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Year : 2021  |  Volume : 4  |  Issue : 2  |  Page : 32-35

Epidemiology of cervical spine injury in Northern India: A retrospective study

Department of Orthopaedics, PGIMER, Chandigarh, India

Date of Submission15-Mar-2021
Date of Decision16-Jun-2021
Date of Acceptance18-Jun-2021
Date of Web Publication26-Aug-2021

Correspondence Address:
Dr. Amit Kumar Salaria
Department of Orthopaedics, PGIMER, Sector -12, Chandigarh - 160 012
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jodp.jodp_3_21

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Background: The epidemiology of cervical spine injuries in trauma patients of Northern India is largely unknown. Study Design: Retrospective study. Objectives: To find out the epidemiology and demographic factors associated with patients of traumatic cervical spinal injury presented to a level 1 trauma center. Patients and Methods: The study sample includes patients with cervical spine injury admitted to our level one trauma centre from the period of July 2018 to June 2019. Those patients who succumbed to their injuries due to various reasons before imaging or brought dead having suspected cervical spine injury were excluded from the study. Results: During the study period, 83 patients having cervical spine injury were admitted and treated. Out of 83, 75.9% (63) were male and the remaining 24.1% (20) were female. The most common mode of injury was fall from height (66.3%) followed by road traffic accidents (24%). About 64% of the patient population belonged to rural areas. The most affected age group in this study was 20–39 years. The most common associated injury is Extremities fracture (9.6%) followed by head injury (8.4%). C5C6 was the most common level and 69.9% underwent surgery. Pressure sore was presented in 12% of cases. Conclusion: The epidemiology of cervical spine injury in Northern India is different from developed countries. In the present study, the most common cause of cervical spine injury was fall from height followed by motor vehicle accidents. Proper awareness program, educating people, national policymaking, and involvement of NGOs and training primary health care workers will help in reducing the incidence of cervical spine injuries in this region

Keywords: Cervical spine injury, epidemiology, Northern India

How to cite this article:
Dagar A, Salaria AK, Kumar V, Rangasamy K, Dhatt SS. Epidemiology of cervical spine injury in Northern India: A retrospective study. J Orthop Dis Traumatol 2021;4:32-5

How to cite this URL:
Dagar A, Salaria AK, Kumar V, Rangasamy K, Dhatt SS. Epidemiology of cervical spine injury in Northern India: A retrospective study. J Orthop Dis Traumatol [serial online] 2021 [cited 2022 Jan 24];4:32-5. Available from: https://www.jodt.org/text.asp?2021/4/2/32/324597

  Introduction Top

The incidence of cervical spinal injuries (CSI) varies between 2% and 12%.[1],[2] The epidemiology and incidence vary in different geographic locations and the epidemiological results of developed countries are not directly applicable to the developing ones. A road traffic accident (RTA) is reported to be the most important cause in the developed countries[1],[2] but in developing countries like India, fall from height takes the top spot. Recent studies showed that in the aging population (>65 years), low falls causing more spinal trauma. Low falls are considered as low energy trauma such as falls from standing height.[1],[3],[4],[5],[6] Timely detection and immobilization of the cervical spine during initial evaluation is important to avoid secondary injury. Most of the patients may have poor Glasgow coma scale because of associated head injury, alcohol intake or intoxication and cervical spine injury should be suspected in these cases during the primary survey and promptly immobilized.[7] Patients with cervical spine injury to be kept at high-risk category and having the highest reported early mortality rate in spinal trauma as they are associated with significant cord injury.[8]

Cervical spine injury may cause permanent sensory, motor, and autonomic dysfunction. Devastating complications such as pressure sores, urinary tract infections, deep-vein thrombosis (DVT), and pneumonia can occur. Traumatic cervical spine injury causes a psychological, social, and economic burden on the population. Since the prognosis of spinal cord injury is still dismal, prevention of CSI based on epidemiology is of paramount importance.[5]

In a developing country like India, most of the patients belong to a low socioeconomic group and they are the primary earning members of their family. The study on epidemiology and demographics is a need of the hour to implement preventive measures and to reduce the social burden of the disease on the country. Since there was no previous epidemiology study conducted on cervical spine injury in Northern India, we think it is worthwhile to conduct a study and to define the different characteristics like the mechanism of injury, age group involvement, level of injury, concomitant injuries, and neurological status at presentation.

  Materials and Methods Top

This was a retrospective study conducted at the Advanced Trauma Centre of Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh. Ours is a level one trauma centre situated in Northern India that receives primary and referral cervical spine injury cases from the nearby 4–5 states. The study sample included patients with cervical spine injury admitted to the orthopedic department at our level one trauma center from July 2018 to June 2019. Patient records were collected from the Medical record department including all outpatients and inpatients. Patients whose imaging couldn't be done due to various reasons or who were brought dead with suspected cervical spine injuries were excluded from the study. Overall, 83 patients were included in the study. The study was approved by Institute Ethics Committee, PGIMER, Chandigarh. The Statistical Package for the Social Science, SPSS for Windows, version 21 (SPSS, Chicago, IL, USA) was used for data analysis.

