create the summary of the findings "Materials and Methods
Study population

 This  was  a   retrospective  cross-sectional  study which was conducted  during  a 30-months  period from October 2009 to March 2012 in Rajaee Trauma Hospital, a level I trauma center affiliated with Shiraz University of Medical Sciences, Shiraz, Iran. Shiraz is the capital and main city of Fars province with an estimated population  of 1,460,665 according to the recent national census. The age distribution  of the Shiraz population is as follow: 525,253 (42.7%) age 18-29 years, 257,048 (20.9%) age 30-39 years, 205,129 (16.7%) age 40-49 years, 125,862 (10.2%) age 50-59 years and 115,424 (49.9%)  age ≥60 years. We included all the patients admitted to the emergency department of our center with impression of cervical spinal column and cervical spinal cord injuries. Cervical spine injuries were defined as fractures of the  all elements of cervical spines (C0/C1 to C7/T1) diagnosed with cervical X-ray, cervical-CT (frequently  supplemented  with  cervical MRI).The patients with no fracture or cord injury were further excluded from  the study. Spinal cord injury was defined as neurological (sensory, motor or sphincter) deficit accompanied by vanished spinal cord reflexes determined by physical examination. The study protocol was approved by institutional review board (IRB) of Shiraz University of Medical Sciences. As this was a retrospective study, the medical research ethics committee of the university did not require informed written consents to be filled by the patients.

Study protocol

 Medical charts of the patients were reviewed and the data were extracted using a standard data collecting form. We recorded the characteristics of the patients age, sex, marital status, mechanism of injury, level of injury, concomitant injury, treatment (non-operative or operative) and clinical outcome. We recorded the concomitant thoracolumbar fracture,neurological deficit at the time of diagnosis (normal, radiculopathy, incomplete SI, complete SI and mortality 1 and 3 months after the diagnosis. Vital status (dead or alive) and time of death were also determined. Neurologic function  was assessed according  to  the  American Spinal Injury Association (ASIA) scale from E to A [10].

Statistical analysis

 The statistical package for social science, SPSS for Windows, Version 16.0 (SPSS Inc., Chicago, IL, USA) was used for data analysis. Data are reported as mean± SD and proportions as appropriate. The data were further compared between men and women and the outcome using chi-square test and independent t-test for non-parametric and parametric data respectively. A p-values less than 0.05 was considered statistically significant.

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Results
Age, Sex, mechanism of injury

 There were 261 patients admitted with impression of cervical SCI (with or without SI) over 2.5 years. After re-evaluation of patients’ documents and x-rays, 55 subjects were excluded from the study because of not having spine or cord injury, and the remaining 206 recruited in the study. The mean age of patients was 37.2±15.9 years. Among 206 patients, 155(75.2%) were males and 51 (24.8%) were females with M/F ratio of 3:1.Table 1 summarizes  the  demographic information  and the mechanisms of injury of 206 patients.

Table 1
Baseline characteristics of cervical column and cervical cord  injuries in 206 patients  admitted  to  our  center between October 2009 and March 2012

Characteristic	Value
Age (years)	37.2±15.9
Gender	 
Men (%)	155 (75.2%)
Women (%)	51 (24.8%)
 Marital status	 
Married (%)	157(76.2%)
Single (%)	49(23.8%)
Mechanism of injury	 
Car to Car (%)	45 (21.8%)
Car to Motor (%)	20 (9.7%)
Car to Pedestrian (%)	11 (5.3%)
Motor to motor (%)	4 (1.9%)
Motor to Pedestrian (%)	3 (1.5%)
Car turn-over	79(38.4%)
Motor turn over (%)	10 (4.9%)
Falling down (%)	23 (11.2%)
Blunt (%)	7(3.4%)
Other (%)	4 (1.9%)
 Level of Fracture	 
Atlas Fx (%)	9 (4.4%)
Axis Fx (%)	39 (18.9%)
Combination C1-C2 Fx (%)	8 (3.9%)
C3 Fx (%)	28 (12.6%)
C4 Fx (%)	25 (12.1%)
C5 Fx (%)	42 (20.4%)
C6 Fx (%)	60 (29.1%)
C7 Fx(%)	50 (24.3%)
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Fracture location

 The most common spine fracture was C6 vertebra in 60 (29.1%)  cases, and the least injuries were combination C1-C2 fracture found in 8 (3.9%) patients. There  were 64 cases with upper cervical (C0-C1-C2) and 205 with lower cervical fractures. The  site of  fractures  is demonstrated  in  Table 1. The impairment  scale according ASIA scale is demonstrated in Table 2.

