports | 5, 2.8% | 1, 1% | 6, 2.1% |
| Others | 18,10% | 9, 9% | 27, 9.6% |
Fig. 2.
Vertebral level of Injury in spine trauma patients.
Spinal cord injury (SCI) was seen in 82.1% (n = 230) spine trauma patients. Of the 230 patients who sustained spinal cord injuries, 50.5% of patients had complete neurological deficit (ASIA grade A) while the remaining 49.5% had incomplete neurological deficit of varying severity (ASIA grade B, C and D) (Fig. 3). Complete neurological deficit (ASIA grade A) was seen maximum in AO type C fracture morphology (75/101, 74.25%) followed by AO type A4 (32/108, 29.6%) on comparing the fracture type and neurological deficit (p-value< 0.001) (Fig. 4). Complete paralysis was seen maximum in patients with cervical spine injury (n = 35/52, 67.3%) followed by thoracolumbar spine (n = 47/89, 52.8%), association was found to be significant (p-value< 0.0001) (Table 2).
Fig. 3.
Neurological status of Spine trauma patients with SCI (n = 230).
Fig. 4.
Neurological status in spine trauma patients according to AO typeA.
Table 2.
Region wise distribution of neurological deficit in patients with SCI (n = 189).
| Location of injury(n) | ASIA A | ASIA B | ASIA C | ASIA D |
|---|---|---|---|---|
| Cervical (52) | 35 | 7 | 5 | 5 |
| Thoracic (59) | 31 | 18 | 8 | 2 |
| Thoracolumbar (89) | 47 | 22 | 20 | 0 |
| Lumbar (30) | 3 | 2 | 5 | 20 |
| Total | 116 | 49 | 38 | 27 |
Seasonal variation was observed in the incidence of spine trauma. Males sustained spine trauma mostly in May–June (Monsoon) while females mostly sustained trauma during months of March–April (Summers).
Gender wise distribution of spine trauma showed there was a statistically significant association between gender and mechanism of injury (p-value < 0.0001) while no significant association was found with the location of injury (p-value – 0.054). 154/180 (85.5%) males had SCI of varying severity while 76/100 (65%) females sustained SCI, this association was also found to be statistically significant (p-value – 0.045).
4. Discussion
Spine trauma accounts for the great social and economic burden on patients and their families as patients with SCI have to stay bedridden for long duration leading to financial loss especially when the affected person is young who is the main earning member of the family. Also, there is a lack of resources and tertiary care hospitals for the management of these spine trauma patients with SCI in developing countries like- India.10,11 Comprehensive services of rehabilitation care optimize the outcome but are generally not available at a large number of facilities in Low –Middle-Income countries.12,13 As a result, rehabilitation of these bedridden patients is compromised leading to increased complications. Hence it is important to understand the demographic profile of spine trauma patients so that better prevention strategies, resources for treatment, and rehabilitation can be developed.
In the present study, we observed that the maximum number of spine trauma patients belonged to 16–30 yrs of age group indicating that young active patients are most vulnerable to spine trauma in sub-Himalayan regions. This observation is similar to various studies done in past in India6,10,14, 15, 16, 17, 18 affecting individuals in the age range of 20–49 yrs (Table 3). This is the most productive age group who are the main financial support of their family. Traveling to distant places in hilly areas for daily wage-earning and occupations like tree cutting might put these young individuals at great risk of spine trauma.
Table 3.
Various previous Indian studies on demographics of spine trauma.
| Author | Study Year | Region | Method | No of patients | Age | Male:Female ratio | M.C Mechanism of injury | M.C location | SCI (%) | AIS Grade | SCI level | Associated Trauma |
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Birua GJS et al.6 | July 2013 to June 2017 | Sikkim | Retrospective | 57 | 20-39 Yrs > 50–59 Yr | 4.2:1 | FFH (59.64%) >RTA (35.08%). | Cervical (52.63%) > thoracic (19.29%) | 91.22% | Head trauma > Chest | ||
| Singh G et al.10 | May 2013 to April 2014 | Punjab | Cross sectional study | 157 | Mean age −27 Yrs | RTA (42.6%) >FFH (29.1%) | Thoracic (37.6%) > cervical (36.3%). | Head trauma > Abdomen | ||||
| Mathur N et al.14 | Jan 2000 to Dec 2008 | Jaipur | Prospective observational stud | 2716 | 20-49 Yrs >50–69 yrs | 4.2:1 | FFH (53%) >RTA (28%). | Cervical > Thoracolumbar | A −43.9%,B −6.4%, C-8%, D-16.4%,E−13% | Head trauma > Extremity | ||
