Epidemiological Study of Traumatic Spinal Injuries in Iranian Patients from 2007 to 2017

AUTHORS

Mohamadreza Saatian ORCID 1 , Nayereh Kasiri ORCID 2 , 3 , Younes Mohamadi ORCID 4 , Sajjad Sangestani ORCID 5 , Ali Abdoli ORCID 1 , Ehsan Mazloumi ORCID 2 , 3 , *

1 Department of Neurosurgery, Hamadan University of Medical Sciences, Hamadan, Iran

2 Department of Public Health, School of Health, Torbat Heydariyeh University of Medical Sciences, Torbat Heydariyeh, Iran

3 Health Sciences Research Center, Torbat Heydariyeh University of Medical Sciences, Torbat Heydariyeh, Iran

4 Department of Epidemiology, Hamadan University of Medical Sciences, Hamadan, Iran

5 Department of Health Information Management, School of Management and Medical Information Sciences, Iran University of Medical Sciences, Tehran, IR Iran

How to Cite: Saatian M , Kasiri N , Mohamadi Y, Sangestani S , Abdoli A, et al. Epidemiological Study of Traumatic Spinal Injuries in Iranian Patients from 2007 to 2017, Hormozgan Med J. Online ahead of Print ; In Press(In Press):e103203. doi: 10.5812/hmj.103203.

ARTICLE INFORMATION

Hormozgan Medical Journal: In Press (In Press); e103203
Published Online: November 17, 2020
Article Type: Research Article
Received: March 31, 2020
Revised: August 4, 2020
Accepted: August 5, 2020
Uncorrected Proof scheduled for 25 (1)
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Abstract

Background: Traumatic spinal cord injury (TSCI) can cause numerous adverse effects on the spinal cord and neural tissues. These injuries may have negative effects on physical and psychological health during the lifespan.

Objectives: The present study aimed to investigate the epidemiology of TSCI in patients with trauma admitted to Bessat Hospital of Hamadan between 2007 and 2017.

Methods: A cross-sectional study was conducted on 3,219 patients with traumatic spinal injuries admitted to Bessat Hospital of Hamadan between 2007 and 2017. Data were collected from the hospital information system. Data analysis was performed using SPSS. Quantitative data were expressed as mean, standard deviation, and frequency, and qualitative data were analyzed using the chi-square and Fisher's exact tests. The significance level was considered to be less than 0.05.

Results: Mortality was significantly associated with gender (P = 0.001), age (P = 0.051), external causes of injury (P = 0.001), and type of injury (P = 0.001). The length of hospital stay was significantly associated with the type of injury (P = 0.001) and external causes of injury (P = 0.001), whereas there was no significant relationship between the length of hospital stay and gender, age, and surgery (P > 0.05).

Conclusions: Mortality rates were highest at the age of 55 years or over among other age groups. Thus, effective interventions and programs should be implemented for this age group.

1. Background

Traumatic spinal cord injury (TSCI) can lead to numerous unpleasant impacts on the spinal cord and neural tissues and may adversely affect physical and psychological health during the lifespan. Some degree of neurological deficits occurs in 10 - 20% of all patients at the spine injury level, 40% at the cervical spine level, and 15 - 20% at the thoracolumbar level. Despite advances in emergency ward services in pre-hospital settings, TSCI is still a major cause of mortality and morbidity globally. These complications have adverse impacts on the patient's life, as well as his/her family members' lives and society (1, 2). Over the past two decades, the death from TSCI in trauma patients has shown a steady trend and has been reported as 17% (3). The prevalence of TSCI varies in different regions depending on the economic, social, political, and cultural context. The prevalence of these complications varies from 12.1 to 57.8 per 1,000,000 population in developed countries and 17.7 to 29.7 per 1000,000 population in developing countries (4, 5). In addition, the reported annual incidence rate of traumatic spinal fractures varies between 19 and 88 per 100,000 population and that of spinal injuries between 14 and 53 per 100,000 population (6, 7).

Given that the data on the epidemiology of spinal fractures with or without spinal cord injury is different and even in some sources, it has been combined with spinal cord injuries, and that spinal fractures are common in injured people involved in various accidents, the present study was conducted to investigate the epidemiology of spinal cord injuries in trauma patients admitted to Bessat Hospital in Hamadan from 2007 to 2017.

2. Objectives

Given the high prevalence of spinal cord fractures in various types of injuries and inconsistent epidemiological data on spinal cord fractures with or without spinal injuries, the present study aimed to investigate the epidemiology of TSCI in patients with trauma admitted to Bessat Hospital of Hamadan between 2007 and 2017.

