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Year : 2015  |  Volume : 18  |  Issue : 2  |  Page : 203-208

Cervical Spine Injury: A ten-year multicenter analysis of evolution of care and risk factors for poor outcome in southeast Nigeria

1 Neurosurgery Unit, Department of Surgery, University of Nigeria Teaching Hospital (UNTH), Enugu, Nigeria
2 Orthopaedic Unit, Department of Surgery, Enugu;, Nigeria
3 Hilltop Orthopaedic Hospital, Enugu, Enugu State, Nigeria
4 Neurosurgery Unit, Department of Surgery, University of Nigeria Teaching Hospital (UNTH), Enugu; Department of Surgery, Federal Medical Center, Umuahia, Abia State, Nigeria

Date of Acceptance28-May-2014
Date of Web Publication10-Feb-2015

Correspondence Address:
E O Uche
Department of Surgery, University of Nigeria Teaching Hospital (UNTH), Ituku Ozalla, Enugu, Enugu State
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/1119-3077.151042

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Study Design: Retrospective study.
Objective: To describe the evolution of care and risk factors for poor outcome in patients with cervical spine injury (CSI) treated at three centers in southeast Nigeria.
Setting: Nigeria, southeast.
Materials and Methods: A 10-year retrospective multicenter analysis of patients with CSI, managed at three centers in southeast Nigeria, from January 2003 to December 2012.
Results: Two hundred and seven patients (55%) had CSI out of 377 spinal injury cases in the three study centers, but 195 cases had complete records and were studied. There were 148 males and 47 females. The age range was 3-74 years with a mean of 32.6 (΁1.9) years 95% CI. Most injuries (149 cases) resulted from motor vehicular accidents (MVA). The C5 spinal level was involved in 75 (38%) cases One hundred and seventeen patients (60%) presented with American Spinal Injury Association A (ASIA A) injury. CSI care evolved from the application of a Minerva jacket or cervical traction only to cervical traction and spinal fusion resulting in a reduction in hospital stay (F = 52.5, DF (2, 3) P < 0.05). When compared to 51 patients with incomplete injuries, who improved in neurologic al status at discharge, only three patients with ASIA grade A experienced some improvement. The mortality rate from our series is 16% (32 patients). Those who died were more likely to have a complete injury (25 patients) or a high cervical injury (X 2 = 61.2, P < 0.05) among other factors.
Conclusion: The cervical spine is the most commonly injured spinal segment in southeast
Nigeria. Although treatment evolution has resulted in reduction of hospital stay, the associated mortality risk still remains high.

Keywords: Cervical spine injury, pattern, southeast Nigeria, treatment outcome

How to cite this article:
Uche E O, Nwankwo O E, Okorie E, Nnezianya I. Cervical Spine Injury: A ten-year multicenter analysis of evolution of care and risk factors for poor outcome in southeast Nigeria. Niger J Clin Pract 2015;18:203-8

How to cite this URL:
Uche E O, Nwankwo O E, Okorie E, Nnezianya I. Cervical Spine Injury: A ten-year multicenter analysis of evolution of care and risk factors for poor outcome in southeast Nigeria. Niger J Clin Pract [serial online] 2015 [cited 2020 Jul 5];18:203-8. Available from:

   Introduction Top

Cervical spine injury (CSI) is a known major contributor to the disability and death burden of spinal injuries worldwide. [1],[2],[3],[4],[5],[6],[7] This reputation for a high mortality risk is in part due to a high incidence of associated severe neurological impairment and respiratory complications. [7],[8],[9] Serious injuries of the cervical spine are becoming increasingly common in the western world [8],[10],[11],[12] and also in our region. [1],[2],[3],[4] Management of patients with CSI requires a holistic care approach as well as functional emergency medical services to salvage these patients and restore them to a useful life. [7],[8],[10]

Observations from our previous studies and those of other workers had suggested that the cervical spine segment was the predominant region of the spine involved in spinal injury. [1],[2],[3],[4],[6],[10] and CSI was complicated by a high mortality and morbidity risk. [7],[8],[9],[10] We have, by our current study, cultivated these observations by focusing on CSI in the three tertiary hospitals in southeast Nigeria, where we cared for them, to ascertain how it has evolved over a 10-year period.

