Traumatic spinal injuries in the Kingdom of Saudi Arabia: a study of associated injuries, management and mortality

Introduction traumatic spinal fracture is a painful and disabling injury associated with poor long-term functional outcome. The objective of the present study was to assess the frequency of spinal fractures in road traffic accident (RTA) victims, their management, mortality rate and associated injuries. This study reveals and adds useful insights to the literature from Kingdom of Saudi Arabia (KSA) in terms of incidence of RTA-related spinal fractures, including their management and mortality rate. Methods a cross-sectional study was conducted at King Khalid Hospital and Prince Sultan Center for Health Services (KKH & PSCHS) in AlKharj, KSA from September 2016 to June 2017. A total of 120 patients suffering from spinal/vertebral fractures due to RTAs were included in this study. The data was collected from patients' charts, including age, gender, region or distribution of the spinal fracture, associated fractures, number of fractures, degrees of shock, admission to intensive care unit (ICU), treatment modalities, along with the management of spinal fractures, days of hospital stay, referral and discharges or deaths. Results the mean age of patients was 29.21. The most common anatomic region of the fracture was the cervical region (35%). Injuries associated with traumatic spinal fracture were predominated by clavicular fractures. More than half of the victims (58.30%) had a cervical brace applied before leaving the hospital. 29.20% patients required posterior stabilization with pedicle screws. Anterior corpectomy, grafting and plating was done to 4.30% patients. Conclusion traumatic spinal fractures require prompt diagnosis and timely management in order to improve the outcome.


Introduction
A spinal fracture is a disabling condition that imposes a significant effect on the patient's quality of life. It may potentially lead to disability, inability to work and poor social and financial outcomes.
Road traffic accidents (RTA) are considered the most frequent cause of spinal fractures all over the world [1]. The reason RTAs are the most common cause of spinal fractures may be attributed to the increasing number of vehicles on the roads. According to one estimate, KSA will have 10.03 million vehicles by 2020 [2]. RTAs are estimated to account for between 20.9% and 33.6% of all spinal fractures [3]. Generally, spinal fractures affect young adults and indicate a higher degree of injury severity, in terms of associated injuries and increased mortality rate [1,4]. RTAs result in a plethora of traumatic spinal injuries and associated injuries, depending on certain factors such as age, speed of the vehicle, type of crash and type of vehicle. Motor vehicle accidents account for 80.1% of spinal injuries in KSA [5]. Among RTAs, car accidents are a major cause of spinal fracture, contributing to 40% of RTA-related spinal injuries, where the most common mechanism of spinal injury is carrollover [6,7]. RTA-related vertebral fractures pose a higher severity of trauma, morbidity and mortality rate [5]. Increased severity, morbidity and mortality of patients with RTA-related spinal fractures depend upon several factors, such as old age, associated lifethreatening injuries or penetrating injuries, and co-morbid conditions [8]. Unfortunately, spinal injuries (6.6%) are often missed during primary survey at the accident site, which results in increased disability, and risk of death [9]. The reasons spinal fractures are missed may include lack of obvious spinal deformity or radiological findings. In these circumstances, spinal stabilization is a key intervention to avoid further damage to the patient. Therefore, when dealing with victims of RTAs, it is necessary to carefully examine the spine at the accident site, during the transportation of the victims and in the hospital. Common injuries, which accompany spinal or vertebral fractures, include injuries to extremities, head and chest, including fractures of ribs and the sternum [10]. A spinal fracture with concomitant rib or sternal fractures will adversely affect the outcome, and may cause neurological dysfunction. Studies have reported rib fractures in 7.2% to 17.8% of patients suffering from traumatic spinal fractures [10]. This means that patients with injuries to extremities, head, neck and chest are at higher risk of accompanied spinal trauma.
Hence, it is critical to look for a spinal injury and ensure stabilization to avoid further harming the patient. Delaying the diagnosis and management of spinal fractures increases morbidity and mortality [10].
The thoracolumbar region is the most common site involved in spinal or vertebral fractures [11]. Freitas et al. conducted a prospective study on vertebral fractures in 5995 elderly patients (age > 65 years) suffering from traumatic spinal fractures, and reported that 33.3% of vertebral fractures occurred at the thoracic level, 56% of fractures in the lumbar region and 10.7% of fractures in the cervical region [11].
In another cross-sectional study, Wang et al. [10]  corpectomy, grafting and plating) is to decompress the spinal cord canal, and stabilize the vertebral column [12]. An RTA-related spinal fracture is a painful and disabling injury associated with poor long-Page number not for citation purposes 3 term functional outcome (6%) [13]. The present study assesses the frequency of spinal fractures in RTA victims, their management, mortality rate and associated injuries. Comprehensive literature on the incidence of RTA-related spinal fractures in the Kingdom of Saudi Arabia (KSA) is lacking, including patient management and mortality rate. Hence, the present study is an important addition to the study.

