Traumatic cervical spine injury: Short-and medium-term prognostic factors in 102 patients

INTRODUCTION

Knowing the significant prognostic factors associated with cervical spine injuries (CSIs) would facilitate early, rapid, and better management. This potentially would minimize risks and complications associated with various therapies and thereby reduce the morbidity and mortality for these patients.

Here, we have analyzed several major risk factors to determine whether they would significantly impact patients’ outcomes following SCI.

MATERIALS AND METHODS

Patients

We retrospectively studied 102 traumatic CSI patients, with/without other trauma, over an 11-year period (e.g., January 2004–December 2014).

They were treated surgically/nonsurgically by neurosurgeons (e.g., undergoing spinal surgery) and a subset required other surgical procedures.

Patients were neurologically evaluated using the Frankel grading system [Table 1] (e.g., using the Statistical Package for the Social Sciences 13.0).

Table 1:: Frankel scale.

Prognostic factors were assessed utilizing univariate and multivariate logistic regression analysis [Table 2].

Table 2:: Univariate and multivariate analysis of several factors associated with poor outcome.

Clinical data

From 350 registries, we identified 102 patients for our CSI series [Table 3]. Patients averaged 36.02 years of age (16–85 years), and there was a clear male predominance (93 men: 91.2% and 9 women: 8.8%).

Table 3:: Clinical data and findings.

Traumatic etiologies included falls 53 cases (52%), motor vehicle accidents: 37 patients (36.3%), and diving: 10 cases (9.8%).

Of the 102 patients, 58 had no neurological deficits (56.86%), while 44 patients (43.13%) had varying Frankel grade deficits.

The lower cervical spine involved in 71 cases, followed by the upper cervical spine (24 cases), while 4 had mixed proximal/distal lesions and 3 cases did not have any vertebral lesions.

There were 26 patients who were treated with cervical spine traction and/or placement of a cervical collar. Alternatively, 69 had surgery an average of 5 days (range 15 h–20 days) following the traumatic event consisting of anterolateral approaches (64 cases) and posterior approaches (4 cases).

RESULTS

DISCUSSION

Several clinicoradiological factors have been reported in the literature to be predictive of prognosis in TCSI, including original neurological deficit, medullary magnetic resonance imaging (MRI) signal, surgical delay, concomitant injuries, and mechanism of trauma.[1,3,14,15,19] However, some factors lack precision or may not be easily obtained such as MRI studies which may not be available in developing countries or mechanism of trauma which may not be deduced in unconscious traumatized and without major bone or discoligamentous injury. In addition, the benefits of early surgery is unclear[17,18] and delay of surgery remains a controversial factor; indeed, some studies consider an early surgery within 24 h of injury,[7-10] other studies spread this delay to 72 h.[11-13,16]

As the best independent prognostic factors in TCSI are the original neurological deficit, which correlate well with spinal cord damage severity, the Frankel grading system, which is simple, easily reproducible, and widely used, makes it possible to envisage the outcome according to the initial involvement.

In Frankel Grade A, except some rare cases of transient spinal stasis, neurological recovery is absent and mortality rate is high.[2] In Frankel Grades (B, C, or D), functional recovery is variable, about 85% of Grade C or D patients will recover ambulation.[2,5-17] In pure radicular involvement, the prognosis is better, although sphincter disorders recover less easily.

According to our study, a Frankel Grade A is associated with 114-fold increased risk of poor outcome as well as Frankel Grade B is associated with 51-fold increased risk of poor outcome (e.g., respectively, P = 0.001 and 0.006). Similarly, immediate neurovegetative disorders are associated with 32.5-fold increased risk of bad evolution (P < 0.001) and are also a statistically significant poor prognostic factor.

Regarding other prognostic factors, some studies identified early surgery as associated with better neurological recovery compared to delayed surgery or conservative treatment.[5,6] This finding is not consistent with our data, where an operating delay >48 h does not modify the prognosis of TCSI patients (P = 0.8). Diving accidents, [Figure 1] although rare, are associated with 4-fold increased risk of bad evolution compared to motor vehicle accidents [Figure 2]; this would be explained by the high energy of these traumas and their mechanism in flexion and compression which is well correlated with poor prognosis.[4] Concomitant injuries in patients with TCSI (e.g., traumatic brain injury and/or thoracic injury) are associated with 2-fold increased risk of bad evolution (P = 0.25).

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Figure 1:: Diving accident in a 22-year-old man. Preoperative X-ray: C5-C6 dislocation. Postoperative X-ray: anterior discectomy C5-C6, use of the graft taken from the iliac crest, and fixation by anterior plate on C5-C6.

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Figure 2:: Motor vehicle accident in a 30-year-old man, preoperative X-ray and computed tomography scan: C5 fracture and C4-C5 and C5-C6 dislocation, with receding of the posterior wall and spinal cord compression, postoperative X-ray: C5 corpectomy and discectomy of C4-C5 and C5-C6 with placement of the graft taken from the iliac crest and fixation by anterior plate on C4-C6.

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CONCLUSION

We investigated prognostic factors for outcome following TCSI. We found that worse Frankel grades (e.g., A and B) and immediate neurovegetative disorders are statistically significantly associated with an increased risk of poor outcome in short and medium term. Other factors, such as concomitant injuries and TCSI by diving, were also associated with increased risk of poor outcome, but these results were not statistically significant.