   Materials and Methods Top

The medical records of patients with CSI from January 2003 to December 2012 were retrieved for analysis. The patients' demographics, relevant clinical and radiological (including MRI) findings, and follow-up data were recorded. The outcome was defined as the American Spinal Injury Association (ASIA) Impairment Scale (AIS) status on discharge or death. The AIS grade was used to identify the methods of treatment over the study period. These data were analyzed using the statistical package for social sciences program, version 16 (Chicago Il, USA). All cases with incomplete records were excluded. A rigid cervical brace with chin support, preferably a Philadelphia collar, was applied to all trauma patients suspected to have cervical spine injury in the Emergency Room during resuscitation. However, due to incomplete records, we could not study the degree of compliance among the patients. A 12-week program for management of patients with spinal cord injuries, with the aid of relatives, previously described in one of the study centers, [1],[2] was applied for the care of patients managed conservatively.

Patients with unstable CSI were mainly treated with Minerva jacket application or cervical traction with Crutchfield or Gardner-Wells tongs. However, from our data, some patients with unstable CSI were treated with operative reduction and spinal fusion during the last half of the study period. Other patients who received surgical treatment included those with penetrating injury, presence of a foreign body in the spinal canal or evidence of persistent or progressive cord compression. Documented surgical procedures performed varied from laminectomy or hemilaminectomy with or without fusion for canal decompression, to laminectomy with dural repair for penetrating injuries or foreign body in the spinal canal with associated cerebrospinal fluid leakage.

Posterior spinous process wiring (Roger's technique) was the documented procedure

performed for most unstable fractures affecting the posterior column, while for anterior

column injury, cervical discectomy with or without corpectomy and fusion using an autologous tricortical iliac graft, without instrumentation, was the procedure performed. Patients who received operative treatment were managed with a neck brace in the postoperative period for a minimum of six weeks. AIS was used in the assessment both on admission and at discharge. Improvement and/or deterioration in the spinal injury impairment scale during admission and within a six-month follow-up period were recorded. For patients who died, the cause (s) of death were also analyzed.

   Results Top

Three hundred and seventy seven patients presented with spinal injuries in the study centers within this period. Two hundred and seven (55%) patients had CSI, but 195 had complete records, and were studied. Patients whose injuries were localized to the cervical region were distributed as follows: UNTH 105, Hilltop Hospital 30, and FMC Umuahia 60. There were 148 males and 47 females (M: F =3.15: 1). Age range was from three years to 74 years with a mean of 32.6 (±1.9) years, 95% CI, as presented in [Table 1]. Students (45), farmers (40), and traders (33) were the most commonly affected occupational groups. Other occupation al groups affected include d civil servants (27), transporters (20), military/police (10), artisans (10), sportsmen (five), and retired civil servants (five) [Table 2].
Table 1: Age distribution (years)

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Table 2: Occupational groups

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Most CSI (n = 149 cases, 76%) resulted from motor vehicular accidents (MVA). Falls in 30 cases and assault in 16 cases were the other causes of spinal injury recorded in our series. Among the MVA cases , the implicated vehicle type was a commuter bus in 51 cases, motor bike in 39, car in 27, lorry/trailer in 20, and tricycle/bicycle in 12. One hundred and one cases were passenger accidents, while 48 were pedestrian injuries. Thirty patients sustained injuries from a fall. Thirteen of the fall victims sustained their spinal injury from building scaffolds, seven from trees, five under the weight of a heavy object, while the remaining five experienced the fall at home. Among the patients who sustained injury from assault, seven experienced armed robbery attack, five were interpersonal assault, while three experienced mob assault. The mechanism of injury was flexion in 103 cases, axial loading in 30, extension in 35, distraction in 12, and shea ring in 15. CSI was classified as ASIA A in 117 patients, ASIA B in 15, ASIA C in 29, ASIA D in 21, and ASIA E in 13 [Table 3].
Table 3: Pre - treatment injury grade (ASIA Impairment scale)

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The C5 segment was injured in 75 cases, C6 in 35, C7 in 23, C4 in 33, C3 in 10, and C1 - C2 in 19 [Table 4]. Anterior column injury occurred in 31 cases, posterior column injury in 23, and middle column injury in 11. In many cases (n = 85), two or more columns were affected. Fifteen (15) cases were with spinal cord injury withoutradiographic abnormality (SCIWORA). Fifty-three 53 (27%) patients had associated injuries - chest trauma 15 patients, long bone fractures 15, head injury 10, abdominal trauma five, urogenital trauma three, and polytrauma five.
Table 4: Spinal column injury

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Forty-two patients had associated medical illness prior to their injury; 20 patients had diabetes mellitus and 22 patients had hypertension. Two patients had vertebral artery transections and in one, the vertebral artery injury was bilateral. Complications recorded included respiratory tract infection/aspiration 35 patients (18%), respiratory failure 13 (7%), bedsores 33 (17%), urinary tract infections 31 (16%), deep vein thrombosis 27 (14%), and autonomic dysreflexia eight (4%). Fifteen patients had two or more complications.

