J Clin Med Res

Journal of Clinical Medicine Research, ISSN 1918-3003 print, 1918-3011 online, Open Access

Article copyright, the authors; Journal compilation copyright, J Clin Med Res and Elmer Press Inc

Journal website http://www.jocmr.org

Original Article

Volume 5, Number 2, April 2013, pages 75-83

Geriatric Trauma Patients With Cervical Spine Fractures due to Ground Level Fall: Five Years Experience in a Level One Trauma Center

Figure 1. Flow diagram of trauma patients with cervical spine fractures. Among all trauma patients, 5.67% (726/12,805) patients had sustained C-spine fracture(s) and 19.15% (139/726) of C-spine fracture patients were geriatric. Furthermore, approximately half of these geriatric patients obtained C-spine fractures due to fall.

**Table 1.** Clinical Characteristics of Trauma Patients With Cervical Spine Fractures
	Geriatric Trauma Patients n = 139	Non-geriatric Trauma Patients n = 587	P
SD: standard deviation; MVC: motor vehicle collision; * Others: including E-code 805.2 (pedestrian hit by rolling stock), 807.8 (railway accident of unspecified nature injuring other specified person), 826.1 (pedal cycle accident), 910.9 (accidental drown/submersion), 916.0 (struck accident by falling objects), 918.0 (caught accidentally in or between objects), 919.2 (machinery accident), 925.2 (accident electric current - industrial wires/appliance/machinery), and 958.8 (suicidal/self injury-hanging), etc. Basic characteristics of trauma patients with C-spine fractures. Geriatric trauma patients tended to have male in predominance (P < 0.001), sustain more C-spine injuries due to fall, whereas in non-geriatric patients C-spine injuries mainly occurred from MVC (P < 0.001).
Age (Mean ± SD)	78.02 ± 8.52	37.15 ± 13.69	< 0.001
(95%CI 76.59 - 79.45)	(95%CI 36.04 - 38.26)
Gender (% Male)	56.83% (79/139)	74.11% (435/587)	< 0.001
Mechanism
MVC	40.29% (56/139)	79.56% (467/587)
Fall	53.96% (75/139)	12.44% (73/587)
Assault	1.44% (2/139)	2.39% (14/587)
Others*	4.32%(6/139)	5.62% (33/139)	< 0.001

Table 1. Clinical Characteristics of Trauma Patients With Cervical Spine Fractures

Geriatric Trauma Patients
n = 139

Non-geriatric Trauma Patients
n = 587

SD: standard deviation; MVC: motor vehicle collision; * Others: including E-code 805.2 (pedestrian hit by rolling stock), 807.8 (railway accident of unspecified nature injuring other specified person), 826.1 (pedal cycle accident), 910.9 (accidental drown/submersion), 916.0 (struck accident by falling objects), 918.0 (caught accidentally in or between objects), 919.2 (machinery accident), 925.2 (accident electric current - industrial wires/appliance/machinery), and 958.8 (suicidal/self injury-hanging), etc. Basic characteristics of trauma patients with C-spine fractures. Geriatric trauma patients tended to have male in predominance (P < 0.001), sustain more C-spine injuries due to fall, whereas in non-geriatric patients C-spine injuries mainly occurred from MVC (P < 0.001).

Age (Mean ± SD)

78.02 ± 8.52

37.15 ± 13.69

< 0.001

(95%CI 76.59 - 79.45)

(95%CI 36.04 - 38.26)

Gender (% Male)

56.83% (79/139)

74.11% (435/587)

< 0.001

Mechanism

MVC

40.29% (56/139)

79.56% (467/587)

Fall

53.96% (75/139)

12.44% (73/587)

Assault

1.44% (2/139)

2.39% (14/587)

Others*

4.32%(6/139)

5.62% (33/139)

