Surgical Science, 2011, 2, 407-413
doi:10.4236/ss.2011.28089 Published Online October 2011 (
Copyright © 2011 SciRes. SS
Blunt Traumatic Cervical Spine Fractures in Iran
Soheil Saadat1, Aliashraf Eghbali1, Alexander R. Vaccaro2, Mahdi Sharif-Alhoseini1,
Vafa Rahimi-Movaghar1,3
1Sina Trauma and Surgery Research Center, Tehran University of Medical Sciences, Tehran, Iran
2Department of Orthopaedic Surgery, Thomas Jefferson University and Rothman Institute, Philadelphia, USA
3Research Centre for Neural Repair, University of Tehran, Tehran, Iran
Received April 4, 2011; revised Augu st 25, 2011; accepted September 26, 2011
Background: Blunt traumatic cervical spine fractures (TCSF) are serious injuries which may be associated
with considerable mortality and morbidity. We describe the epidemiology of blunt traumatic cervical spine
fracture in Iran over a definable time period. Methods: in a cross-sectional study, the data including the dis-
tribution of TCSF, demographics, mechanisms, abbreviated injury scale (AIS), spinal cord associated inju-
ries and final outcome of patients, was extracted from the Iranian national trauma registry database in target
hospitals in eight major cities of Iran from 1999 to 2004. The Chi square test was used to compare mortality
and one-way ANOVA was used to compare ISS amongst th e cate gorie s of TCSF. Results: T CSF was identi-
fied in 120 cases, of these 70.8% were male. Their mean age was 36.6 ± 17.2 years. The overall incidence of
TCSF among all trauma patients was 0.7% (95%CI: 0.61% - 0.88%). The TCSF incidence among all spine
fractured patients was 19.38% (95%CI: 16.34% - 22.72%). The most common mechanism of TCSF was a
motor vehicle collision (66.7%). The overall percentage of in-hospital death for TCSF was 12.6%. There
were no statistically significant difference in death and injury severity scores (ISS) among TCSF categories
(p > 0.05). Spinal cord and root injuries occurred in 34.9% and 2.4% of TCSF, respectively. Conclusions:
preventive strategies need to be developed in order to reduce the number and severity of TCSF in the general
Iranian population.
Keywords: Cervical Spine, Fractures, Iran, Motor Vehicle Crash, Trauma
1. Introduction
Injuries to the cervical spine are of critical importance
given the potential risk of damage to the spinal cord
leading to paralysis and life long consequences [1].
Studies of cervical spinal injury report prevalences rang-
ing from 1% to 14% [2]. Blunt traumatic cervical spine
fractures (TCSF) accounts for 1% to 3% of trauma pa-
tients [3,4] but the resulting loss of neurologic function,
i.e. incomplete/complete quadriplegia following cervical
spinal cord injuries are an important source of mortality
and morbidity [5]. TCSF is seen in 19.2% - 20.8% of
blunt traumatic spine fractures [6-8]. It most frequently
occurs in male patients [9]. The cervical spine is vulner-
able to injuries resulting from high-energy motor vehicle
collisions and falls [10]. TCSF can be potentially devas-
tating, with delayed diagnosis and neurologic damage
resulting in death and disability [11-13]. Prompt immo-
bilization and timely diagnosis are essential for optimal
therapy. Delayed, missed, or inaccurate diagnosis can
result in life-long devastating i mplicatio ns [14].
Among patients undergoing emergency department
cervical spine radiography following blunt trauma, cer-
vical spine injuries were found to be more common
among the young male patients [8,15] and the C1 - C2
was the most common location of inj ury [4].
The Injury severity score (ISS) is an anatomically
based ordinal scale, with a range from 1 to 75. To com-
pute the ISS, the nine abbreviated injury scale (AIS)
body regions are grouped into six: head or neck, face,
chest, abdominal or pelvic contents, extremities or pelvic
girdle, and external. The ISS is then calculated as the
sum of t he sq uar es of the high e st AIS sc or es fo r the t hre e
most severely injured body regions [16].
So far, there has been no reliable investigation of dis-
tribution of TCSF among hospitalized traumatic patients
in Iran. The purpose of this study is to describe blunt
TCSF in traumatic patients ad mitted to general hospitals
in Iran by using a cross-sectional study and to determine
the incidence, demographics, etiology, severity, associ-
ated injuries and final outcomes.
2. Methods
This is a cross-sectional study which was performed us-
ing the data from Iran national trauma registry database
from August 1999 to February 2004. This data was col-
lected from target hospitals in eight major cities of Iran.
