create the summary of  the findings "Materials and Methods
This retrospective hospital-based study was performed in governmental, private, and military
hospitals of Tehran which had a neurosurgery department, during 16 months (March 21, 2010 to
July 22, 2011). Given the ministry of health website (http://avab.behdasht.gov.ir/hospital/), appropriate hospitals were selected. After coordination
with vice - chancellors in treatment affairs of five
Tehran universities of medical sciences (Artesh,
Baghiatollah, Shahed, Shahid-Beheshti, and Tehran), as main regulators of hospitals, this research
started.
Among 68 hospitals of Tehran which had a neurosurgery department, 61 were studied. Three private and two military hospitals did not allow surveying their data. Computerized medical record
systems of two governmental hospitals were corrupted. In the Medical Records Departments of
hospitals, patients’ files with the diagnosis of
“TSCI” were surveyed. To prevent data missing,
besides “TSCI”, patients with the diagnosis of
“traumatic fracture or dislocation of spine” were
investigated, too.
The first author (MS) studied all available records
and documented the general demographic characteristics of the patients (name, gender, age, marital status, profession, nationality, residential location address, phone,etc.), cause of injury, season,
level of spinal injury, associated injuries, AIS on
admission and discharge, timing of surgery, duration of hospital stay, final outcome, and the hospital costs that was paid by the patients in a designed and specific questionnaire. To ensure the
accuracy of the information, 15% patients were
contacted, randomly.
The falls were divided into two groups according
to height: less than 6 meters (m) as low height falls,
and at least 6 m as high ones (10, 11). Surgical decompression within 24 h and after that was considered early and late surgery, respectively.
After data entering, patients who had hospitalized
in more than one hospital were matched. Before
the data was processed, all data was rechecked to
minimize data entry errors and missing data.
The overall incidence was calculated based on the
patients who lived in Tehran and were injured between March 21, 2010 and March 20, 2011 (the
Persian calendar year).Population of Tehran was
considered 7,976,000 which have been determined
by the Statistical Center of Iran in 2006.
Descriptive summaries were conducted using
PASW (SPSS Inc., Illinois, USA). Descriptive statistics are reported using proportions and means
for the categorical and continuous data, respectively and a P value less than 0.05 was considered
significant. The proportions and relationships
most relevant to the emerging patterns in TSCI
and to clinically important factors were examined
for strengths of association using chi-square tests.
Results
Of 867 patients with spine fracture, 621 (71.6%)
were male. Two most common mechanisms of
the vertebral fracture were fall with 393 cases
(45.3%) and road traffic crash (RTC) with 228
cases (26.3%). Figure 1 shows the distribution of
these mechanisms based on sex and age of the
patients. Vertebral fracture was more prevalent in
the following seasons, respectively: summer,
spring, autumn and winter. The above-mentioned
prevalence was seen in both causes of fall and
RTC. However, fall was more prevalent in winter
and RTC was more prevalent in spring. L1 was
the most common site of fracture, accounting for
22.7% of all fractures, and T12 fractures as the
second most common vertebra were seen in
12.9% of the patients. The number of vertebral
fractures in fall and RTC has been shown in Fig.2.
Figure 2 and 3, allowing the comparison of the
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distribution of vertebral fracture between fall and
RTC. Of 867 patients with spine fracture who
survived to hospital admission, 138 (15.9%) had
TSCI (Table 1). The majority of TSCI patients
were male (84.8%). Their mean age was 33.2 ±
14.3 years. 63 cases (16%) of 393 vertebral fractures due to fall and 56 cases (24.6%) of 228 vertebral fractures due to RTC led to TSCI. Namely,
RTC had more TSCI than fall (P<0.001). 54.3%
patients were residing in Tehran and the others
were referred from other cities. 16 patients
(11.6%) had foreign nationality. Therefore, the
mean annual incidence of hospitalized TSCI patients of Tehran was 10.5 per million populations
per Year (95% Confidence Interval (CI): 9-12).
77% of TSCI patients had single vertebral fracture,
whereas double, triple, quadruple and nonaccessible ones were 18, 4, 0.3 and 0.7%, respectively. The distribution of vertebral fracture in
TSCI patients has been shown in figure 4. The
most common level of injury was at thoracic segments (49.6%), particularly T12 (18.1%), and lumbar segments (27.6%), in particular L1 (14.9%).
The number of vertebral fractures in fall and RTC
among TSCI patients has been shown in figure 3.
Lesions in Individuals with TSCI caused by fall
are mostly located in lower thoracic and lumbar
levels. Injury due to RTC caused lesions mainly at
cervical, middle and lower thoracic and lumbar
levels. The mean height of fall was 7.7±4.2 meters.
Among 240 falls from low height and 153 ones
from high height, 23 and 40 cases led to TSCI,
respectively (P<0.001). The mean age of low fall
cases was 41.3±16 years, whereas the mean age of
high fall cases was 29.3±10.7 years (P=0.018).
