Prevalence of Neurologic Deficits in Combined Facial and Cervical Spine Injuries: A Retrospective Analysis

Abstract

Study design: A retrospective data analysis of maxillofacial trauma patients with combined cervical spine injuries. Objective: This study is based on investigating the importance of timely diagnosis of patients who suffer with cervical spine injuries along with maxillofacial trauma by estimating the prevalence of neurologic deficits and its relation with etiology. Methods: A database of 4460 patients suffering from maxillofacial injuries and admitted in specialized environment surgery of Government Medical College, Trivandrum, Kerala was taken under consideration. The prevalence and types of neurologic deficits and its relation with etiology were assessed in patients with combined facial and cervical spine injuries. Results: Of 4460 patients, 48 were having cervical spine injury along with facial damage with the prevalence of 0.01%. Neurologic deficits were seen highest with etiology of road traffic accidents followed by falls from height. Most of the accidents occurred in bike riders and helmets were absent. Conclusions: It was concluded that most of the accidents engage bike riders and drivers, due to unethical and unsafe driving. There was no significant correlation found between facial and cervical spine injuries.

Introduction

Maxillofacial trauma subjects can face life-threatening complications during management when their injuries are combined with cervical spine injuries. Neurologic deficits associated with spine injuries can make the morbidity and mortality rates higher for such cases. Road traffic accidents (RTAs) are the major cause of such injuries. The frequency of traffic collisions is at the highest in the world. According to The Global Status Report on Road Safety 2013, India experienced more than 231,000 fatalities from RTAs each year. Approximately 50% of these fatalities are of motorcyclists, pedestrians trying to cross roads, and cyclists. They are included in a category of vulnerable road users.[1] Hence, in addition to the various socioeconomic factors that are affecting the incidence, types and patterns of maxillofacial injuries in different areas of the globe, poor maintenance of lane or yield for oncoming traffic while turning, zero degree practice of applying helmets and seatbelts are the prime causes. Moreover, vehicle type and sobriety of drivers are further reasons for frequent accidents and severe injuries. These factors are also the key contributors to the severity of accidents.[2]

When considering the management of combined maxillofacial and cervical spine injuries, the techniques to manage the airway have to be modified. Depending on the neurologic deficit caused by injury to spinal cord, specific changes have to be made in the traditional methods of management of maxillofacial injuries. A study focused on maxillofacial trauma stated that such injuries are seen higher among two wheelers than four wheelers.[3] The results of the study showed that out of 532 road accidents, 490 patients were bike riders while car crashes were only 28. Moreover, the age-group from 21 to 30 years is determined as etiological factor in the study for road crashes since most victims belonged to this bracket. Other than this, driving during night and intense consumption of alcohol by patients are other contributing factors that lead to road accidents and cruel injuries consequently.

Mostly patients require surgical treatment for their severe injuries that particularly involves multiple operations. Patients suffering from complex midfacial fractures with intermaxillary fixation posed significant problems if intubation is required for general anesthesia. Data related to prevalence of maxillofacial trauma within level-1 trauma centers have been used for making a comparison with the outcomes of current study.[4] Therefore, the study aims to emphasize the significance of prompt diagnosis of patients suffering from cervical spine injuries with maxillofacial trauma by determining the prevalence of neurologic deficits and its etiology. Simultaneously, this study also aims to establish the relationship between facial and spinal injuries, and the etiology.

Materials and Methods

During the period of 21 months, a database was commenced that took into account the details of 4460 patients with maxillofacial injuries reported to the emergency department of oral and maxillofacial surgery. The patients were admitted in various surgical specialties and also in intensive care units. Furthermore, a retrospective case note evaluation was also conducted, which includes the data of mortality. The etiology of injuries was assessed. In case of RTA, the type of vehicle, type of collision, sitting position of patient, whether a seat belt and/or helmet had been worn, whether intoxicated or not were noted altogether.

Analysis of the causes of injury was conducted on the basis of age, gender, type of cervical spine injury, type of facial injury, presence of concomitant injuries, and presence of neurologic deficits. Facial injuries included all forms of tissue damages, such as hard and/or soft tissues, from supraorbital margin to chin. The radiographs taken included the lateral and anteroposterior views of cervical spine, MRI of cervical spine, posteroanterior view of skull with mandible, and computed tomography scan of head and face. The radiographs were assessed by neurosurgeons, maxillofacial surgeons, and the radiologists.