Information on every patient who was admitted in these
hospitals due to trauma and had a hospital stay of more
than 24 hours was registered into the database. The data
which was extracted from the original database for this
study included patients’ general demographic character-
istics, mechanism of trauma, levels and regions of spinal
injury, associated injuries, AIS, duration of hospital stay,
and final disposition/outcome. The type of TCSF and the
mechanism of accident were coded according to the In-
ternational Classification of Diseases, the 10th revision
(ICD-10). The region of TCSF was divided by ICD-10
diagnostic codes and classified into C1 (S12.0), C2
(S12.1), C3-7(S12.2) and multiple (S12.7), Concussion
and edema of the cervical spine cord (S14.0), Unspeci-
fied injury of the cervical spinal cord (S14.1), Injury of
the cervical nerve root (14.2), Injury of a peripheral up-
per extremity nerve (14.4).
The statistical analysis was conducted using SPSS
15.0 (SPSS Inc, Illinois, USA). The Chi square test was
used to compare mortality and one way analysis of vari-
ance was used to compare ISS amongst the categories of
3. Results
Of 16,321 enrolled patients, 120 (0.74%) (95% CI:
0.61% - 0.88%) had a cervical spine fracture. The overall
incidence of TCSF among all spine fractured patients
was 19.38% (95% CI: 16.34% - 22.72%). Enrollment
rates in all trau ma patients var ied by age ( Figure 1). The
absolute number of TCSF also varied by age and was
greatest in young adults (aged 15 to 45 years) and older
individuals (aged 60 to 64 years) (Figure 2). The distri-
bution of fractures is listed in Table 1. C2 was the most
common site of fracture, accounting for 20.8% of all
fracture, whereas lower cervical spine (C3 to C7) frac-
tures were seen in 65 (54.2%) patients. The characteris-
tics data are presented in Table 2. The majority of the
patients were male (70.8%). Their mean age was 36.6 ±
17.2 years.
Figure 1. Number of enroll ed patients for each age categ ory.
Copyright © 2011 SciRes. SS
Figure 2. Number of traumatic cervical spine fracture for each age categ ory.
Table 1. The distribution of cervical spine fract ures.
Spine Level No. of Fractures % of All Fractures
C1 12 10
C2 25 20.8
C3 14 11.7
C4 12 10
C5 18 15
C6 12 10
C7 9 7.5
Multiple Fractures 18 15
Total 120 100.0
The dominant occupational category in upper cervical
fracture was office workers (33.3%), but in lower cervi-
cal, it was housewife (21.5%) and for multiple fractures,
it was construction wor kers (27.8%).
The most common geographic location of a single
cervical vertebral fracture was the Outer—city highways
with 51 cases (50%). The educational level of patients
was as follows: 19.7% of the cases were illiterate, 29.1%
completed primary school, 21.4% middle school, 23.9%
high school and 5.9% were graduates of college or uni-
The most common mechanism of a single cervical
vertebral fracture fro m C1 to C7 was motor vehicle crash
(MVC) with 74 cases (72.5%) but in multiple fractures, it
was violence with 7 cases (38.9%) (Table 2). The spe-
cific etiologies of MVC are presented in Table 3. Only
1.7% of the car occupants who were found to have TCSF
had used seat belts and none of motorcycle riders who
had TCSF had used helmet s.
Accidental falls were the second most common me-
chanism of TCSF (21.7%) and these fractures were most
commonly due to falls of less than 4 meters (50% of all
fractures) (Tabl e 4).
The mean of ISS was 13.3 and 13.9 in patients with
fracture of upper and lower cervical spine fracture, re-
spectively. The ISS was 10.3 in patients with multiple
cervical vertebrae fractures. However, the difference in
ISS among all patient groups was not statistically sig-
nificant (p = 0.115).
Spinal cord and root injuries occurred in 34.9% and
2.4% of TCSF, respectively. Neurological deficits in-
cluded concussion and edema of cervical spinal cord in
13.3% of the patients, unspecified injuries of cervical
Copyright © 2011 SciRes. SS
Table 2. Chara cteristics of pati ents w i th traumatic cervical spine fractures.