Methods
We conducted a retrospective study, which included 120 patients suffering from spinal/vertebral fractures due to RTAs, at King Khalid and discharges or deaths. The hospital was visited on a daily basis to collect and record data on a proforma (attached) that was specially designed for the study. The data was saved in softcopy as well as in hard copies in respective file folders, and proper coding was done.
The data was properly managed by retaining the completed proforma and entering the data on a daily basis in SPSS-21 for statistical analysis. Data cleaning was done to check for any missing data or improperly filled questionnaires during data collection. Quantitative variables, such as age, number of fractures and duration of accident at presentation were derived by calculating the mean and standard deviations. Qualitative variables such as gender, marital status, ethnicity, education and mortality were derived by calculating frequency and percentages. After data analysis, the results were presented in the form of tables, graphs and figures.
Degrees of shock: more than half (58.3%) of the patients did not develop shock, and were stable. Of those remaining, 20.8% developed first degree shock, 16.7% developed second degree shock, and only 4.2% were reported to have developed third degree shock.
33.3% were admitted to the ICU from the accident and emergency department, and 48.8% of victims were referred to another hospital.
There was an overall mortality rate of 12.5% (Table 1).

Discussion
Spinal fracture, a painful and disabling condition, significantly affects a patient's quality of life in terms inability to work and poor socioeconomic outcome. In this retrospective study, the majority of the patients were young adult males. The reason behind the predominance of male gender is the jurisdiction in the country, wherein, the women were not allowed to drive until June 2018 [14].
The most common site of spinal fractures was the cervical region, (11.3%) and C2 (8.3%). In this context, the results of the present study do not match the results of research by Wang et al [10]. In their study, the most common victims were car drivers. However, they reported that the most common fractures among motorcycle drivers were at C3-C7. The reason behind the higher rate of cervical injuries in motorcycle riders may be attributed to being thrown from their bikes without being protected by car compartments. This means that the type of vehicle involved in MVAs affects the level of spinal fractures. Similarly, contrary to the results of the present study, Freitas et al. [11] reported that the majority of injuries were in the thoracolumbar region. This anomaly may be explained by their inclusion of traumatic spinal injuries other than those caused by RTAs.
However, there is a need for a large study to determine the relationship between the type of motor vehicle and level of traumatic spinal fractures. Similarly, Ovalle et al. [15] reported that the most common traumatic spinal injuries occurred in the thoracolumbar region. Yunoki et al. [16] retrospectively reviewed 134 patients with traumatic intracranial hemorrhage (ICH), skull fractures and spinal fractures among those whowere injured in traffic accidents or falls.
They reported spinal fractures in 10 patients, with the thoracolumbar region being the most common location of spinal fractures. In contrast, the most common level of spinal fractures seen in the present study was at C6, followed byL3. This difference between these two studies may be due to a number of factors, including the type of vehicle [10], type of trauma [11], vehicle speed at the time of the accident and preventive measures, such as seat belts. Spinal spinal column, decompression of spinal nerves, and surgery [17]. The most important management at this stage is to stabilize the spine, keeping the spinal collar in place and treating the spinal shock with emergency medical therapy. In the present study, patients with traumatic spinal fractures were managed with cervical collar, cervical brace, anterior or posterior stabilization with pedicle screws, anterior corpectomy, grafting and plating and skeletal traction. Traumatic spinal fractures are associated with higher severity, morbidity and mortality [5]. Serious spinal fractures (especially those with associated injuries) most often require ICU admission for intensive care. Such patients may require blood transfusions, particularly those who present with second and third degree shock. However, in the present study, the degree of shock did not affect the mortality rate.
The present study offers reliable local data related to traumatic spinal injuries, associated injuries and mortality, which may provoke interest in conducting further studies in order to validate the results of the present study and to implement policies to prevent spinal injuries at the local level. However, single-centered retrospective design of the present study does not enable the generalization of the study. Also, the present study had not determined the relationship of associated injuries in terms of mortality. Therefore, multi-centered prospective studies are required to validate the results of the present study.

Conclusion
In conclusion, a traumatic spinal fracture is a disabling condition which affects functional outcome. As a rule of thumb, prompt diagnosis and timely proper management improves the outcome.
Moreover, the implementation of traffic laws regarding speed limits, drinking, helmet and seatbelt usage will reduce MVAs and traumatic spinal fractures in KSA.

Competing interests
The authors declare no competing interests.

Authors' contributions
Khalid Mansour Alkhathlan: introduction, data collection and entry; Mohammad Ghormallah Alzahrani: discussion, data collection and entry; Khalid Hadi Aldosari: discussion, data collection and entry; Mohammed Ibrahim Alsheddi: data analysis, data collection and entry; Abdullah Abdulrahman Alqeair: result, data collection and entry. All the authors have read and agreed to the final manuscript.     Page number not for citation purposes 8