An epidemiological analysis of traumatic cervical spine fractures at a referral spinal unit : a three-month study
Aim To determine the profile of traumatic cervical spine fractures with respect to the epidemiology, clinical presentation, types of fractures, conservative and surgical intervention, short-term post-intervention (i.e. post-conservative and post-surgical) complications and short-term post-surgical rehabilitation of patients presenting at the Spinal Unit of King George V Hospital over a 12-week period. Methods Patients who presented to the King George V Hospital Spinal Unit from surrounding hospitals with traumatic cervical spine fractures were evaluated by the medical staff. Data concerning the epidemiology, clinical presentation, types of fractures, conservative and surgical intervention, short-term post-intervention (i.e. post-conservative and postsurgical) complications and short-term post-surgical rehabilitation data were recorded by the researcher. A p-value of <0.05 was considered as statistically significant. Appropriate statistical tests were applied to the hypothesis-testing objectives. These involved the Pearson’s Chi Square Tests for categorical variables or Fisher’s Exact Tests as appropriate where sample sizes were small. Paired t-tests were done to compare preand- post-surgical Frankel grading and Norton Pressure Sore Assessment scores. Results The number of patients who presented to the Spinal Unit over a 12-week period was 20, of this number 17 were males, three were females and all were black. Eleven patients were treated surgically while nine patients were treated conservatively. The most frequent aetiology of cervical spine fractures was motor vehicle accidents (n = 10) followed by falls (n = 9). The most common co-existing medical conditions were smoking (n = 7), HIV (n = 5), alcohol abuse (n = 3) and obesity (n = 3). The most frequent locations of cervical spine fractures were C2 (n = 6), C1 (n = 4) and the posterior column of C6 (n = 3), while dislocations occurred primarily at the C5-C6 levels (n = 5) of the lower cervical spine. Odontoid fractures (n = 6), Jefferson’s fractures (n = 4) and unilateral facet dislocations (n = 6) were the most common fractures and dislocations v observed. Head injuries (n = 4) and lower limb fractures (n = 3) were the most common extra-spinal fractures. All subjects who sustained head injuries also had associated C1 or C2 fractures. Neurological complications most frequently involved the upper limb where loss of motor function (n = 8) and weakness (n = 4) were observed. The majority of the patients (n = 8) reported a Frankel Grading of E. There were no significant associations between types of fracture and gender with the exception of fracture/dislocation observed in two females. There was a statistically significant difference in the NPSA score (p = 0.004). Conservative care utilized included soft collar (n = 6), cones calipers (n = 6), physiotherapy (n = 4), Minerva jacket (n = 4) and SOMI (sterno-occipital mandibular immobilization) brace (n = 1) while surgical intervention included anterior decompression (n = 8), anterior fusion (n = 8), allograft strut (n = 8), discectomy (n = 8), anterior cervical plating (n = 8), anterior screw fixation (n = 2), a transoral approach (n = 1) and a corpectomy (n = 1). The short-term post-conservative care complications observed in this study were an occipital pressure sore (n = 1), severe discomfort (n = 1) as well as severe neck pain (n = 1), while the short-term post-surgical complications were severe neck pain (n = 2), oral thrush (n = 1), pneumonia (n = 1), odynophagia (n = 1) and hoarseness (n = 1). Of the 11 patients who underwent cervical spine surgery, ten were sent for physiotherapy and one for occupational therapy. No significant associations were seen between the type of cervical spine fracture and the age of the subject. There was a significant association between fracture/dislocation and the female gender (p = 0.016). There was significant negative association between odontoid fracture and: anterior decompression, anterior fusion, allograft strut, discectomy and anterior cervical plating (p = 0.006). Conclusion The results of this study reflect the presentation and management of cervical spine fractures at a referral spinal unit of a public hospital in KwaZulu Natal. The impact of HIV and other co-existing medical conditions were not determined due to the small sample size in this study. Further epidemiological studies are required to be conducted in the Spinal Units of all South African public hospitals in order to confirm or refute the observation of this study.