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Indian Journal of Community Medicine

Traumatic Spinal Cord Injuries in Haryana: An Epidemiological Study

Author(s): Roop Singh, Sansar Chand Sharma, Rajeev Mittal, Ashwini Sharma

Vol. 28, No. 4 (2003-10 - 2003-12)

Deptt, of Orthopaedics, Paraplegia and Rehabilitation,
Pt. B.D. Sharma PGIMS, Rohtak


Research question: What are the preventable risk factors in traumatic spinal cord injury (SCI)?

Objectives: 1. To study the risk factors in traumatic spinal cord injuries. 2. To identify preventable risk factors.

Study design: Prospective study.

Setting: Accident and emergency services and department of Orthopaedic Surgery and Rehabilitation of Pt. B.D. Sharma PGIMS, Rohtak.

Participants: New traumatic SCI patients.

Study variables: Age, sex, mode of injury, SCI level, seasonal variation, associated trauma, duration of hospital stay, socio-economic status.

Results: Four hundred and eighty three new traumatic SCI cases reported in 2000-2001. Male to female ratio was 2.96:1 and the average age at injury was 35.4 years. Fall from height was most common cause of trauma (44.5%), followed by motor vehicle accidents (34.7%). One hundred and sixty four patients were tetraplegics and 283 patients were paraplegics, while 36 patients had no neurological deficit. Most common level of injury was first lumbar vertebra among paraplegics and fifth cervical vertebra among tetraplegics. There was increase in incidence of SCI during summer and rainy season. Average hospital stay was 39.5 days.

Conclusions: Certain preventable risk factors in traumatic SCI (falls, vehicular accidents, improper pre hospital care and improper transportation) need to be addressed in order to reduce the frequency and morbidity of SCI, burden on meagre financial and health resources.

Key Words: Spinal cord injury, Incidence, Epidemiology


In the Indian setup, as in most developing countries, very little is known about the exact incidence of spinal cord injuries (SCI). Approximate 20,000 new cases of SCI are added every year. 60-70% of them are illiterate, poor villagers 1 . Most of them sustain this injury by fall from unprotected roofs, trees or fall into uncovered wells, which infact are preventable causes. A careful epidemiological study can provide information regarding magnitude of the problem of spinal trauma and resultant demand on medical and social resources; and can help identify the risk factors involved and actual causes of SCI. It may help to formulate preventive measures which may modify or eliminate the risk factors and may decrease the incidence of this incapacitating injury.

Material and Methods:

The study was conducted between January 2000 to Dec. 2001. All the patients with traumatic spinal injuries reporting to Accident and Emergency Deptt. and outdoor and indoor patients of orthopaedics department were included in the study. Patients who died before reaching hospital were not taken into account. Detailed history with respect to age, sex, occupation, socio-economic status and mode of trauma was taken, followed by a clinico radiological examination to ascertain the exact spinal and associated injuries. Few additional questions were asked about type of pre-hospital care, mode of transfer, time of reporting and whether a trained person accompanied the patient during the transportation.

Results and Observations:

Table I: Age and sex distribution of SCI cases.

Age Group
no. of Cases (n=483)
no. % no. % no. %
0-9 2 0.55 - - 2 0.41
10-19 17 4.71 13 10.66 30 6.21
20-29 157 43.49 46 37.7 203 42.03
30-39 99 27.42 29 23.77 128 26.50
40-49 53 14.68 22 18.03 75 15.53
50-59 21 5.82 12 9.84 33 6.83
60-69 10 2.77 - - 10 2.07
70+ 2 0.55 - - 2 0.41

Four hundred and eighty three cases of SCI reported between January 1st 2000 to 31st Dec. 2001. There were 361 males and 122 females; male to female ratio was 2.96:1. The average age at injury was 35.4. The most prevalent age group was 20-29 followed by 30-39.

Table II: Mode of Injury (n=483)

Mode No. %
Fall from roof/tree electricity pole 215 44.51
road accidents 168 34.78
Sports injury 19 3.93
Burial under mud while digging (cave in) 31 6.42
Assault (gunshot/stab) 17 3.52
Fallof heavy weight on back 13 2.69
Fall into well 09 1.86
Others 11 2.28

The most common cause of injury was fall from height including roof, trees, electricity pole (44.5%) followed by motor vehicle accidents (34.7%). Falls were more prominent in second and third decades. Roadside accidents were commoner in third and fourth decade.

One hundred sixty four patients were tetraplegic and 283 patients had paraplegia. Thirty six patients had no neurological deficit. Dorsolumbar spine injury was the commonest with first lumbar being the most common fractured vertebra followed by twelfth dorsal vertebra, cervical spine injury was next with most common site being fifth and sixth cervical vertebrae. Seasonal variation was observed. Frequency of SCI showed an increase during summer followed by rainy season. In 72% cases no associated trauma was identified. Most prevalent associated injury was head injury (7%) followed by extremity fractures (6.3%), chest injury (3.1%), abdominal injury (0.9%) and pelvic injury (0.7%).