< 0.001

**Table 2.** Type and Distribution of C-Spine Fractures in Trauma Patients
Location of C-spine Fractures	Trauma Patients with C-spine Fracture	Trauma Patient with C-spine Fracture due to GLF
Different type and distribution of C-spine fractures in trauma patients. Among all trauma patients with C-spine fractures, geriatric patients tended to sustain more C1 and C2 fractures than non-geriatric patients (P < 0.001), whereas non-geriatric patients tended to sustain more C6 and C7 fractures (P < 0.001). Similar results showed on patients with C-spine fracture due to GLF with more non-geriatric patients sustained single C-spine fracture.
C1	38 (27.34%)	80 (13.63%)	< 0.001	16 (45.71%)	5 (27.78%)	0.206
C2	75 (53.96%)	129 (21.98%)	< 0.001	20 (57.14%)	3 (16.67%)	0.005
C3	11 (7.91%)	47 (8.01%)	0.971	4 (11.43%)	3 (16.67%)	0.594
C4	18 (12.95%)	78 (13.29%)	0.916	6 (17.14%)	6 (33.33%)	0.182
C5	15 (10.79%)	110 (18.74%)	0.026	4 (11.43%)	5 (27.78%)	0.133
C6	19 (13.67%)	188 (32.03%)	< 0.001	2 (5.71%)	2 (11.11%)	0.481
C7	26 (18.71%)	243 (41.40%)	< 0.001	2 (5.71%)	0 (0%)	0.301
Single C-spine fracture	94 (67.63%)	378 (64.40%)	0.473	19 (54.29%)	15 (83.33%)	0.037

Table 2. Type and Distribution of C-Spine Fractures in Trauma Patients

Location of C-spine Fractures

Trauma Patients with C-spine Fracture

Trauma Patient with C-spine Fracture due to GLF

Geriatric Trauma Patients

Non-geriatric Trauma Patients

Geriatric Trauma Patients

Non-geriatric Trauma Patients

n = 139

n = 587

n = 35

n = 18

Different type and distribution of C-spine fractures in trauma patients. Among all trauma patients with C-spine fractures, geriatric patients tended to sustain more C1 and C2 fractures than non-geriatric patients (P < 0.001), whereas non-geriatric patients tended to sustain more C6 and C7 fractures (P < 0.001). Similar results showed on patients with C-spine fracture due to GLF with more non-geriatric patients sustained single C-spine fracture.

38 (27.34%)

80 (13.63%)

< 0.001

16 (45.71%)

5 (27.78%)

0.206

75 (53.96%)

129 (21.98%)

< 0.001

20 (57.14%)

3 (16.67%)

0.005

11 (7.91%)

47 (8.01%)

0.971

4 (11.43%)

3 (16.67%)

0.594

18 (12.95%)

78 (13.29%)

0.916

6 (17.14%)

6 (33.33%)

0.182

15 (10.79%)

110 (18.74%)

0.026

4 (11.43%)

5 (27.78%)

0.133

19 (13.67%)

188 (32.03%)

< 0.001

2 (5.71%)

2 (11.11%)

0.481

26 (18.71%)

243 (41.40%)

< 0.001

2 (5.71%)

0 (0%)

0.301

Single C-spine fracture

94 (67.63%)

378 (64.40%)

0.473

19 (54.29%)

15 (83.33%)

0.037

**Table 3.** Associated Injuries With C-Spine Fractures in Trauma Patients due to GLF or Less
	Geriatric Patients	Non-geriatric Patients	P
ICP: intracranial pathology; GCS: Glasgow Coma Scale; GLF: ground level fall; SD: standard deviation; CI: confidence interval; Upper C-spine fractures: C1, C2 spine fractures. The associated injuries with C-spine fractures in trauma patients due to GLF. Geriatric patients with C-spine fractures tended to occur more in female, sustained more fractures in upper C-spine, and co-existed more with ICP than non-geriatric patients (P < 0.05). The occurrence of other injuries showed no significant difference (P > 0.05).
Gender (Male)	13 (37.14%)	14 (77.78%)	0.005
Upper C-spine fractures	26 (74.29%)	7 (38.89%)	0.012
ICP	7 (20%)	0	0.042
Clavicle fractures	0	1 (5.56%)	0.159
Facial/skull fractures	3 (8.57%)	4 (22.22%)	0.165
GCS (mean ± SD, 95%CI)	14.4 ± 1.8 (13.8 - 15.1)	14 ± 2.2 (12.8 - 15.1)	0.450
Rib fractures	1 (2.86%)	0	0.469
Hip/femur fractures	2 (5.71%)	2 (11.11%)	0.481
Facial laceration/abrasion	14 (40%)	7 (38.89%)	0.938