| Singh R et al.15 | Jan 2000 to Dec 2001 | Haryana | Prospective observational stud | 483 | 20-29 Yrs >30–39 yrs | 2.96:1 | FFH (44.5%) >RTA (34.7%). | Thoracolumbar > Cervical | 92.50% | Head trauma > Extremity | ||
| Kumar D et al.16 | 2016–2017 | Uttar pradesh | Cross sectional study | 68 | 15-30 Yrs >30–45 yrs | 5.2:1 | FFH (73.5%) >RTA (26.5%). | Lumbar > Thoracic | A −55.9%,B −7.4%, C andD- 36.8% | |||
| Chhabra HS et al.17 | Jan 2002 to May 2010 | New Delhi | Retrospective | 1138 | 20-29 Yrs >30–39 yrs | 5.9:1 | RTA (45%) >FFH (39.63%) | Cervical (30.3%) > Thoracolumbar (30,5%) | 66.67% | A −71.1%,B −14.68%, C-8 .1%, D-6.02% | Extremity > chest trauma | |
| Agarwal P et al.18 | Jan 2003 to Dec 2004 | Karnataka | Retrospective | 207 | 20-29 Yrs > 40–59 yrs | 3.6:1 | FFH (58.9%) >RTA (21.3%). | cervical spine (36.2%)>thoracic spine (34.3%) | 57% | A- 33.9%; B −18.6%; C −17.8%, D −30.5% | Cervical −50.8%, Thoracic −23.7%, Lumbar −25.5% | |
| Aleem IS et al.19 | Nov 2011 to June 2012 | 14 Hospitals in India | Prospective | 192 | Mean age −51 yrs | 1.5:1 | FFH (72.4%) >RTA (22.9%). | Lumbar (51%) > Thoracic (31.7%) | Head trauma > Chest | |||
| Our study | July 2017–Dec2019 | Uttarakhand | Prospective | 280 | 20-39 > 40-59 | 1.8:1 | FFH(42.5%) >RTA (38.6%) | Thoracolumbar (37.5%) > Cervical (25.3%) | 82.10% | A −50.5%,B −21.3%, C-13.6%, D-11.8% | Cervical −22.6%, Thoracic - 25.6%, Thoracolumbar −38.7%, Lumbar - 13.1% | Head trauma > Chest trauma |
Males were more commonly injured as compared to females with Male: Female ratio observed in our study was 1.8:1. Male predominance is seen in spine trauma patients in various Indian studies6,10,14, 15, 16, 17, 18 where male: female ratio ranges from 1.5 to as high as 5.9:1. Males because of their increased movement for earning have a high incidence of spine trauma as noted in our study leading to a financial burden. However, we found that the ratio of males: females in our study is less as compared to other studies done in the past which points out the increasing incidence of spine trauma in females in hilly terrains. This is partly explained by the fact that women in hilly regions are involved in outdoor activities like grazing cattle or farming. Most of these terrains have step farming practices, a fall while working in fields can lead to spine injury.
The most common mechanism of injury was observed to be due to fall from height (42.5%) followed by road traffic accident (38.6%). Fall from height is the most commonly reported mode of injury in developing countries as noticed in previous Indian studies also6,14, 15, 16,18, 19, 20, 21 which is different from studies done in developed countries where Road traffic accident (RTA) accounts for the maximum number of spine trauma cases.22, 23, 24, 25 Singh G et al.10 and Chhabra HS et al.17 have reported RTA as the most common mechanism of injury in their studies as their study population mainly involves people residing in urban areas. Low socioeconomic status, involvement in occupations like tree cutting, construction worksites, lack of fencing of the terrace, hilly terrain of our study accounts for fall from height as the most common mechanism of injury.
Gender wise difference in the mode of trauma was observed in our study where Road traffic accident was the most common mechanism of injury among males while females sustained spine trauma mainly due to fall from height and association was found to be statistically significant. Only few previous studies14,16,18 have reported gender wise distribution of mechanism of injury. Mathur et al.14 also reported FFH as most common mechanism of injury among females whiles RTA as most common among males. RTA was more common in urban population than in rural areas among males. Kumar D et al.16 and Agarwal et al.18 reported FFH as most common mechanism in both males and females, Road traffic accident was more common in males in both studies.
Thoracolumbar spine was the most common location of injury (37.5%) followed by cervical spine (25.3%) in our study. Singh R et al.15 also reported a higher incidence of thoracolumbar fractures in spine trauma patients. Though most previous studies have reported cervical spine as the most common location,6,14, 15, 16 occupational differences in rural/hilly area settings from urban/semi-urban areas might be responsible for this observation. Most people in hilly sub-Himalayan regions are involved in occupations like climbing trees, construction work, heavy manual work, transporting weights due to which impact of trauma is more on thoracolumbar spine, which is the junctional area. Cervical spine injuries are more common in Road traffic accidents in urban areas and developed countries.
