The epidemiology of spinal fractures: A nationwide data-based study in Iran

Background Blunt trauma is a physical injury to a part of the body, mainly caused by road accidents, direct blows, attacks, sports injuries, and falls in elderly people. Spinal fractures are observed only in a small percentage of injured patients. Accordingly, the present study was conducted on collected data between 2018 and 2022 to determine the frequency of spinal fractures in blunt trauma in Iran while also considering the mechanism of injury as a secondary outcome of interest. Methods In this retrospective study, blunt trauma patients with spinal fractures, regardless of age were included by the census sampling method. Data were obtained from the National Trauma Registry of Iran. Means and standard deviations were used for continuous variables, and the chi-square test was used to assess the relationship between the variables. Results Among 25,986 cases of all-cause trauma patients, 1,167 cases (4.5%) of blunt trauma and spinal fracture were included in the study. Gender, the severity of injury, and the cause of trauma showed a significant difference among different age groups (p < 0.05). Significant differences were found in the injury mechanisms across various spine regions (p < 0.05). The majority of patients (68.2%) had lumbar spinal fractures. Road traffic collisions were the most common cause of spinal cord injuries, accounting for 58.3% of cases, followed by falls (36.1%). The injury severity score was higher in younger patients (under 18 years old), with a mean of 4.4 ± 3.5, and in patients with cervical injuries. The majority of injuries occurred in the lumbar area (68.2%), followed by the thoracic area. Furthermore, notable variations existed in Emergency Room (ER) stay duration, overall hospitalization, Intensive Care Unit (ICU) stay duration, and injury severity levels, all influenced by the spinal regions (p < 0.05). Distinctively, ICU stay durations and ER stay duration showed significant differences, particularly in relation to injuries in the lumbar and thoracic regions (p < 0.05). Conclusion According to the results of the present study, trauma is more severe, and cervical injuries are more common in young people, which is a critical finding that underscores the need for targeted interventions to mitigate the severity of trauma in this age group. Additionally, the majority of cervical injuries occurred in young people, which is a particularly concerning finding given the potential for long-term disability and impact on quality of life. Our findings suggest that strategies to reduce cervical injuries, such as speed control, seat belt use, and phone-free driving, are crucial interventions for mitigating the severity of trauma and promoting patient outcomes in young people.


ABSTRACT
Background: Blunt trauma is a physical injury to a part of the body, mainly caused by road accidents, direct blows, attacks, sports injuries, and falls in elderly people.Spinal fractures are observed only in a small percentage of injured patients.Accordingly, the present study was conducted on collected data between 2018 and 2022 to determine the frequency of spinal fractures in blunt trauma in Iran while also considering the mechanism of injury as a secondary outcome of interest.Methods: In this retrospective study, blunt trauma patients with spinal fractures, regardless of age were included by the census sampling method.Data were obtained from the National Trauma Registry of Iran.Means and standard deviations were used for continuous variables, and the chisquare test was used to assess the relationship between the variables.Results: Among 25,986 cases of all-cause trauma patients, 1,167 cases (4.5%) of blunt trauma and spinal fracture were included in the study.Gender, the severity of injury, and the cause of trauma showed a significant difference among different age groups (p < 0.05).Significant differences were found in the injury mechanisms across various spine regions (p < 0.05).The majority of patients (68.2%) had lumbar spinal fractures.Road traffic collisions were the most common cause of spinal cord injuries, accounting for 58.3% of cases, followed by falls (36.1%).The injury severity score was higher in younger patients (under 18 years old), with a mean of 4.4 ± 3.5, and in patients with cervical injuries.The majority of injuries occurred in the lumbar area (68.2%), followed by