  Observation and Results Top

Among 83 patients, 63 (75.9%) were male and 20 (24.1%) were female. This 3:1 sex ratio is comparable with previous studies.[3],[4],[5]

The most common age group is between 20 and 39 years. Thirty-seven (44.6%) patients belong to this young, active adult age group [Figure 1]. Only 5 (6%) belong to age ≥60 years and the mechanism of injury being mostly due to low falls (low-energy trauma such as fall from standing height) who had prior degenerative spine with osteophytes/ligament calcifications.
Figure 1: Bar diagram shows the incidence of cervical spine injuries in different age groups

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Approximately 59 (71%) patients belong to outstation areas (outstation areas being considered more than 50 km away from trauma center) and 53 (64%) patients coming from the rural region [Figure 2]. The patients coming from rural region reaches hospital late because of lack of proper transportation, improper referral facilities, a misconception regarding spinal injuries and dependence on native treatments, etc. The average delay from the date of injury to hospital admission was 2.71 days. However, this average delay further increases to 5.32 days when considering the rural population alone. The prognosis of spinal cord injury is directly linked to early decompression, this delay in seeking medical care has detrimental effect on the prognosis of patients.
Figure 2: Pie chart shows locality distribution among cervical spine injury patients

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The most common cause of injury is fall from height (66.3%) followed by RTA which comes around 24% which is different from the developed countries [Table 1] and comparable with previous data from India.[3],[4],[5] While coming onto the seasonal trend, most of the cervical spine injuries occur during June, July, March [Figure 3] showing that lot of population movement and farm/industrial activities occurring during this period. The other reason for the spike in cases of spinal injury in these months is because of the habit of people sleeping outside on rooftops during this summer season and most rooftops in rural India still lacking roof railings for safety. During the winter month of November to January, people prefer to stay inside houses.
Table 1: Mode of cervical spine injury (n=83)

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Figure 3: Bar diagram shows the monthly incidence of cervical spine injuries in a year

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On the assessment of the level of cervical injury C5 and C6 form the majority of more than 63%. Fracture dislocation of C5C6 was the most common pattern of cervical injury [Figure 4]. One case of SCIWORA was noted in our study. In our study of 83 cases, 58 (69.9%) patients underwent surgery because of spinal instability, facet joint dislocation and for decompression. The most common approach used was anterior (42 cases), followed by the combined posterior + anterior (10 cases) which is followed by posterior only approach (6 cases) [Figure 5]. Out of 25 cases managed nonoperatively, we applied Halo vest for 16 cases and the remaining by Sternal Occipital Mandibular Immobilizer Brace.
Figure 4: Bar diagram shows incidence of different level of cervical spine injury

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Figure 5: Pie chart shows distribution of surgical approaches in an operated cervical spine injury cases

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  • On the assessment of associated injuries, 8 cases (9.6%) had injury on extremities, followed by 7 cases (8.4%) had head injuries and 3 cases (3.6%) had chest injuries. Pressure sore developed in 10 cases (12%) and DVT in 8 cases (9.6%) in our study. Most of the cases present late to our hospital being referred/under native treatment. On the assessment of neurology according to Asia Impairment Scale (AIS) grading at time of admission, most of them belong to AIS Grade C (38 cases) and 11 cases had normal neurology at presentation. At the time of discharge, only one case deteriorates from AIS Grade C to B, the remaining cases show improvement or remain static [Table 2] and [Table 3].
Table 2: Neurological status according to Asia Impairment Scale grading at admission

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Table 3: Neurological status according to Asia Impairment Scale grading at discharge

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  Discussion Top

Assessment of epidemiology of cervical spine injury will help identify disease morphology, planning and implementing preventive measures and designing strategies to increase awareness and hence reduce the social and financial burden of disease. In this study, most of the injuries occur in the young, active adult population which is about 44.6% in the age group of 20–39 years. This result is comparable with another previous study from India.[3],[4],[5] In developed countries, there is a bimodal age distribution with the first peak between 15 and 45 years and the second peak occur after 60 years of age.[1],[2],[6] In our assessment, there were only 6% population belongs to this ≥60 year's age group and mostly due to low falls. The high morbidity associated with cervical spine injury means the young person who is usually the bread earner of a family, himself become dependent on family resources. This has not only economic implications but also the social fabric of family is also torn.

On assessing sex, the male: female ratio was 3:1 which is more or less the same as compared with other studies from India.[3],[4],[5] The higher incidence in males being they are actively involved in outdoor activities and most of the females in the village region stays indoor, involved in household activities. In our study, 64% of the population belonged to the rural region whereas another study from India by Mathur et al. shows 79% belongs to the rural population.[9] This shows safety awareness among rural people is insufficient in developing countries. The addition of small safety features in farms, houses, and rural industries can significantly reduce the incidence of cervical spine injuries.