Table 3. Associated Injuries With C-Spine Fractures in Trauma Patients due to GLF or Less

Geriatric Patients

Non-geriatric Patients

(n = 35)

(n = 18)

ICP: intracranial pathology; GCS: Glasgow Coma Scale; GLF: ground level fall; SD: standard deviation; CI: confidence interval; Upper C-spine fractures: C1, C2 spine fractures. The associated injuries with C-spine fractures in trauma patients due to GLF. Geriatric patients with C-spine fractures tended to occur more in female, sustained more fractures in upper C-spine, and co-existed more with ICP than non-geriatric patients (P < 0.05). The occurrence of other injuries showed no significant difference (P > 0.05).

Gender (Male)

13 (37.14%)

14 (77.78%)

0.005

Upper C-spine fractures

26 (74.29%)

7 (38.89%)

0.012

ICP

7 (20%)

0.042

Clavicle fractures

1 (5.56%)

0.159

Facial/skull fractures

3 (8.57%)

4 (22.22%)

0.165

GCS (mean ± SD, 95%CI)

14.4 ± 1.8 (13.8 - 15.1)

14 ± 2.2 (12.8 - 15.1)

0.450

Rib fractures

1 (2.86%)

0.469

Hip/femur fractures

2 (5.71%)

2 (11.11%)

0.481

Facial laceration/abrasion

14 (40%)

7 (38.89%)

0.938

**Table 4.** Intracranial Pathology (ICP) and C-Spine Fractures in Trauma Patients due to GLF
	Geriatric Trauma Patients due to GLF (n = 504)	Non-geriatric Trauma Patients due to GLF (n = 1,128)	P
The occurrence of ICP and C-spine fracture in trauma patients due to GLF. It indicated that geriatric trauma patients tended to sustain not only C-spine fractures but also ICP as well. Additionally, only ICP and C-spine fracture co-existed in geriatric trauma patients due to GLF in this study (P < 0.001).
C-spine fractures	35 (6.94%)	18 (1.59%)	< 0.001
ICP	32 (6.34%)	36 (3.19%)	0.0049
C-spine fracture and ICP	7 (1.38%)	0 (0%)	< 0.001

Table 4. Intracranial Pathology (ICP) and C-Spine Fractures in Trauma Patients due to GLF

Geriatric Trauma Patients due to GLF (n = 504)

Non-geriatric Trauma Patients due to GLF (n = 1,128)

The occurrence of ICP and C-spine fracture in trauma patients due to GLF. It indicated that geriatric trauma patients tended to sustain not only C-spine fractures but also ICP as well. Additionally, only ICP and C-spine fracture co-existed in geriatric trauma patients due to GLF in this study (P < 0.001).

C-spine fractures

35 (6.94%)

18 (1.59%)

< 0.001

ICP

32 (6.34%)

36 (3.19%)

0.0049

C-spine fracture and ICP

7 (1.38%)

0 (0%)

< 0.001

**Table 5.** Logistic Regression Analysis of Risk Factors of Head Injury in Trauma Patients With C-Spine Fractures due to GLF
Risk Factors	Adjusted Odds Ratio	P	95% Confidence Interval
Upper C-spine fractures including C1 and C2 fractures, GCS: Glasgow Coma Scale, Facial fractures including skull fractures. The results of logistic regression analysis. Potential risk factors that could predict the co-injury patterns of C-spine fracture and intracranial pathology in trauma patients were analyzed and adjusted odds ratios were showed. Two clinical variables (age and male gender) were considered independent risk factors to predict this co-injury pattern in trauma patients.
Upper C-spine fractures	0.04	0.076	0.00 - 1.39
GCS	0.73	0.360	0.38 - 1.41
Age	1.17	0.031	1.01 - 1.35
Gender (male)	91.57	0.038	1.29 - 6,472.43
Facial Laceration/abrasion	0.10	0.219	0.00 - 3.90
Facial Fractures	0.45	0.639	0.01 - 12.29
Femur Fractures	3.17	0.504	0.10 - 94.40

Table 5. Logistic Regression Analysis of Risk Factors of Head Injury in Trauma Patients With C-Spine Fractures due to GLF

Risk Factors

Adjusted Odds Ratio

95% Confidence Interval

Upper C-spine fractures including C1 and C2 fractures, GCS: Glasgow Coma Scale, Facial fractures including skull fractures. The results of logistic regression analysis. Potential risk factors that could predict the co-injury patterns of C-spine fracture and intracranial pathology in trauma patients were analyzed and adjusted odds ratios were showed. Two clinical variables (age and male gender) were considered independent risk factors to predict this co-injury pattern in trauma patients.