The majority of cases presented with paraplegia
(61.9%). The number of tetra or para plegic/paretic patients due to different causes is
shown in the Table 2. Fall was more common
than RTC (P=0.047). Admission AIS for 119 patients (86.2%) was A, whereas, 3.6, 2.2, and 8%
had AIS B, C, and D, likewise. No change in neurologic deficit was seen in 119 patients (86.2%).
However, 7 patients (5.8%) improved at least one
AIS grade. During hospitalization, 11 patients
(8%) deceased (except emergency department
deaths) and all were men. Six patients, with the
mean age of 38±20 years had RTC injuries. Three
patients (mean age=52±8 years) had been injured
due to high height fall. The other two were injured
by other causes. Among dead cases, 6 persons had
cervical injuries with complete tetraplegia and 5
others had thoracic injuries with complete paraplegia (OR=3.2, CI=0.9-11.5). The time of death
in these patients ranged from 1 to 77 days (median
= 14, interquartile range = 11–19 days).
Early and late surgery was done for 19% and 81%
of the patients, respectively. The mean duration of
hospital stay for all SCI patients was 14.2±11.9
days. The median day of hospitalization was 12,
but for early and late surgery, it was 7.5 and 12,
respectively (P=0.044). The duration of hospital
stay for tetra-plegic/paretic patients was
22.7±23.7 days, but for para-plegic/paretic patients, it was 12.5±7.5 (P<0.001).
The number of TSCI patients and their hospital
costs based on the cause of injury and type of
hospital has been presented in Table 3. Of 138
patients, 46 (33.3%) TSCI patients were hospitalized in private hospitals which significantly paid
more than other patients (P=0.001).
Table 1: Demographics of patients with vertebral fracture in Tehran, Iran, March 21, 2010 to July 22, 2011 (N=867)
Cause TSCI Not TSCI Total
Male Female Total Male Female Total Male Female Total
n (%) n (%) n (%) n (%) n (%) n (%) n (%) n (%) n (%)
Fall 57(48.7) 6(28.6) 63(45.7) 218(43.3) 112(49.8) 330(45.3) 275(44.3) 118(48) 393(45.3)
RTC 44(37.6) 12(57.1) 56(40.6) 121(24) 52(23.1) 173(23.7) 165(26.6) 64(26) 229(26.4)
Others 16(13.7) 3(14.3) 19(13.8) 165(32.7) 61(27.1) 226(31) 181(29.1) 64(26) 245(28.3)
Total 117(84.8) 21(15.2) 138(15.9) 504(69.1) 225(30.9) 729(84.1) 621(71.6) 246(28.4) 867(100)
TSCI: Traumatic Spinal Cord Injury
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Fig.1: Number of patients with vertebral fracture by age,
sex and two common causes in Tehran, Iran, March 21,
2010 to July 22, 2011
Fig. 2: Number of fractured vertebrae due to Road Traffic Crash (RTC) and fall in Tehran, Iran, March 21, 2010
to July 22, 2011
Fig.3: Number of fractured vertebrae due to Road Traffic
Crash (RTC) and fall among traumatic Spinal Cord Injury
(SCI) patients in Tehran, Iran, March 21, 2010 to July 22,
2011
Fig. 4: Number of fractured vertebrae in traumatic Spinal
Cord Injury (SCI) patients in Tehran, Iran, March 21,
2010 to July 22, 2011 (N=138)
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Table 2: Plegia/Paresis in Traumatic Spinal Cord Injury patients by cause in Tehran, Iran, March 21, 2010 to July 22,
2011 (N=138)
Plegia/Paresis
Cause Para Tetra Total
n (%) n (%) n (%)
Fall 56 (88.9) 7 (11.1) 63 (45.7)
RTC 42 (75) 14 (25) 56 (40.6)
Others 15 (79) 4 (21) 19 (13.8)
Total 113 (81.9) 25 (18.1) 138 (100)
 RTC: Road Traffic Crash
Table 3: Hospital type, cost and Traumatic Spinal Cord Injury patients by cause in Tehran, Iran, March 21, 2010 to
July 22, 2011 (n=138)
Hospital Type
Cause Governmental Military Private Total
n (%) Cost* n (%) Cost* n (%) Cost* n (%) Cost
Mean±SD Mean±SD Mean±SD Mean±SD
Fall 38
(44.7)
5.2±3.3 2 (28.6) 2.8±4.2 23 (50) 8.1±7.1 63
(45.7)
6.4±5.5
RTC 37
(43.5)
5.7±3.3 3 (42.8) 10.7±8.9 16 (34.8) 10.4±7.1 56
(40.6)
7.9±5.6
Others 10
(11.8)
4.1±1.6 2 (28.6) 7.3±7.1 7 (15.2) 8.5±2.6 19
(13.8)
6.8±3.5
Total 85
(61.6)
5.3±1.3 7 (5.1) 7.6±6.9 46 (33.3) 9±6.6** 138
(100)
7±5.4
* 10,000,000 Iranian Rials is equal to 400 USD.
** Private hospital fees were significantly higher (P=0.001)."