INTRODUCTION
Trauma refers to any impact, injury, shock, wound, or event that affects the human body due to external causes, as opposed to internal factors like diseases. 1,2Such incidents may result in severe complications, disability, and financial and social burdens. 3Spinal cord injury (SCI) is a serious medical condition that often results in severe complications and permanent disability.This kind of injury occurs when nerve axons that pass through the spinal cord are disrupted, leading to loss of motor and sensory functions beneath the injured area.Injury is usually the result of major trauma, and the initial injury is often irreversible. 4njuries to the spinal cord are classified as either traumatic [traumatic SCI (TSCI)] or nontraumatic [nontraumatic SCI (NTSCI)], and trauma is the most common cause of SCI globally. 5 The epidemiology of spinal fractures: A nationwide data-based study in Iran a less pronounced male-to-female ratio, and etiology related to malignant neoplasms or degenerative conditions. 7The aging population has led to a significant rise in the average age of SCI and the occurrence of cervical injuries. 7,17In Italy in 2020, the average annual incidence rate was 17.9 cases per million populations. 6This has made health policymakers consider modifications to both organizational and clinical rehabilitation approaches. 6,16On a global scale, an estimated 9 million SCI cases were reported in 2019, marking a 52.7% increase since 1990.The age-adjusted incidence rate for SCIs in 2019 was 11.5 per 100,000 population, with no significant changes observed in the incidence rate between 1990 and 2019 for both males and females. 17ccording to a single-center study conducted in South Korea, the main cause of TSCI is blunt trauma, which mostly occurs as a result of motor vehicle accidents (48%), falls (21%), and sports injuries (14.6%). 18As per recommendation from the World Federation of Neurosurgical Societies Spine Committee recommendations on epidemiology, prevention, and early management of cervical spine injuries, nevertheless, it should be noted that most SCIs (60%) occur in healthy young men aged 15-35 years, and cervical injuries are the most common. 19Furthermore, 80% of patients with SCI have multisystem injuries, including other bone fractures (29.3%) and traumatic brain injury (11.5%). 20In Scotland, falls are the most common precipitator of SCI, followed by road traffic accidents. 5The most common cause of SCI in Western and Central Europe is falls; a common phenomenon in the elderly population. 21n the United States, the most common cause of SCI was motor vehicle collisions (MVCs), which accounted for 38% of new SCIs each year, followed by falls (30%), violence (13%), sports injuries (9%), and medical and surgical problems (5%). 22he prognosis for patients with SCI is very poor, and there is no definitive treatment for the recovery of SCIs.Less than 1% of patients recover before discharge from the hospital. 23The level of disability is directly related to the level of injury.SCI patients suffer significantly higher mortality in the first year after injury, and those who survive still have reduced life expectancy, and merely 12% continue their careers. 24CIs are one of the main causes of disability, which especially affects healthy young people with important socio-economic consequences and causes lifelong care and rehabilitation costs.To gain comprehensive insights into spinal fractures resulting from blunt trauma incidents in Iran, a study was conducted using data collected from 2018 to 2022.This study aimed to ensure a diverse age group representation, thus providing valuable information on the prevalence and characteristics of these injuries across different age groups in the country.Besides determining the frequency of these fractures, the research also explored the injury mechanisms involved as a secondary objective.Upon concluding the analysis, the researchers plan to propose recommendations to help alleviate the issue based on their findings, ultimately contributing to improved prevention and management strategies for spinal fractures resulting from such incidents.

METHODS
This retrospective cohort study was performed on data collected between 2018 and 2022 based on the Trauma Registry data from 14 Trauma Centers, which together constitute the National Trauma Registry of Iran (NTRI).We used this database to identify blunt trauma patients with spinal fractures.The database contains information including demographic information (age, gender, etc.), injury information (cause of trauma, type of trauma, etc.), comprehensive clinical information, diagnostic codes (International Classification of Diseases-Ten Version, ICD-10-CM), severity of injury, and patients' outcomes.In this study, as the researchers only had access to anonymous data that did not permit the identification of individuals, the Research Ethics Committee of Isfahan University of Medical Sciences approved the utilization of such data without requiring patient consent (Approval No.: IR.MUI.MED.REC.1401.043).All individuals admitted to the 14 trauma centers from 2018 to 2022, with TSCI as per ICD-10-CM codes S12.0 to S12.2, S12.7, S22.0, S22.1, and S32.0, were eligible for inclusion. 25A total of VOL.2024 / ART.42 The epidemiology of spinal fractures: A nationwide data-based study in Iran blast waves, animal bites, unknown factors, and so on.Figure 2 shows the injury mechanism in each anatomical region of the spine.A significant difference was observed between the mechanism of injury in each anatomical region of the spine (p < 0.05).Specifically, the lumbar region was more affected by various injury mechanisms compared to other regions.Table 2 and Figure 3 display the demographic and clinical characteristics of patients categorized by the anatomical region of the spine.We found a direct relationship between the amount of time people stayed in the Emergency Room (ER) and Intensive Care Unit (ICU) and the injury severity in TSCI patients (p < 0.05).Figure 4