Anatomical location
Upper cervical (C1 - C2)Lower cervical (C3 - C7)Multiple Total
Number (%) Number (%) Number (%) Number (%)
Male 27 (73) 45 (69.2) 13 (72.2) 85 (70.8)
Sex Female 10 (27) 20 (30.8) 5 (27.8) 35 (29.2)
Age ± SD 36.8 ± 16.4 37.4 ± 17.8 33.3 ± 17.9 36.6 ± 17.2
MVC* 29 (78.4) 45 (69.2) 6 (33.3) 80 (66.7)
Fall 6 (16.2) 15 (23.1) 5 (27.8) 26 (21.7)
Violence 1 (2.7) 3 (4.6) 7 (38.9) 11 (9.2)
Mech anism of
Others 0 (0) 1 (1.5) 0 (0) 1 (0.8)
Home 6 (16.2) 7 (11.1) 6 (33.3) 19 (16.1)
Outer –city highways 23 (62.2) 28 (44.4) 4 (22.2) 55 (46.6)
Street 6 (16.2) 20 (31.7) 2 (11.1) 28 (23.7)
At work 0 (0) 4 (6.3) 5 (27.8) 9 (7.6)
Sports or lei s ure facilities 1 (2.7) 1 (1.6 ) 1 (5.6) 3 (2.5)
Place of tra uma
Others 1 (2.7) 3 (4. 8) 0 (0) 4 (3.3)
Yes 4 (10.8) 8 (12.5) 3 (16.7) 15 (12.6)
Death No 33 (89.2) 56 (87.5) 15 (83.3) 104 (87.4)
*Motor vehicle crash.
Table 3. Specifi c etiology of motor ve hicle crash.
Anatomical location
Upper cervical Lower cervical Multiple Total
Number (%) Number (%) Number (%) Number (%)
Car passenger or driver 16 (55.2) 26 (57.8) 3 (50.0) 45 (56.3)
Pedestrian 2 (6.9) 9 (20.0) 0 (0) 11 (13.8
Motorcycle rider 8 (27.6) 9 (20.0) 0 (0) 17 (21.3)
Bicycle rider 1 (3.4) 0 (0) 1 (16.7) 2 (2.5)
Others 2 (6.9) 1 (2.2) 2 (33.3) 5 (6.3)
Total 29 (100) 45 (100) 6 (100) 80 (100)
All data have been demonstrated as percentage of total.
spinal cord in 21.6%, injury of the nerve root of cervical
spine in 0.8% and the injuries of the peripheral nerve of
neck in 1.6% (Figure 3).
None of patients with C1 fractures admitted into the
hospital died. The percentages of in-hospital death in the
upper, lower, and multiple cervical fractures were 10.8,
12.5, and 16.7, respectively. The mortality above rates
difference was not statistically significant (p = 0.135).
4. Discussion
The aim of this investigation was to d escribe blunt TCSF
in Iran. TCSF is an uncommon injury in Iran, as the in-
cidence among all trauma patients was only 0.7%. This is
similar to the rates found in a recent literature review
noting a TCSF rate of 1 to 3% of all trauma cases [3].
Claytor et al. reported 254 CSF in 572 cervical spine T
Copyright © 2011 SciRes. SS
Table 4. Specific mechanism of fall.
Anatomical location
Upper cervical Lower cervical Multiple Total
Number (%) Nu mber (%) Number (%) Number (%)
>4 m heights 0 (0) 6 (40.0) 2 (40.0) 8 (30.8)
<4 m heights 4 (66.7) 8 (53.3) 1 (20.0) 13 (50.0)
Stairs 1 (16.7) 0 (0) 2 (40.0) 3 (11.5)
Falling to the ground 1 (16.7) 6.7 (15) 0 (0) 7.7 (26)
Total 6 (100) 15 (100) 5 (100) 26 (100)
All data have been demonstrated as percentage of total.
MultipleLower CervicalUpper Cervical
Other injuries of spinal cord
No spinal cord injury
Injury of nerve root
Concussion/edema of spinal
Figure 3. The number of spinal cor d a nd root injuries in upper and lower of cervical spine fractures.
injuries (44.4%) [15]. Thus, it seems that less than half of
the patients with cervical spine injuries have an associ-
ated fracture. We showed that the overall incidence of
TCSF among all spine fractured patients was 19.38%. In
95% of the previous 38 reports, the incidence of cervical
spine injury in all trauma patients varies from 1.5% to
9.0% (Figure 4) [2]. In a meta-analysis gathering 65
studies with a total of 281,864 subjects, Milby et al.
demonstrated that the overall incidence of cervical spine
injury among all trauma patients was 3.7% [2]. The
lower incidence of TCSF among all trauma and spine
fractured patients in our series could be due to the fact
that we excluded any nonbony injury such as a ligamen-
tous injury or a dislocation without a fracture.