For initial care, all patients had rigid cervical bracing. Seventy-five (75) patients in addition had Gardner-Wells traction and 84 patients had Crutchfield tong traction, while 29 patients were treated with the Minerva Jacket. Of the remaining seven patients with gunshot injuries, five required emergency spinal canal exploration, and foreign body evacuation, while two were managed with local wound care and a neck brace because the spinal canal was not breached. On the whole, 37 patients were treated with an operation, while 158 patients were managed conservatively. Open reduction was performed in 30 cases. I n 23 of these patients, the approach was posterior fusion using bone graft with spinous process wiring (20 patients) and with Sonntag's modified Gallie fusion for C2 fractures (three patients), while in seven patients, anterior cervical discectomy/corpectomy with fusion (ACDF) was performed. Among those who had spinal fusion, no case of pseudoarthrosis was reported. There were also no graft recipients or donor site complications.

Duration of treatment varied from eight hours (one-third day) to 265 days (mean 121.7 ± 3.9 days 95% CI) and ranged from 25.5 ± 1.1 days for open reduction to 70.3 ± 2.1 days for traction alone to 257 ± 7.8 days for those treated with the Minerva jacket. One way analysis of variance (ANOVA) test showed a significant difference in the duration of hospital admission among the various modalities of treatment, F = 52.5, DF (2, 3) P < 0.05) [Figure 1]. During the initial half of our study period, 76 (39%) CSI patients were treated. Twenty-seven (13.9%) patients were managed with a Minerva jacket, while 49 (25.1%) received traction and none of the patients had spinal fusion. In the second half of the study, 119 (61%) patients were treated, two (0.02) received the Minerva jacket, 110 (92.4%) had traction, while 30 (15.4%) received surgical treatment [Table 5]. Twenty-four (24,80%) patients of the surgery group were AIS C, D or E, while six (20%) were AIS A or B. Seventeen (17) patients experienced improvement in AIS during the first half of our study, while 37 patients improved during the second half of the study period. Patients who improved were treated with traction and spinal fusion, as compared to those who received the Minerva jacket, and were mostly AIS C, D or E and this relationship was statistically significant using the chi square test (X 2 = 12.0, df = 1, P <0.05) [Table 5]. Four (4) patients deteriorated in AIS during the study period. Three of the patients who deteriorated were treated during the first half of the study period. Among those with complete injuries (n = 117) 89 remained the same, three improved while 25 died. Fifty-one (51) of those with incomplete lesions (n = 78) improved, 20 remained the same, while seven died. Overall, 32 (16%) patients died in our series, 25 (78%) of those who died were AIS A and 19 deaths (59%) occurred during the initial half of the study period [Table 5]. Causes of death include d respiratory failure in nine cases (including the two patients with vertebral artery injury), aspiration five, severe sepsis 11, and pulmonary embolism seven. An analysis of the mortality cases showed high cervical injuries, n = 17 out of 29 patients. The chi square and odds ratio distribution of factors were statistically associated with a high mortality risk in our CSI patients, as shown in [Table 6].
Figure 1 : Treatment modality and mean duration of treatment

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Table 5: Relationship between Study Interval, AIS, Treatment modality, and outcome

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Table 6: Risk factors for increased mortality

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   Discussion Top

Cervical spinal injury, besides the general risk of loss of motor and sensory function that occurs in persons with spinal cord injury is associated with an increased morbidity arising from respiratory complications that occur, especially in patients with high cervical cord injuries. [12],[13],[14],[15] In addition, reduced ability or inability to regulate the heart rate, blood pressure, sweating, and body temperature are common in cervical and upper thoracic injuries, because of autonomic nervous dysfunction. [14],[16],[17] Furthermore, patients with complete lesions above C7 lose the capacity to satisfactorily sustain the normal performance of most activities of daily living, and therefore, cannot function independently. [12],[13] Accounting for 55% (207 of 377) of all spinal injuries, CSI shows a more frequent occurrence in comparison to injuries of other spinal regions and this is consistent with our previous experience and those of other workers from our subregion and elsewhere. [2],[3],[4],[6],[7]

This frequent involvement of the cervical spine may result partly from its higher mobility when compared to other segments of the spine, which renders it more vulnerable to dangerous loading resulting from a sudden application of flexion, extension, rotational, as well as compression forces. [5],[6],[7] Cervical spine injury from this study [Table 1] as well as our previously published study [3] tends to occur more commonly among the younger age groups and students in particular are among the most affected occupational groups [Table 2]. Males were the predominant victims of CSI (M: F = 3.15) and this has also been suggested by previous reports. [3],[7],[12] MVA (76%) and falls (15%) have been the main causes of CSI and this trend has also been previously reported in our environment and elsewhere. [2],[3],[4],[5],[8],[12]