Table 2
Clinical and  fracture  characteristics of  206 cervical column and cervical cord injuries included in the current study

Characteristic	Value
Asia Scale	 
A	28 (13.6%)
B	0 (0%)
C	12 (5.8%)
D	13 (6.3%)
E	153 (74.3%)
Cord  injury	 
Complete (%)	29 (14.1%)
Incomplete (%)	25 (12.1%)
Intact (%)	152 (73.8%)
Location of concomitant injury	 
Fracture of Face and skull	23 (11.2%)
Fracture of upper ext	16 (7.8%)
Fracture of lower ext	15 (7.3%)
Fracture of chest and pelvic	15 (7.3%)
Fracture of other spine	23 (11.2%)
Lung Injury	20 (9.7%)
Brain Injury	39 (18.9%)
Abdomen Injury	1 (.5%)
GCS	 
Mild	178 (86.4%)
Moderate	13 (6.3%)
Severe	15 (7.3%)
Treatment	 
Non-Operative (%)	161 (68.4%)
Post.fix.fus.decomp¹ (%)	15 (7.3%)
Ant.fix.fus.decomp² (%)	44 (21.4%)
360 degree (%)	1 (.5%)
Type 2 odontoid Anterior screw fixed	5 (2.4%)
Outcome	 
Discharge (%)	180 (87.4%)
Release (%)	11 (5.3%)
Death (%)	15 (7.3%)
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 Location concomitant injury and GCS

 The concomitant injuries were categorized as brain, lung and abdominal injuries. Craniofacial fractures (23, 11.2%) and fracture of other parts of spine (23, 11.2%) represented the most prevalent concomitant fractures. Thirty-nine (18.9%) patients suffered brain injury and 20 (9.7%) patient had injury to the lung. One patient had internal bleeding and hemodynamic instability due to abdominal trauma and liver laceration that  required urgent operation. Glasgow Coma Score (GCS) of all patients in the study group was documented on admission, and 178 out of 206 (86.4%) patients suffered mild  brain injury GCS 13–15). Thirteen (6.3%) subjects had  moderate (GCS 9–12) and 15 (7.3%) had severe brain injuries (GCS≤8).

Treatment Methods

 The most common type of operation was anterior decompression, fixation and  fusion in  44 patients (21.4%) followed by Posterior decompression, fixation and fusion in 15 patients (7.3%). Five (2.4%) patients had Type 2 odontoid fracture and underwent anterior screw fixation and one case had 360-degree fixation. The remaining  161 (68.4%) patients  had non-operative management.

Outcome

Fifteen  patients  (7.3%)  expired  during  hospital stay. Eleven patients  (5.3%)  were released before completion of recovery and went to private hospitals on their own request and 166 (87.4%) patients with total recovery were discharged from hospital accompanied by relatives. As shown in Table 3, comparison was made between 9 factors in two groups of survived and expired patients. Of these, 4 were associated with increasing risk of death including longer hospital stay (p=0.001), brain (p<0.001) and lung injury (p=0.008) and cord injury (p=0.001). However, facial fracture, other spine fractures, cord injury, axis fracture and C5 fracture, were not associated with increasing risk of death. Positive correlation was found between other factors which included age, hospital stay, GCS and ASIA scale. These were ASIA scale (from E to A) and length of hospital stay (p<0.001).There was negative correlation between GCS and length of hospital stay (p=0.003).

Table 3
Factors associated with mortality in 206 patients with ervical column and cervical cord injuries included in the current study

 	Alive (n=191)	Dead (n=15)	P -value
Age (years)	36.8±15.6	42.2±15.3	0.182
Length of Stay (days)	6.9±8.3	16.8±14.1	<0.001
Brain injury	30 (15.7%)	9 (60.0%)	<0.001
Lung injury	15 (7.8%)	5 (33.3%)	0.008
Facial fracture	19 (9.9%)	4 (62.6%)	0.070
Other spine fracture	19 (9.9%)	4 (62.6%)	0.070
Cord injury	44 (23.1%)	10 (66.6%)	0.001
Axis fracture	39 (20.4%)	0 (0.0%)	0.080
C5 fracture	36 (18.8%)	6 (40.0%)	0.087
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Associated injuries

 Of 206 patients, 89 had associated injury (AOSI). These included brain, lung and abdominal injuries, fracture of upper and lower extremities, fracture of rib cage, pelvic, face, skull and other spine fracture. Uni-variant  analysis showed that  C7 fracture  and death differed significantly (p=0.021) between patient with and without ASOI (Table 4). Other factors such as age, gender, cord injury and C6 fracture did not differ significantly.

Table 4
Analysis comparing patients with and without associate injuries (ASOI).

 Variable	 ASOI (n=89)	 No ASOI (n=117)	 P-Value
Age	38.5 ± 15.5	36.1 ± 15.6	0.227
Gender (M:F)	65:24	90:27	0.625
Cord injury	25 (28.1%)	29 (24.7%)	0.633
C6 fracture	32 (35.9%)	28 (23.9%)	0.065
C7 fracture	29 (32.6%)	21 (17.9%)	0.021
Death	12 (11.1%)	4 (2.6%)	0.007
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