While coming to the mode of injury 66.3% of people sustained the injury by fall from height (tree, hills, electric poles, paragliding sports, etc.) and the second common cause is RTA. In developed countries, the most common mode of injury is RTA/motor vehicle collisions and it is related to urbanization and increased use of motor vehicles.[1],[2] The previous studies from developing countries like India also shows fall from height being the most common aetiology followed by RTA.[1],[3],[4],[5],[6] Again, adding a simple solution of roof railing on rooftops can reduce the incidence of falls in rural households. Fall from trees and poles can be prevented by making public aware about the use of protection harnesses. Safety inspection of farms and small-scale industries by the labor department can further add to the better safety profile in rural areas.

While comes to seasonal trend it is more common during summer also the same pattern observed by Umana et al. from Ireland and the reason is obvious as being more population movement during this period.[6] While it comes to the level of cervical spine injury C5 and C6 levels forms the majority with more than 63% and many patients had the combination of the levels. However, Umana et al. noticed C2 was the most common level in their study of the Irish population.[6] C5/C6 Fracture dislocation was found to be the most common cervical injury and the same being observed by Birua et al.[5]

The most common associated injury was extremities fracture (9.6%) and which was followed by head injury (8.4%) and then by blunt trauma chest in3.6%. The previous studies from India by Mathur et al. and Birua et al. showed 33% and 10.5%, respectively, had associated head injury.[5],[9] On assessing complications, 9.6% population had DVT and 12% presented with bedsore at the time of presentation. Most of the people from Northern India reach late to the hospital and the reason may be illiteracy, misconception, native treatment/referred late from the primary health center, etc.[4],[5] One Multicentric study previously by Aleem et al. shows 1.6% DVT.[10] Only 13% had no neurological deficit at the time of presentation and 15.7% had complete paraplegia (AIS Grade A) and the remaining majority falls between AIS Grade B to D.

The limitation of the study is that the autopsy reports of the suspected cervical spine injuries who were brought dead or succumbed to their injuries due to various reasons before radiology were not included and those admitted under nearby regional medical college hospitals were not collected. Although our spinal unit is the largest referral unit in Northern India, a multicentric study in different regions of India may give complete epidemiology of cervical spine injuries in our country.

  Conclusion Top

This epidemiological study showed that the most common mode of cervical spine injury in the developing world like India is fall from height and is followed by RTA. This differs from developed countries data where RTA form the most common mode. Cervical spine injury not only affects an individual but also create burden in the family and nation by creating economic and psychosocial stress. Simple safety measures as discussed, proper awareness programme, educating people, national policymaking, and involvement of NGOs and training primary health care workers will help in reducing the incidence of cervical spine injuries in this region.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Clayton JL, Harris MB, Weintraub SL, Marr AB, Timmer J, Stuke LE, et al. Risk factors for cervical spine injury. Injury 2012;43:431-5.  Back to cited text no. 1
Lowery DW, Wald MM, Browne BJ, Tigges S, Hoffman JR, Mower WR, et al. Epidemiology of cervical spine injury victims. Ann Emerg Med 2001;38:12-6.  Back to cited text no. 2
Singh R, Sharma SC, Mittal R, Sharma A. Traumatic spinal cord injuries in Haryana: An epidemiological study. Indian J Community Med 2003;28:184.  Back to cited text no. 3
Manjeet S, Siddhartha S, Iftikhar WH, Agnivesh T, Farid MH, Nirdosh M, et al. Spine injuries in a tertiary health care hospital in Jammu: A clinico-epidemiological study. Internet J Neurosurg 2009;5:2.  Back to cited text no. 4
Birua GJS, Munda VS, Murmu NN. Epidemiology of spinal injury in North East India: A retrospective study. Asian J Neurosurg 2018;13:1084-6.  Back to cited text no. 5
[PUBMED]  [Full text]  
Umana E, Khan K, Baig MN, Binchy J. Epidemiology and characteristics of cervical spine injury in patients presenting to a regional emergency department. Cureus 2018;10:e2179.  Back to cited text no. 6
Hasler RM, Exadaktylos AK, BouamraO, Benneker LM, Clancy M, Sieber R, et al. Epidemiology and predictors of cervical spine injury in adult major trauma patients: A multicentre cohort study. J Trauma Acute Care Surg 2012;72:975-81.  Back to cited text no. 7
Varma A, Hill EG, Nicholas J, Selassie A. Predictors of early mortality after traumatic spinal cord injury: A population-based study. Spine (Phila Pa 1976) 2010;35:778-83.  Back to cited text no. 8
Mathur N, Jain S, Kumar N, Srivastava A, Purohit N, Patni A. Spinal cord injury: Scenario in an Indian state. Spinal Cord 2015;53:349-52.  Back to cited text no. 9
Aleem IS, DeMarco D, Drew B, Sancheti P, Shetty V, Dhillon M, et al. The burden of spine fractures in India: A prospective multicenter study. Global Spine J 2017;7:325-33.  Back to cited text no. 10


  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]

  [Table 1], [Table 2], [Table 3]


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