We demonstrated the distribution of cervical spine
fractures according to spine level, separately. Based on
that, upper cervical spine fracture accounted for 30.8%
of TCSF, however a literature search notes that injur y to
the upper cervical spine accounts generally for 19 to
32.7% of all cervical spine injuries [3,4]. Fractures of C2
occurred most frequently in our study and this is the
same as noted in the literature.
The majority of the patients were male (70.2%) and
the male/female ratio was 2.4; our data were supported
by previous reported studies [4,12,14,15]. In addition,
the male population, in all age groups, has a higher inci-
dence of cervical fractures than females [1,17]. Of course
Schoenfeld et al. surveyed a large multicultural military
population, but our study was hospital-based [17].
The overall number of TCSF varies with age in a bi-
Copyright © 2011 SciRes. SS
Figure 4. Incidence of cervical spine injury in trauma pa-
tients in different seri es.
modal fashion. This bimodal distribution was previously
reported in the USA [15]. The first age peak was almost
the same as seen in our study. Mean age for TCSF was
36.6 years in Iran and slightly older in the United States
(42.3 and 43.8 years) [8,18]. The difference may be due
to unsafe driving behavior in young adults and the
younger population in Iran. The second peak in the USA
was in individuals aged 65 to 85 years, which is older
than our patients. This older peak may be due to osteo-
porotic fractures following falls or the longer length of
life in developed countries.
The lower cervical spine is the most frequent location
for spinal trauma. Our study did not show any age-de-
pendent difference in region of TCSF. However, it has
been shown that upper cervical spine injuries are the
most frequent location for the population over 65 years
of age [19].
We demonstrated the mechanisms of accident were
coded according to the ICD-10. The most common
mechanism of TCSF was MVC which has also been re-
ported [4,17,20]. In some other studies, the most com-
mon mechanism was fall [8,21]. In Sweden, transporta-
tion related cervical fractures have dropped since 1991,
leaving fall accidents as the sole largest cause of cervical
trauma [1]. The most common mechanism of our patients
was car occupants (56.6%) in which just 4.4% used seat
belt. In the 20.5% of MVC due to motorcycle accidents,
no one used a safety helmet. Seat belt has been clearly
shown to reduce overall mortality and morbidity in car
accidents [17,22,23] but no association has been shown
between helmet use and the occurrence of cervical spine
injuries in motor cycle collisions [24].
Spinal cord and root injuries occurred in 34.9% and
2.4% of TCSF, respectively. Our results were almost the
same as Sokolwski et al. which found that 31% of pa-
tients with upper cervical injuries and a higher percent-
age of lower cervical injuries had neurologic deficits on
presentation [25]. In the study of Leucht et al., most of
the neurological deficits occurred in response to cervical
spine fractures, followed by thoracic and lumbar spine
fractures and the highest number of complete motor and
sensory neurological deficits was diagnosed in patients
with cervical spine fractures [8].
The mean ISS was 13.3, 13.9 and 10.3 in upper, lower
and multiple cervical spine fractures respectively, which
is near to the median ISS of 14 reports in the literature
[26]. In another study, the ISS was less than 16 in 8 pa-
tients, between 16 and 25 in 60 patients, and more than
26 in 53 patients [6].
The lowest percent of TCSF was at C7 (7.5%) in Iran,
however in the 808 cervical spine injuries in the NEXUS
group study, ther e were 1 9.08% of inj uries invo lving the
C7 level [4]. This difference may be due to probable
missed C7 cases following inadequately performed cer-
vical radiography.
Based on the present study, the overall percentage of
in-hospital death for TCSF was 12.6%. Tolonen et al.
showed that died patients following cervical spine injury
comprised more than 10% of the causes of death in MVC
[27], but Claytor et al. didn’t reveal to rate of TCSF
which lead to death [15].
This study has limitations that the readers should bear
in mind. Providing further information on the anatomic
distribution, location, different parts of each vertebra
fracture, such as odontoid, dislocations by cervical spine
level and radiographic findings would be helpful.
The most common mechanism for TCSF was MVC.
The young in all populations appear to be most affected
which unfortunately is the pro ductive labor force in Iran,
a country more prone to TCSF.
5. Acknowledgement
The database was provided by the Sina Trauma and Sur-
gery Research Center of Tehran University Medical Sci-
ences. The authors thank Mrs. Bita Pourmand for her edit
of the manuscript.
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