DISCUSSION
After analyzing a sample consisting of 1,167 patients with blunt trauma and spinal fracture, according to Table 1, the average age was found to be 43.9 ± 5.5 years, with 816 (69.9%) of them being male.The majority of patients, 796 (68.2%), had lumbar spinal fractures.Road Traffic Collisions (RTCs) with 680 (58.3%) cases and falls with 421 (36.1 %) cases were the most frequent causes of SCI injuries, respectively.The severity of injury mean was equal to 4.4 ± 3.5.In 2021, Iran's population, as reported by the World Bank, was approximately 83.85 million.The population had a gender distribution with males constituting 47.7% and females making up 52.3%.The United Nations provided age distribution data for 2020, highlighting that the majority were under 65 years old.Among these age groups, the 25-54-year demographic contributed 46.59% to the population, while the 10-24 years age group accounted for 15.74% of the total population.The injury severity score was higher in younger patients (under 18 years old).RTCs were more common in the 19-49 age group, while non-road traffic accidents were more frequent in the age group above 50 years.Men outnumbered women in all age groups.Also, according to the results of Table 1 and Figure 1, falls were reported as the 1,167 patients with blunt trauma in at least one of the cervical, thoracic, or lumbar vertebrae were included in the study by the census sampling method.The exclusion criteria were any blunt fracture other than the cervical and thoracolumbar and brain death patients.Injuries to the sacrum were not considered because the sacrum is a fixed vertebra and is normally considered part of the pelvis.Also, to predict the outcome and likelihood of mortality, the injury severity score (ISS) was used.The ISS is an anatomical scoring system that provides an overall score for patients with multiple injuries.Every injury is given a score based on the abbreviated injury scale and is assigned to one of the six body regions.The ISS score is calculated by squaring the scores of the three most severely injured body regions and adding them together.The ISS score goes from 0 to 75. 26 Statistical Package for Social Sciences was used for the statistical analysis (Version 22, IBM Corp., Armonk, NY, USA).In terms of descriptive statistics, means and standard deviations were used for continuous variables and percentages were used for categorical variables.The chi-square test was used to assess the relationship between the variables and to explore the risk factors.A p-value of <0.05 was defined as statistically significant.

RESULTS
From 2018, there were 25,986 traumatic cases registered on the NTRI website.Out of these cases, 1,167 cases (4.5%) were related to blunt traumas and spinal fractures.Table 1 and Figure 1   The epidemiology of spinal fractures: A nationwide data-based study in Iran most common cause of injury in men over 50 years old.A statistically significant difference was observed between the causes of injury in each anatomical region of the spine, as shown in Figure 2. The majority of injuries occurred in the lumbar area, followed by the chest area.According to Table 2, there was a statistically significant difference observed between the length of stay in ER, hospitalization and length of stay in the ICU, and the severity of injury by the anatomical region of the spine, the severity of injury being higher in the cervical region.Finally, gender, the severity of injury, and the cause of injury showed a statistically significant difference among different age groups.
Although other studies have been conducted on patients with spinal fractures, few studies have followed the objectives of this study.In 2023, Rayatdoost et al. 27 conducted a study on patients with SCIs in Jahrom, Iran.The participants had an average age of 40.89 ± 15.85 years, and 78.7% of them were male, and the main causes of injury were reported to be RTCs (58.70%) and falls (33.30%).These findings were consistent with the results of the present study.In 2020, Andalib et al. 28 evaluated 1,014 patients with TSCI in Isfahan (Iran) and reported that the most common mechanism of trauma was RTCs (83.4%) followed by falls (12.7%), and the lumbar area had the highest incidence of TSCI (38.3%) followed by thoracic spine fractures (27.4%).These results aligned with the outcomes obtained in the current investigation.According to the high agreement between the results of our study and the findings of the two studies of Rayatdoost and Andalib that were conducted in Iran, the similar road accident rates among young people in various parts of Iran could be attributed to a range of factors such as infrastructure, road conditions, driving culture, enforcement of traffic laws, and access to education and resources regarding safe driving practices.Furthermore, driving behaviors and risk-taking tendencies among young people may also be influenced by societal and economic factors in different regions. 29 In the Swedish Fracture Register, 27,169 fractures were reviewed by Bergh et al. 32 The average age at the time of fracture was 57.9 years (ranging from 16 to 105 years), and the majority of fractures (64.5%) occurred in women.The results of this study were also not consistent with those of the present study.This disparity could potentially be attributed to not only variations in trauma patterns across distinct nations but also to disparities in population demographics.Notably, the higher age of trauma and fractures observed in Bergh's study average age of the patients was recorded as 37.10 years, with males accounting for 79.2% of the cases.The most frequent cause of injury was road accidents with 54.5%, and the lumbar spine was the most common fracture site with 47.5%.
Notably, the study identified sex, nationality, anatomical site of fracture, and injury mechanism as significant risk factors.The findings of this study were more similar to the results obtained in the present study.In the other study conducted by Utheim et al. 33 a total of 2,153 patients with traumatic cervical fractures were reviewed over a span of 5 years in Norway.The average age of the patients was 62 years, with 68% being male.Among the patients, 53% had multiple traumas, while 12% had cervical spinal injuries.Most of the injuries were caused by falling (57%), but this finding was different from what we found in our study.The differences in results can be due to differences in the age groups involved with trauma in the two studies.That is to say, the patients were younger in the current study, so RTCs are the most common mechanism of trauma, but in Utheim's study, which includes the elderly, falls were the most common mechanism of trauma. 33 the year 2018, Passias et al. 34  Although the age groups in the two studies were different, the cause of trauma in both studies was MVC.
Consistent with previous research, [31][32][33][35][36][37][38][39] our findings indicate a higher incidence of trauma in men compared to women. Furthemore, the finding of this study showed that the most prevalent mechanism of injury in Iran is road accidents, highlighting the need for increased attention to traffic laws in the country.The authors of the above-cited articles suggest implementing measures to increase road safety, such as using cell phone blocking technology, satellite technology, self-driving or connected and autonomous vehicles, Internet of Things, artificial intelligence, and 5G.38 They also propose enforcing traffic laws, such as effective punishment, improved police enforcement   (with enhanced demerit points for young drivers and drug testing, etc.), educating the public about road safety hazards, and improving young driver culture and attitudes, raising the level of traffic standards, and providing secure transportation facilities to prevent and manage TSCI.39 These actions are crucial for managing the growing number of individuals with TSCI as young adults are considered a critical population due to their role in society as the backbone of society, the reserve force, the active force, and the national treasure of society.