Children younger than 10 years of age were excluded from the study to get homogenous groups for statistical analysis. The classification system proposed by Hackl et al was adopted to classify the severity of facial and cervical spine injuries as either simple or complicated. According to this, patients were categorized into four groups.[5]

The uncomplicated injuries of face included contusions, hematomas, superficial and deep skin and mucosal lacerations, whereas facial bone fractures and dentoalveolar trauma were categorized as complicated injuries. Uncomplicated injuries of cervical spine included neck sprains and contusion, while the fractures, dislocations, and presence of neurologic deficits were classified as severe.

Statistical analysis was conducted with software version 14 of “Statistical Package for the Social Science (SPSS).” Two groups have been developed in the study for assessing the complications and severity of symptoms. The two groups included study group and control group, which had 48 and 4460 participants, respectively. Comparisons between study and control groups were performed with chi-square test. This was followed by a logistic regression analysis to determine the independent factors for the occurrence of combined injuries. The final regression model included etiology, type of facial injury, and type of cervical spine injury. Furthermore, multivariate correlation analysis was also performed in order to determine the association between various parameters. Lastly, multiple logistic regression models were used to compute the adjusted odds of neurologic deficits, controlling for the effects of other covariates.

Results

Incidence and Etiology

Of 4460 patients engaged in the study, 48 were suffering from cervical spine injury associated with facial injuries showing a prevalence of 0.01%, when all etiologies were considered. This was not significantly different when prevalence was compared with those occurring only due to RTA, 0.01% P > .05.

Road traffic accidents were found to be the major cause of trauma in both study and control groups followed by falls. Here, a statistically significant difference between study and control groups by nature of etiology (P < .05) was present (

Table 1. Distribution of patients by etiology.^a.

	Study group	%	Control group	%
Etiology	N1		N2
RTA	32	66.6	2926	65.6
Falls	13	27.1	748	16.7
Assault	1	2.1	682	15.4
Daily activities	2	4.2	104	2.3
Total	48	100	4460	100

Abbreviation: RTA: road traffic accident. ^aχ² = 9.909, P < .01; N1, number of patients in study group; N2, number of patients in control group; %, percentage.

). However, there was no significant relationship between the etiology and nature of severity of injury in the study group (

Table 2. Distribution of patients by etiology and nature of injury in study group.^a.

Etiology	Category 1 N1	%	Category 2 N2	%	Category 3 N3	%	Category 4 N4	%
RTA	4	8.3	3	6.3	13	27.1	12	25
Falls	1	2.1	4	8.3	4	8.3	4	8.3
AssaultDaily activities	1	2.1	1	2.1	1	2.1
Total	6	12.5	8	16.7	18	37.5	16	33.3

Abbreviation: RTA: road traffic accident. ^aχ² = 5.800; P > .05. Category 1, mild C-spine/mild facial injury; N1, number of patients in category 1. Category 2, severe C-spine/mild facial injury; N2, number of patients in category 2. Category 3, mild C-spine/severe facial injury; N3, number of patients in category 3; Category 4, severe C-spine/severe facial injury; N4, number of patients in category 4.

). Moreover, there was no significant relationship established between age, gender, and severity of injury in the study group either.

Collision Pattern

Bike accidents dominated in study group by 56.3%. Among these accidents, 31.3% cases occurred by collision with stationary objects like posts, resulting in whiplash injuries. No patients were reported to have utilized any kind of head restraints or seat belts at the time of accident and majority of bike riders were under the influence of alcohol at the time of crash.

Types of Injuries

In the study group, 21 (43.8%) patients had facial bone fractures combined with soft tissue injuries and 11 (22.9%) cases had sustained dentoalveolar trauma. In the control group, majority patients (54.8%) had sustained soft tissue injuries of the face. The difference is statistically significant among the study and control groups when considering the type of facial injury and the nature of severity (

Table 3. Distribution of patients by type of facial injury.^a.

).

Among the cervical spine injuries, hard tissue injuries alone were displayed in 50% cases while both hard and soft tissue injuries were found in 41.6%. No significant association was noted between the type of cervical spine injury and the severity.

A significant association between the etiology and the type of facial injuries was found, P < .01. However, no significant relationship was established between the etiology and the occurrence of cervical spine fractures, dislocations/subluxation, and soft tissue widening and cervical spine straightening. Statistically significant relationship was found between etiology and the incidence of cervical cord syndrome, which is P < .05. Cervical cord syndrome was commonly associated with fall from heights (

Table 4. Type of facial injury and the etiology in the study group.^a.

Type of facial injury	RTA	Falls	Others	Total (%)
Soft Tissue	11	5		33.3
Both Hard and Soft Tissue	17	4		43.8
Dentoalveolar	4	4	3	22.9
Total	32	13	3	100

Abbreviation: RTA: road traffic accident. ^aχ² = 27.896,P < .01.

and

Table 5. Type of C-spine injury and the etiology.^a.