3. Methods

A cross-sectional study was conducted on 3,219 patients with TSCI admitted to the Bessat Hospital of Hamadan between 2007 and 2017. Bessat Hospital is the largest and the most sophisticated hospital in western Iran. Data were collected from the hospital information system. The inclusion criteria were fulfilling the definition of trauma, ICD-10 coding conventions, and head and cervical spine trauma codes (8). Patients with more than two incomplete demographic items (30% or higher), non-traumatic head injury, and TSCI false-positivity were excluded from the study. The ICD-10 codes for TSCI included T09.5 (spinal cord injury with nonspecific level), S12.90 (cervical fracture with nonspecific level), S14.1 (other unknown cervical spinal cord injuries), S22 (the fracture of the rib, chest, and thoracic spinal cord), and S32 (fractures of lumbar spine and pelvis). Data were collected using a checklist including items on gender (male or female), age (including 15 years or higher, 15 - 24 years, 25 - 34 years, 35 - 44 years, 45-54 years, 55 - 64 years, and 65 years or older), type of injury (spinal cord or cervical spinal cord injuries, cervical fracture, lumbar or pelvic fractures, fractures of the ribs, and thoracic spinal cord injuries), external causes of injury (pedestrian, motor vehicle crashes, falls, etc.), surveillance (recovery or death), and length of hospital stay (seven days or lower, seven days or higher).

Data analysis was performed using SPSS, version 23. Quantitative data were expressed as mean, standard deviation, and frequency, and qualitative data were analyzed using the chi-square and Fisher's exact tests. The significance level was considered to be less than 0.05.

4. Results

The average age of the participants was 41.7 ± 17.07 years, and 22.6% were aged between 25 and 34 years (n = 729). About 66% (n = 2148) of the subjects were male. The frequency of death was 4.9% (n = 158) among our participants. The most common cause of TSCI was motor vehicle accidents (45.9%), followed by falls (43%) (Figure 1 and Table 1). Besides, TSCI in all age groups was significantly more prevalent among men than in women (P = 0.001, Table 2). The epidemiological investigation of TSCI showed an increasing trend between 2007 and 2012, and a decreasing trend between 2012 and 2013. The observed decrease in Figure 2 is due to the Trauma II Center in Hamadan province. Since then, TSCI showed an increasing trend between 2013 and 2016 (Figure 2).

Figure 1. External causes of morbidity and mortality among patients with traumatic spinal cord injury in Hamadan Province, Iran
Table 1. Factors Associated with Mortality and Length of Hospital Stay in Patients With Traumatic Spinal Cord Injury in Hamadan Province, Iran
VariableTotal, No (%)MortalityP-ValueLength of Hospital StayP-Value
Non-SurvivedSurvived< 7> 7
Gender0.0010.001
Male2148 (66)125 (5)2018 (96)1559 (72)589 (27)
Female1071 (34)33 (3.1)1037 (96.9)759 (70)312 (30)
Age (y)0.0510.001
< 1581 (2.5)2 (2)79 (98)56 (69)25 (31)
15 - 24456 (14.2)16 (3)440 (97)329 (72)127 (27)
25 - 34729 (22.6)27 (3)699 (97)526 (72)203 (27)
35 - 44594 (18.5)31 (5)562 (95)418 (70)176 (30)
45 - 54583 (18.1)28 (4)554 (96)420 (72)163 (28)
55 - 64439 (13.6)32 (7)406 (93)332 (75)107 (25)
> 65337 (10.5)22 (6)315 (94)237 (70)100 (30)
Mechanism0.0010.001
Pedestrian188 (5.8)41 (25.9)141 (4.6)116 (5)72 (8)
Vehicle - related1383 (43)0(0)1383 (45.3)1051 (45.3)332 (36.8)
Falling1476 (45.9)117 (74.1)1359 (44.5)1036 (44.7)440 (48.8)
other172 (5.3)0 (0)172(5.6)115 (5)57 (6.3)
Surgery0.0010.001
Yes1784 (55)67 (4)1362 (96)489 (27)1295 (73)
No1435 (45)91 (6)1693 (94)412 (28)1023 (72)
Type of injury0.0010.001
Cervical spinal cord injury559 (17)70 (12)489 (88)446 (78)119 (22)
Cervical fracture342 (10)0 (0)342 (100)191 (55)151 (45)
Spinal cord fracture1351 (42)88 (6)1263 (94)1034 (76)317 (24)
fractures of the ribs, and thoracic spine961 (29)0 (0)961 (100)647 (67)314 (32)
Table 2. Age Versus Gender Distribution of Patients with Traumatic Spinal Cord Injuries in Hamadan Province, Iran
Age (y)Male, No (%)Female, No (%)Total, No (%)P-Value
< 1536 (1.1)45 (1.4)81 (2.5)0.001
15 - 24329 (10.2)127 (3.9)456 (14.2)
25 - 34518 (16.1)211 (6.6)729 (22.6)
35 - 44412 (12.8)182 (5.7)594 (18.5)
45 - 54395 (12.3)188 (5.8)583 (18.1)
55 - 64280 (8.7)159 (4.9)439 (13.6)
> 65178 (5.5)159 (4.9)337 (10.5)
Figure 2. The trend of spinal cord injury among patients with traumatic spinal cord injury hospitalized between 2007 and 2017

5. Discussion

Trauma is one of the leading causes of disability-adjusted life-disability (DALY) in productive and active groups in society. Due to the irreversible consequences of failing to care for injured patients and given that most traumatic events (especially in children) are preventable, it is essential to figure out the pattern and distribution of fatal traumas such as spinal and spinal cord trauma in different geographic areas for health policy-making so that preventive measures could be taken.