Upper C-spine fractures

0.04

0.076

0.00 - 1.39

GCS

0.73

0.360

0.38 - 1.41

Age

1.17

0.031

1.01 - 1.35

Gender (male)

91.57

0.038

1.29 - 6,472.43

Facial Laceration/abrasion

0.10

0.219

0.00 - 3.90

Facial Fractures

0.45

0.639

0.01 - 12.29

Femur Fractures

3.17

0.504

0.10 - 94.40

**Table 6.** List of C-Spine Trauma Patients With Intracranial Pathology due to GLF
	Age	Gender	ICP	C-spine Fractures	GCS	Other injuries
ICP: intracranial pathology; SDH: subdural hemorrhage; SAH: subarachnoid hemorrhage; EDH: epidural hemorrhage; GCS: Glasgow coma scale. The list of all C-spine fracture patients with associated ICP. All patients sustained C-spine fractures due to GLF. Their mean ages were 81.85 ± 9.33 and 85.7% (6/7) were male. None of these patients had GCS < 14.
1	65	Male	SDH, SAH	C5	14	N/A
2	79	Male	SDH, SAH	C2	14	Femur Fracture
3	93	Male	EDH	C1	15	N/A
4	86	Male	SDH	C3	15	Facial laceration/abrasion
5	76	Male	SDH	C7	15	Facial Fractures
6	88	Female	SDH	C2	14	Facial laceration/abrasion
7	86	Male	SAH	C4	14	N/A

Table 6. List of C-Spine Trauma Patients With Intracranial Pathology due to GLF

Age

Gender

ICP

C-spine Fractures

GCS

Other injuries

ICP: intracranial pathology; SDH: subdural hemorrhage; SAH: subarachnoid hemorrhage; EDH: epidural hemorrhage; GCS: Glasgow coma scale. The list of all C-spine fracture patients with associated ICP. All patients sustained C-spine fractures due to GLF. Their mean ages were 81.85 ± 9.33 and 85.7% (6/7) were male. None of these patients had GCS < 14.

Male

SDH, SAH

N/A

Male

SDH, SAH

Femur Fracture

Male

EDH

N/A

Male

SDH

Facial laceration/abrasion

Male

SDH

Facial Fractures

Female

SDH

Facial laceration/abrasion

Male

SAH

N/A

**Table 7.** The Role of Alcohol in C-Spine Fracture Trauma Patients due to GLF
Blood Alcohol Level (mg/dL)	Geriatric Trauma Patient	Non-geriatric Trauma Patient
*Not including 200 mg/dL. P < 0.001. The results of blood alcohol level (BAL) in trauma patients due to GLF. Only 48 patients had BAL recorded in trauma registry data. From these 48 patients, only one patient from geriatric group had toxic BAL, whereas over 50% of non-geriatric trauma patients had elevated BAL (P < 0.001).
< 80 mg/dL	30	8
80 - 200 mg/dL*	1	2
≥ 200 mg/dL	0	7

Table 7. The Role of Alcohol in C-Spine Fracture Trauma Patients due to GLF

Blood Alcohol Level (mg/dL)

Geriatric Trauma Patient

Non-geriatric Trauma Patient

n = 31

n = 17

*Not including 200 mg/dL. P < 0.001. The results of blood alcohol level (BAL) in trauma patients due to GLF. Only 48 patients had BAL recorded in trauma registry data. From these 48 patients, only one patient from geriatric group had toxic BAL, whereas over 50% of non-geriatric trauma patients had elevated BAL (P < 0.001).

< 80 mg/dL

80 - 200 mg/dL*

≥ 200 mg/dL