Flexion injury (53%) was the most commonly documented injury mechanism responsible for CSI from our study. A similar trend has also been reported by Kiewerski in Poland. [18] AIS A grade was the most common injury grade occurring in 60% of cases, indicating a more severe functional impairment among our CSI patients. Also, 44% of our CSI patients presented with unstable fractures and 15% sustained high cervical injuries (C4 and above). From our study, C5 was the most commonly affected vertebral segment. However, Ersmark and co-workers [8] in Sweden have reported that the C2 vertebral level is the most commonly injured segment followed by C5. The relatively low occurrence of C1-C2 injuries in our series may also have resulted from a high incidence of missed injuries on conventional imaging, which has been reported to be common with C1-C2 injuries, especially when the injury is asymptomatic. [9],[10] Associated injury occurred in 27% of the cases, further increasing the severity of injury in these patients. Medical comorbidity affected the course of CSI care in 22% of the patients. The evolution of measures for cervical spine reduction and immobilization over the study period provides a view of the paradigm shift in the approach to care. In the early half of the study period, neck bracing with collar and the original Minerva jacket (thermoplastic type was not available) or Crutchfield tong traction were employed, almost exclusively, for reduction and immobilization, together with the 12-week program for management of the spinal cord injured with participation of the patients' relatives. [1],[2] Operative reduction was not performed during this segment of the study period, except for patients with gunshot injury or foreign body in the spinal canal.

Among the 76 patients treated during the initial half of our study, 27 patients were treated with a Minerva jacket, while 49 patients had cervical traction. Seventeen patients experienced some improvement, while four patients deteriorated in the AIS grade. No patient with AIS A improved during this period [Table 5]. Also, the burden of care of the cervical spine injured patients was borne by the few orthopedic surgeons with interest in spine care, as there were very few neurosurgeons in our region at that time. [1],[2],[3] In the last half of our study period, more patients (n = 119) with CSI were treated. The Minerva jacket was used in treating only two (0.02%) patients, while cervical traction was used to treat most CSI patients (n = 110). Additionally, spinal fusion techniques (n = 30) were performed in the latter half of the study, as a result of a useful collaboration between neurosurgeons and orthopedic surgeons, thereby, providing multidisciplinary care to patients with CSI. Patients who improved (37 of 119 cases) were treated with traction and spinal fusion, as compared to those who received the Minerva jacket (0 of 29 cases), and were mostly AIS C, D or E (32 cases) and this relationship was statistically significant when using the c hi square test (X 2 =12.0, df = 1, P < 0.05) [Table 5]. This suggests that traction and spinal fusion may more positively affect the outcome, especially among CSI patients with these AIS grades, in comparison to the Minerva jacket application. The evolution of care for CSI patients from more conservative measures in the initial period to cervical traction and spinal fusion in the later stages of our study, was associated with a significant reduction in the overall length of hospitalization [Figure 1]. This experience may have reduced the cost of care for this subgroup of patients, especially with the useful application of a cheap and affordable adult traction device, popularized by other workers in our country. [14] We could not study the cost of care of our patients as a result of incomplete records. We cannot, therefore, make statistical conclusions. This we believe is a limitation of our study. Factors associated with increased mortality risk in our study [Table 6] include high cervical injury (Odds ratio: 11.8, X 2 =61.2, P < 0.05) and this has also been previously reported. [13 ] The dearth of emergency medical services and facilities for intensive and critical care of patients with a life-threatening injury requiring respiratory and cardiac support, such as, high cervical injuries in our country, [3],[15] may contribute to the high mortality experienced by this subgroup of patients. Elderly patients with CSI, as well as those with medical comorbidity and associated chest or brain trauma, were also associated with high mortality risk. These factors have previously been associated with high mortality among patients with spinal injury. [14],[15],[19] The mortality rate of 16% (32 persons) recorded in our study is comparable to what is currently experienced in other centers from our region. [2],[3],[4],[6] Most deaths resulted from respiratory complications (25%). This highlights our inability to optimally manage respiratory problems in CSI patients as well as its significant contribution to the high mortality rate in our experience, when compared to reports from the western world. [9],[18],[20]

   Conclusion Top

Cervical spine injury currently constitutes a major part of our spinal injury profile. Although care of CSI patients has evolved through multidisciplinary collaborations and a trend toward operative care, with reduction in the duration of hospitalization, the experienced mortality rate is higher than what is currently observed in the western world, especially when the injuries are of the high cervical type. Establishment of emergency medical services and facilities for critical care as well as trauma systems may help to improve the current poor outcome associated with CSI among our population.

   References Top

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  [Figure 1]

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]

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