Seasonal distribution showed increased incidence during summer and Monsoon season. Birua GJS et al.6 and Singh R et al.15 reported an increased incidence of spine trauma in the summer season followed by rainy season. Increased movement of people out of their homes during summers, landslides, and poor road conditions during rainy season might be responsible for an increased incidence of spine trauma in hilly regions during these seasons. Due to an increase in tourism, unplanned development ignoring characteristics of the terrain, road construction without due consideration of slope profiles have led to an increase in the incidence of landslides in sub-Himalayan region. Modifying road alignments and improving slope profiles, stabilization by vegetation, retaining walls can be used as measures to mitigate landslides.26 Our study population belongs to difficult hilly terrain with poor geographical and climatic conditions, lack of good quality roads, frequent landslides thus making it prone to Road Traffic Accidents (RTA). Drunken driving, high speed, sleep & use of mobile phones while driving further adds to the problem. Public health measures such as time to time maintenance of roads, community-based campaigns to generate awareness among the common masses about safe driving habits should be carried out.27
There was a significantly higher number of spine trauma patients who had Spinal cord Injury (SCI) as observed in our study (82.1%). Birua GJS et al.6 and Singh R et al.15 also reported a similar percentage of patients with SCI in their studies (91.22% and 92.5% respectively. However, SCI reported in our study is high as compared to other studies17,18 with SCI % ranging from 57%18 to 66.67%.17 The skew in the pattern of neurological deficit in our population may be explained by the fact that patients with no neurological deficit after falling from height or motor vehicle accident would not reach hospital. Most simple fractures without neurological deficit are managed by local practitioners and only injuries with neurological deficit are referred to tertiary care hospitals. Similar to previous studies,6,15,17,18 our study showed that males sustaining SCI were significantly more in number than females. Complete neurological deficit (ASIA grade A) was the most common presentation of SCI seen in around 50.5% that correlates with other Indian studies.14,16, 17, 18 Lack of proper prehospitalization care, initial management by quacks, late presentation and poor transportation of injured patients to tertiary care hospitals, as prevalent in the region all account for high rates for complete injuries as reported in the IDAPP study also.2 Cervical spine injuries were most commonly observed to translate to complete neurological deficit. However, our results were different from Mathur et al.14 and Agarwal et al.18 who reported Lumbar and Thoracolumbar injuries respectively to be the most common level for complete traumatic SCI.
Our study is one of the few handful of studies done to document the pattern of spine fracture in this type of geographic location in India. Results from our study reiterated the findings of the most commonly affected age group, etiology of trauma, and SCI % reported in a previous study done by Birua GJS et al.6 in North East India with a similar geographical profile of patients. Fall from Height in Young age individuals as the most common mechanism of injury and high SCI % was found in both studies. Though Cervical spine was the most common location of injury reported by Birua GJS et al.,6 thoracolumbar region was the most common location of injury in our study. Table 3 depicts the results of various previous Indian studies and helps in understanding the region-wise demographic profile of spine trauma patients.
Knowing the burden due to SCI (Spinal Cord Injury), prevention of such injuries is the cornerstone in the management and further, understanding injury patterns according to the geographical region is of paramount importance in formulating prevention strategies.
Limitations: Patients with simple fractures without neurological deficit were not referred to our tertiary care center, which could have accounted for selection bias and over-reported SCI % in our study.
5. Conclusion
Spine trauma is more common in young aged individuals (age group 16–30 yrs), with fall from height as the most common mechanism was observed while doing our study in sub-Himalayan region. Thoracolumbar junction (D10-L2) was the most common location of injury. AO type A was the most common fracture morphology. Spinal cord Injury (SCI) was seen in 82.1% of spine trauma patients. Complete paralysis was seen maximum in patients with cervical spine injury followed by thoracolumbar spine.
Most of the epidemiological studies regarding SCI are from developed nations while studies from countries like India are lacking because there are no well-defined SCI registries for documentation and follow up of these patients. Preventive measures should be taught to people involved in high-risk occupations and those living in high altitudes to decrease the incidence of spine trauma. There is a need of improving prehospital care, teaching about the transportation of spine trauma patients to hospitals. Since there are not many studies in past regarding the demographic profile of spine trauma patients in hilly regions of India, this study can be used to depict a trend in geographically similar regions of our country.
Data archiving
The datasets generated and/or analyzed during the current study are available from the corresponding author on reasonable request.
Declaration of competing interestCOI
None.
Fundings
None.
Statement of ethics
We conducted our study after obtaining institutional ethical clearance from ethical committee of AIIMS rishikesh, India.
Author’s contribution
Dr Samarth contributed to writing the report, extracting and analysing data, interpreting results. Dr Arvind Rana contributed in writing report. Dr Kaustubh contributed to data extraction and data analysis. Dr Syed contributed to analyzing data. Dr Bhaskar contributed in providing feedback and reviewing the paper. Dr Pankaj Kandwal contributed in providing feedback and reviewing the paper.
Acknowledgments
None.
Contributor Information
Samarth Mittal, Email: shankymtl11@gmail.com.
Arvind Rana, Email: ranaaarvindrana@gmail.com.
Kaustubh Ahuja, Email: Kaustubh1@live.in.
Syed Ifthekar, Email: dr.syedifthekar@gmail.com.
Bhaskar sarkar, Email: drbhaskarsarkar@gmail.com.
Pankaj Kandwal, Email: pankaj.orth@aiimsrishikesh.edu.in, pankajkandwal27@gmail.com.
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Data Availability Statement
The datasets generated and/or analyzed during the current study are available from the corresponding author on reasonable request.