The results of the present study showed that TSCI was significantly more prevalent among men in all age groups than in women. Hasler et al. reported the prevalence of TSCI as 65% in men and 35% in women (7). In addition, Thietje et al. showed that 94% of patients with TSCI were male (9), which is in agreement with our study. The prevalence of TSCI showed an increasing trend between 2007 and 2012, and a decreasing trend between 2012 and 2013, and since then, TSCI showed an increasing trend between 2013 and 2016, which is due to the establishment of another trauma center in the studied region.

Majdan et al. conducted a study in Australia and found that the TSCI-related mortality rate increased from 3.1 per one million population in 2002 to 6.2 per one million population in 2012. In addition, the prevalence of RTAs increased from 27% in 2002 to 55% in 2012 (10). Because motor vehicle crashes were the most frequent accidents in this study, it can be concluded that the TSCI trend was associated with the use of motor vehicles, as the increased use of motor vehicles and the public's ignorance of traffic and safety rules increased the prevalence of TSCI. Moreover, findings regarding factors associated with TSCI-related mortality reveal that the TSCI-related mortality rate is significantly higher in men than in women. Singh et al. reported that higher TSCI-related mortality in men was attributed to motor vehicle trauma, which is consistent with our study (11). However, some studies have shown that women and individuals under 40 years have a lower life expectancy in traffic crashes (12, 13). Furthermore, studies conducted in Scandinavian countries have shown higher RTA-related mortality rates (13-15). Sabre et al. used the Cox proportional hazards model and demonstrated no significant relationship between gender and RTA-related mortality rate (12), which is inconsistent with the present study. In the present study, the number of female patients was lower than that of male patients, and therefore, the RTA-related mortality rate was reported to be lower in women (16).

The TSCI-related mortality rate was reported higher in the age range of 25 - 34 and 55 - 64 years, with a statistically significant difference. A study by Ghaem et al. showed that trauma-related mortality was higher in patients older than 55 years (17). Besides, Majdan et al. argued that the TSCI-related mortality rate was higher in patients older than 65 years (18), which is in agreement with our study. Interestingly, the prevalence of TSCI is significantly higher among young adults, and differences between age groups may be due to differences in methodology, socioeconomic status, culture, and area of living. Besides, according to the findings of the present paper, elderly people did not have the satisfactory physical endurance to cope with illnesses and accidents due to the weakness of the body, special health conditions, and comorbidities.

The mortality rate was significantly higher in trauma patients with motor vehicle collisions. Thietje et al. investigated mortality among patients with spinal cord injuries and found that motor vehicle crashes were the most common cause of TSCI in trauma patients, which is in line with our study (9). Singh et al. reported that 52% of death was attributed to Road Traffic Accidents (RTAs). Sharma et al (19). reported a death rate of 57%, and Sindhu et al. reported RTA-related mortality of 45% (20), which are in agreement with the current study. The high prevalence of RTAs can be attributed to multi-polar vehicles on the road, high speed, and ignorance of pedestrians and the public of different road safety rules. Moreover, the results showed that the mortality rate was significantly higher in patients with cervical spine and spinal cord injuries. Majdan et al. reported that the most common cause of death in trauma patients was cervical injuries (66% in males vs. 55% in females), followed by lumbar injuries (19% in males vs. 26% in females) (18). A study by Majdan et al. in Australia showed that the most common level of injury was cervical damage, which complied with our study. The length of hospital stay in TSCI patients was significantly higher in men than in women, which was inconsistent with Wu et al., who reported no significant difference in the length of hospital stay between men and women (21). The length of hospital stay was not significantly different between male and female patients in different age groups, which was inconsistent with the studies by Wu et al. (21) and Jin Jang et al. (22). The length of hospital stay was significantly higher in patients with motor vehicle injuries and cervical fractures. However, Wu et al. found no significant relationship between the length of hospital stay and the level of injury (21). Some studies have revealed that the length of hospital stay is considerably longer in trauma patients than in other patients (23, 24). Since trauma patients require extra medical care for recovery, the length of hospital stay is quite longer among them (25).

According to the findings of the current study, the mortality rates and length of hospital stay were not significantly different between patients who underwent surgery and patients with did not, which is inconsistent with the results of other studies (21, 26). These studies have argued that surgery increases the length of hospital stay for full recovery in trauma patients (21).

Our results showed that mortality rates were highest at the age of 55 years or higher among other age groups. Thus, effective interventions and programs should be implemented for this age group. Our study was a prospective cross-sectional study, and the reliability of our findings depends mainly on the precision of records and data drawn from the hospital information system. The study population was an appropriate representative of the general population of Hamadan, and therefore the results can be generalized to the whole population of the city. Besides, the application of similar ICD-10 codes during the study period confirmed the validity of our results.

Footnotes

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