Type of C-spine injury	RTA	Falls	Others	Total (%)
Hard tissue	18	6		50
Soft tissue	1	3		8.4
Both tissues	13	4	3	41.6
Total	32	13	3	100

Abbreviation: RTA: road traffic accident. ^aχ² = 1.659,P > .05.

) and resulted in high morbidity and mortality rates.

Neurologic Deficits

In the study group, neurologic deficits were observed in 19 cases. Motor deficits were present in 7 patients while combined motor and sensory deficits were found in 45%. Sensory deficits alone were found in 10 patients (52%). Majority had sustained severe neurologic deficits (57.8%) like quadriparesis, and upper limb weakness followed by moderate deficits (26.4%) like facial palsy and mild deficits like paraesthesia (15.8%). A significant association was established between the etiology and the prevalence of neurologic deficits, P < 0.01. Neurologic deficits were seen highest with etiology of RTAs followed by falls from height. Nonetheless, no such relationship between type of neurologic deficit and etiology was present (

Table 6. Distribution of patients by etiology and the prevalence of neurologic deficits.^a.

Neurologic deficit	RTA	Falls	Others	Total	%
Absent	21	5	3	29	58.3
Present	11	8		19	41.7
Total	32	13	3	48	100

Abbreviation: RTA: road traffic accident. ^aχ² = 8.058,P < .05.

).

Additional Injuries

Fifty-two percent cases occurred without any additional injuries. Head injury was observed in 15 patients in study group (31.3%), subarachnoid hemorrhage was seen most commonly among head injuries. Sciatic nerve injury in posterior hip dislocation was also reported in 1 patient. There was no significant association found between the presence of additional injuries and etiology.

Correlation Between Facial and Cervical Spine Injuries

No significant association was noted in correlating the levels of facial and cervical spine injuries (

Table 7. Correlation of types of facial and cervical spine injuries.^a Site of cervical spine.

).

Multivariate Correlation Analysis

• A significant inverse correlation was observed between midface injuries and upper face injuries, r = −.344^a in relation to cervical spine injuries. It shows that midface injuries are less likely to occur in presence of upper face injuries and vice versa when cervical spine is involved.
• A highly significant inverse correlation was observed between the prevalence of lower facial injuries and upper face injuries in relation to the occurrence of cervical spine, r = −.456^b.
• A highly significant inverse relationship was observed between the prevalence of facial fractures and cervical spine straightening, r = −.449^b. This explains that prevalence of facial fractures is directly related to the nature of severity of cervical spine injuries.
• A highly significant direct correlation was observed between the prevalence of dislocations of the cervical spine and nature of severity of injury, r = .446^b.
• A significant inverse correlation was observed between cervical spine straightening and the nature of severity of injury, r = −.321^a (

  Table 8. Multivariate correlation analysis.

  ).
• Correlation is significant at the .05 level (^a) and at the .01 level (^b).

Logistic Regression Analysis

• The risk to sustain a combined cervical spine injury and facial trauma in traffic accidents is twofold when compared with other etiology, OR = 1.9, 95% CI 1.7–1.9, P < .05.
• The risk to sustain concomitant upper face injuries is twofold, OR = 1.9, 95% CI 1.7–1.9, P < .05, and lower face injury is 2.5-fold, OR = 2.4, 95% CI 2.1–2.4, P < .01, in traffic accidents.
• The risk to sustain facial fracture is found to increase by twofold, OR =1.7, 95% CI 1.4–1.7, P < .05, and the risk to sustain subluxations of cervical spine increase by fivefold, OR = 5.4, 95% CI 5.1–5.4, P < .001, in traffic accidents.
• Concomitant midface injuries are found to cause a risk reduction by half-fold, 95% CI 0.2–0.5, P < .05, for cervical spine injuries.
• There is a twofold risk to sustain neurologic deficits, OR = 1.7, 95% CI 1.5–1.7, P < .05, and cervical cordsyndrome, OR 1.9, 95% CI 1.7–1.9, P < .05, in traffic accidents.

Discussion

The prevalence of cervical spinal injury in association with facial injury was not high in this study, and this outcome has been supported by many past research studies.[6,7,8,9,10] The study has observed a prevalence of 0.01% of combined injuries when all etiologies were considered. It has been evaluated by an authentic resource that RTAs were the major cause of trauma in both groups.[8] A total of 22 (46%) patients in the study group were young adults between the age of 21 and 30 years.[11] In this study, the chance of occurence for concomitant neck injury nearly doubled in the presence of facial trauma resulting from RTA, OR 1.94, 95% CI 1.7-1.94, P < .05.