Limitations
Our study has a few limitations.First, due to some incomplete information, the accuracy and reliability of the study's findings could have been affected as missing or inaccurate data could lead to errors in analysis and interpretation of results.Second, although this study included a relatively large number of patients, its sample size could still be considered relatively small, which could limit its generalizability and applicability to other populations.Third, the accuracy and completeness of the data in the registry may vary depending on the reporting practices of individual hospitals.Some hospitals may have more complete data than others.Finally, it is essential to note that this study focused solely on blunt trauma and spinal fractures as causes of spinal injuries; however, some injuries could also result from other mechanisms such as tumors or infections, which were not addressed in this study.Therefore, future research should aim at addressing these limitations and expanding its scope by including a wider range of spinal injuries and populations in its study design.

CONCLUSION
According to the results of the present study, trauma is more severe, and cervical injuries are more common in young people, which is a critical finding that underscores the need for targeted interventions to mitigate the severity of trauma in this age group.Additionally, the majority of cervical injuries occurred in young people, which is a particularly concerning finding given the potential for long-term disability and impact on quality of life.The safety of young drivers, particularly young

Figure 1 .
Figure 1.Demographic chart of the distribution of gender, hospitalization, type of accidents, and level of involvement of the vertebral column, categorized by age groups.

Figure 2 .
Figure 2. Injury mechanism of traumatic spinal cord injury patients in each anatomical region.

Figure 3 .
Figure 3. Demographic chart of average age, duration of hospitalization, and severity of injury based on ISS, categorized by the location of vertebral injury.

Figure 4 .
Figure 4. Demographic chart of average age, duration of hospitalization, and severity of injury based on ISS, categorized by age groups.
Conti et al.'s study provided insights into the incidence and mortality of SCI in Italy's Piedmont Region from 2008 to 2020 through a retrospective population-based cohort study.The study found that Italy's SCI also shows the demographic chart of average age, duration of hospitalization, and severity of injury based on the ISS score, categorized by age groups.

Table 1 . Demographic and clinical characteristics of patients with traumatic spinal cord injury by age group.
display the demographic and clinical characteristics of patients categorized by age group.The analysis by gender, severity of injury, and cause of trauma depicted a significant difference among various age groups (P < 0.05).The epidemiology of spinal fractures: A nationwide data-based study in Iran

Table 2 . Demographic and clinical characteristics of patients by the anatomical region of the spine.
reviewed 488,262 patients by using the National Inpatient Sample database for the United States.The mean average age of the patients was 55.96 years and males constituted 60% of the studied patient sample.MVCs and falls were independently associated with cervical spine injury.It was found that MVCs accounted for 29.3% of cases.Moreover, the most prevalent fracture type, observed in 32% of instances, was related to the C2 vertebra.