Severity and neurosurgical management of patients with traumatic spinal fractures in Saudi Arabia: a cross sectional study

Introduction Road traffic accidents (RTAs) are the most frequent cause of traumatic spinal injuries (TSIs), which account for up to 33.6% of all spinal fractures. The Kingdom of Saudi Arabia (KSA) is one of the countries which has high rates of SCIs and bears the economic burden of that situation. Methods 120 patients were included in this study, using a stringent set of inclusion and exclusion criteria. The patients were followed-up from the point of triage to admission and discharge. We analysed the clinical notes of the patients to determine the severity of their traumatic spinal injuries, the neurosurgical management carried out, and other prognosticating factors such as blood transfusion and the Glasgow Coma Scale (GCS). The data collected was analysed anonymously, and the confidentiality of all participants was respected. Results Most of the patients were young adults and adolescents under the age of 40 (n = 96). There was a male preponderance of 84.1%. With respect to spinal injury stratification, 55 patients had cervical spine fractures, 10 patients had cervical lacerations, 85 patients had thoracolumbar spinal fractures, and 10 patients had thoracolumbar spinal lacerations. 35 patients had other fractures documented. All 120 patients were followed up to assess the management of their traumatic spinal injuries. 66.6% (n= 80) of all patients were managed conservatively, whereas the remaining 33.3% (n=40) were managed surgically. Conclusion Trauma is an important cause of spinal injuries (TSIs), and untreated TSIs may lead to poor clinical outcome, especially if the cervical region is involved.


Introduction
Traumatic spinal injuries (TSIs) are a frequent cause of morbidity and mortality among young adults, contributing to substantial individual impairment, as well as considerable psychological and socioeconomic burden globally [1]. It has been estimated that 768,473 cases of TSIs occur annually around the world [2]. Every year, approximately 25,000-50,000 people experience spinal cord injuries (SCIs) worldwide, 90% of which are caused by trauma [3]. According to a recent estimate, SCIs resulted in 1,000,000 years of healthy life loss among the American population in a 44-year time span [4]. Road traffic accidents (RTAs) are the most frequent cause of TSIs, which account for up to 33.6% of all spinal fractures [5]. The Kingdom of Saudi Arabia (KSA) is one of the countries which has high rates of SCIs and bears the economic burden of that situation. Management of TSIs or SCIs is a clinical challenge for neurosurgeons, as these injuries result in profound and long-term devastating physical and socio-economic consequences. The pathophysiology of SCIs is unique and critical, as the primary traumatic injury leads to progressive secondary insult in the form of ischemia, apoptosis and inflammation of the affected tissues [6]. Subsequently, the inflammatory mediators and cytotoxic debris add to the post-traumatic microenvironment, resulting in further loss of function and related complications.
Therefore, the management of TSIs or SCIs is based on the management of the severity of the trauma and post-injury cascade of these events [6]. Standard management of TSIs or SCIs involves the protocols of basic life support (BSL), starting with the assessment of airway, breathing and circulation. Initial survey is followed by instant recognition of the spinal cord injury and rapid referral to the respective healthcare centers. Dealing with the patient suffering from a spinal injury is critical, as the treatment of such patients commences before the patient reaches the hospital. In this context, before handling or referring the patient to relevant centers, the immobilization of the injured part of the spine with the help of rigid cervical collar and backboard is very important because mishandling of patients with spinal cord trauma may worsen the injury, leading to poor outcome. It has been reported that 3-35% of spinal cord injuries develop after the primary injury during transportation and the early management [7]. Therefore, immobilization of the spine is the priority of pre-hospital management of the patients with spinal trauma.
Studies have reported that spinal immobilization results in improved outcome. However, this spinal stabilization should not delay the treatment of the patient with life-threatening penetrating trauma, as immobilization delays the life-saving resuscitation.
On reaching the hospital, thorough neurological assessment is performed using different scales of grading for SCIs. After that, radiological assessment using radiological tools to evaluate the possible pathology of the trauma using imaging techniques is carried out. It has been reported that the patients with spinal cord injuries are at high risk of hypotension and hypoxemia due to hypovolemia secondary to polytrauma and decreased sympathetic tone [6]. Local hypoperfusion may result in spinal shock, leading to the loss of vascular tone and further low blood pressure and hypoperfusion [7,8]. Therefore, large volumes of crystalloids or Norepinephrine may be needed to maintain blood pressure. However, aggressiveness of the management depends upon the severity of the injury. Use of steroids is still controversial in patients suffering from SCIs. In addition to cardiovascular complications, thermoregulatory and bronchopulmonary derangements are also common in patients with SCIs [8].   Table 1, Table 2, Table 3, Table 4, Table 5, Table 6 below. With respect to spinal injury stratification, out of the 120 patients who were recruited for this study, 55 patients had cervical  Tables Table 1, Table 2, Table 3, Table 4, Table 5, Table 6 Table 2, Table 3, Table 4, Table 5, Table 6 below.  Table 2, Table 3, Table 4, Table 5, Table 6 below. All 120 patients were followed up to assess the management of their traumatic spinal injuries. 66.6% (n= 80) of all patients were managed conservatively, whereas the remaining 33.3% (n=40) were managed surgically ( Figure 1). Of the surgically managed patients, 25% underwent surgical decompression of the spinal cord, 37.5% underwent surgical repair of the spinal cord, 12.5% underwent a craniotomy and evacuation, and 12.5% underwent cervical collar placement and fixation. These figures can be referenced in Table 1 below. 26.6% of patients required an admission to the ICU, and 54.2% of patients were referred to another hospital for further management.

Discussion
Traumatic spinal cord injury (TSCI) is devastating, and the neurological sequelae associated with it constitute a significant burden to the affected patient, and the healthcare system as a whole [11].         Figure 1: management of traumatic spinal injuries