The crash mechanism among the bike accidents in the study group, was due to collision with motionless objects like posts and related blocks. This resulted in severe whiplash injuries in 5 patients (31.3%). None of the patients was subjected to wear safety equipment such as helmets and/or seat belts when they encountered an accident. Fifty percent of patients in our study were young adults involved in vehicular mishaps with a high frequency of alcohol consumption. This could lead to a delayed diagnosis. However, most soft tissue facial injuries were managed in the emergency setting or soon after admission. Adequate treatment for skeletal injuries was compromised because of concomitant cervical spine injury.

In this study, no significant association was found between the site of facial fracture and the site of cervical spine injury. A past study mentioned that 30 cases of fractures in cervical spine occurred in C5-7 segment, the most mobile portion of the cervical spine.[5,10,12] Similarly, another study has identified that fractures of maxilla which are associated with severe injuries of the cervical spine are found along with fractures of mandible in 50% cases.[13]

Soft tissue injuries were seen dominant in both, study and control groups, comprising 77% and 85% weights, respectively. Severe injuries were found in 66.7% in study group and 45% in control group. Important relationships were noted between fractures of mandible and lower cervical spine and soft tissue injuries of the upper face and fractures of the lower cervical spine. There has been highly significant association between the type and nature of facial injury and the etiology, P < .001. However, there was no consistent relation between the type of facial fracture and the type of concurrent neck injury.

Moreover, closed head injuries and facial fractures did not contributed much in increasing the risk for cervical spine injury. Neurologic deficits were observed in 19 cases. A significant association was there between etiology and the prevalence of neurologic deficits. However, there was no such association to be found between the type of neurologic deficit and the etiology.

In this study, a risk reduction factor for cervical spine injuries was found when there are mid facial fractures. Similarly, a past study has indicated that greater forces are required to fracture buttressed bones like midface,[12] which is more likely to carry and dissipate the trauma forces within the bone with less dissipation to the cervical spine. However, a recent study reported a higher risk for C-spine injury when associated with midface fractures. Also they reported a high risk for C-spine injuries when a ramus condyle unit of mandibular fracture is combined with midface fracture.[14,15] Although similar studies are available, this trauma center is unique in that we received around 5000 cases of maxillofacial trauma cases in a 21-month period with an average of 10 cases per day with bike accidents, the most prevalent mode of cause. This would have helped us in estimating the prevalence of combined injuries and neurologic deficits in RTA and other etiologies. Also this study emphasized on the morbidity associated with such injuries by estimating the prevalence of neurologic deficits, the prime factor inducing morbidity. Nonetheless, another study has mentioned that type of facial and cervical spine injuries are varied and failed to demonstrate any characteristic pattern or vector of force.[10] The main limitations we noticed in this study is the occurrence of combined injury as low as 0.01%. Low prevalence of 0.01% cannot possibly give any useful hint to clinicians, but a much higher prevalence of combined injury in the facial injury cases with bone fractures could help reminding clinician to check the possibility of combined injuries. Also we did not include the specific sites of mandibular fractures combined with C-spine injuries mainly due to the absence of any significant association found between facial fractures and C-spine injuries. The study emphasizes on proper clinical and radiographic evaluation of all cases of severe facial trauma of high velocity to prevent considerable morbidity and mortality rates among trauma patients. An in-depth knowledge of the type and severity of associated injuries can assist in rapid assessment and treatment.[16] Thus, a multidisciplinary and coordinated approach is important for optimum stabilization.

Conclusions

WHO has been engaged in spreading awareness related to traffic sense and preventions for accidents. The primary objective of this campaign is to convince people for practicing road ethics in respect to national road safety strategy. These ethics comprise of application of helmets and seat belts while driving motorcycles and cars respectively. Moreover, drivers must avoid consumption of alcohol and engagement on cell phones while on road. This campaign is intensely working on Hyderabad and Visakhapatnam districts where combined population figure is almost 13 million.[1]

Besides the campaign, WHO has been active in providing their suggestions to the law enforcers related to enhancements in road safety system and immediate measures that must be taken into account after the accidents. Furthermore, these activities emphasize on wearing helmets and seat belts, plus they influence audience for zero intake of alcohol while driving.

As the majority of victims in this study were young adults, the importance of timely diagnosis and management is emphasized to decrease the morbidity related to neurologic deficits and mortality rates. Also it is important to consider the etiology of trauma and the presence of physical restraints in the initial assessment of trauma victims in order to predict the severity of such injuries and implement emergency management.