Eighty one patients had a monthly household income of more than Rs. 10,000. One hundred eighty five patients between Rs. 5,000-10,000 and 217 patients had family income of less than Rs. 5,000. Seventy patients were graduate and above, 213 patients had studied upto middle or high school, 200 patients had less than primary school education or were illiterate.

Three hundred sixty eight patients (76.19%) reported to institute directly. Ninety one patients (18.8%) were initially seen by village quacks or unqualified practitioners. Only 24 patients (4.97%) were referred after initial care by qualified doctors. 23% patients used an ambulance for transfer, whereas, 77% patients were transported by vehicles unsuitable for a spinal patient such as car, jeep or maxi cabs which are prevalent in this region. 81% of the patients reported within 6 hours of injury, 90.3% within 24 hours and 9.7% reported late. Only 9 patients (1.86%) had an accompanying trained personnel with them during transfer.

Average duration of hospital stay was 39.5 days (range 7 to 93 days). Those without neurological deficit or stable injuries were discharged early and had a short stay. Twenty one cases died during the study period. Out of these twenty-one, 16 cases were of cervical spine injury with complete neurological deficit.


The abrupt onset of SCI is tragic and has a profound impact on the individuals and their families. Knowledge of epidemiology of SCI in a given country is important not only for planning of resources, but also for adequate treatment and rehabilitation.

Most of the studies in medical literature are from advanced countries where the problem and presentations are different with respect to mode of injury, sex, incidence etc. Though this study may not be a true representation of epidemiology of all spinal injuries in the society, as it is restricted only to one institute, it can best be taken as the trend, as we receive patients from a vast area, the institute being the only medical college in the state.

The age distribution of patients is comparable with studies from the other parts of the India and World. Most common affected age group being 20-29 1-3 signifying higher incidence in young, active and productive population of the society. Higher incidence in males can be explained by examination of etiological factors, men being more exposed to risk factors since they are more active on account of occupation. Fall into well was exclusively seen in females. Road traffic accident (RTA), fall from tree, sports injuries were commoner in males.

Table III: Comparison of sex ratio in different series.

Series year M:F ratio
Chaco et al7 (India) 1986 13.5 : 1
Shanmugasundram 4(India) 1987 8.98 : 1
Dave et al5 (India) 1994 3.7 :1
David Chen 6(India) 1999 3.7 :1
Karacan et al3 (Turkey) 2000 2.5 : 1
Lan et al 8(Taiwan) 1993 4 : 1
Shingu et al 9(JApan) 1994 4.3 : 1
Present Study 2001 2.96 : 1

Sex distribution has shown a male female ratio of 2.96:1, which is comparable to other recent studies, but reflects a changing trend when compared to studies conducted 15 to 20 years back3-7. There has been substantial decrease in male female ratio which reflects changing face of social norms where females are becoming more active and outgoing. In our region agriculture being the main profession, females are equally participant at work.

Table IV: Mode of injury - a comparison of different series.

Series Fall from Height (%) RTA (%)
Chacko et al7 (1986, India) 55.2 12.8
Shanmugusundram 4(1987, India) 66 14
Dave et al 5(1994, India) 49.4 36.5
Madras Model2(India) 29.42 25.19
Present series 44.5 34.8
Karacan et al3 (2000, Turkey) 36.5 48.8
Lan C et al 8(Taiwan) 23.3 61.6
Shingu et al 9(1994, Japan) 29.2 44.6

Mode of injury in SCI is dependent on local factors. In all Indian series fall from height rates highest among the aetiological factors, whereas, in advanced countries RTA ranks highest 2-5,7-9 (Table IV). There is a gradual trend towards increasing incidence of RTA indicating gradual urbanisation of society and increase in number of vehicles on roads in India. Dorsolumbar injury is the commonest site because of the anatomical reasons. The dorsal spine is fixed and less mobile because of rib cage as compared to lumbar spine which is very mobile portion of spine. The sudden transition from fixed to mobile portion makes dorsolumbar area as a precarious site. Seasonal distribution of SCI showed a marked increase during summer, signifying increased movement of people in this season. In winters people remain confined to their homes, Head injury was the most common associated trauma, especially with cervical spine injury. Most common extremity fracture was fracture calcaneum in cases of fall. Large chunk of patients were from poor socio-economic strata belonging to rural areas. There is tremendous lack of basic infrastructure and trained medical personnel, especially in rural areas, involved in initial management of patient. Vast majority of people lack basic knowledge about the initial immobilization and transportation of these patients to higher centres and by the time patient reaches a general or institutional hospital, there may be an extensive damage to neurological status, which could be prevented.

Long hospital stay does reflect the loss of productive hours of the nation, and a financial burden on state as well, which in fact is preventable to a certain extent. We thus conclude that there is a strong need to identify the risk factors and to take steps to control them by disseminating information to masses, to train paramedical staff in rural areas about initial handling and transportation of patients having spinal cord injuries.


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