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.
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 206recruited 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.
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.
Cervical column and cord injury
34 Bull Emerg Trauma 2014;2(1)
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
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 Fracture (%) 9 (4.4%)
Axis Fracture(%) 39 (18.9%)
Combination C1-C2 Fracture (%) 8 (3.9%)
C3 Fracture (%) 28 (12.6%)
C4 Fracture (%) 25 (12.1%)
C5 Fracture (%) 42 (20.4%)
C6 Fracture (%) 60 (29.1%)
C7 Fracture (%) 50 (24.3%)
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%)
Glasgow Coma Score (GCS)
Mild 178(86.4%)
Moderate 13(6.3%)
Severe 15(7.3%)
Treatment
Non-Operative (%) 161(68.4%)
Posterior fixation, fusion decompression (%) 15 (7.3%)
Anterior fixation, fusion decompression (%) 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%)
Kamravan HR et al
www.beat-journal.com 35
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).
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."