Archives of Academic Emergency Medicine. 2022; 10(1): e80 REV I EW ART I C L E Epidemiology of Traumatic Spinal Cord Injuries in Iran; a Systematic Review and Meta-Analysis Mohsen Saheban Maleki1, Behzad Khedri2, Maryam Ebrahimpour Roodposhti3, Hesamedin Askari Majdabadi4,5, Seyedeh Omolbanin Seyedrezaei6, Nasir Amanat4,5, Mohsen Poursadeqiyan7, Farahnaz Khajehnasiri8∗, Roya Amiri9 † 1. Department of Anesthesia, Clinical Research Developmental Unit Bohlool Hospital, Gonabad University of Medical Science, Gonabad, Iran. 2. Department of Social Work, Social Studies Faculty, Hanze University of Applied Science, Groningen, Netherlands. 3. Trauma Research Center, Faculty of Nursing and Midwifery, Kashan University of Medical Sciences, Kashan, Iran. 4. Nursing Care Research Center, Semnan University of Medical Sciences, Semnan, Iran. 5. Department of Emergency Nursing, Faculty of Nursing & Midwifery, Semnan University of Medical Sciences, Semnan, Iran. 6. Department of Emergency Medicine, School of Medicine, Shahroud University of Medical Sciences, Shahroud, Iran. 7. Social Determinants of Health Research Center, Ardabil University of Medical Sciences, Ardabil, Iran. 8. Department of Community Medicine, School of Medicine, Tehran University of Medical Sciences, Tehran, Iran. 9. Department of Intensive Care Nursing, Kish Free Zone, Kish Specialty & Sub Specialty Hospital, Kish, Iran. Received: July 2022; Accepted: August 2022; Published online: 6 October 2022 Abstract: Introduction: Understanding the epidemiology of traumatic spinal cord injuries (TSCIs) can be helpful for poli- cymakers and planners to consider appropriate strategies to control and prevent these injuries. This study aimed to determine the epidemiological characteristics of TSCI in Iran in order to increase knowledge and awareness of these injuries. Methods: A systematic literature search was conducted up to January 2022 in the electronic databases, including PubMed, Scopus, Web of Science, Google Scholar, SID, Iranmedex, and Magiran. The qual- ity of included studies was evaluated using the STORBE checklist. Comprehensive meta-analysis was used to analyze the data. Results: Nineteen studies involving 9416 cases were included in the study. Participants’ pooled mean age was 35.80 ± 1.07 years (95% CI: 33.69 to 37.91), of whom 69% (95% CI: 68% to 70%; P<0.05) were male. The most frequent TSCI occurred in the age group of less than 30 years. Motor vehicle collisions (MVCs) was the most common cause of TSCI (57%; 95% CI: 25% to 63%), followed by falls (32%; 95% CI: 26% to 38%). Most participants had thoracolumbar (27%; 95% CI: 10% to 55%) and cervical injuries (23%; 95% CI: 16% to 31%), respectively. The incidence of TSCI was estimated at 10.5 per million people. The prevalence of TSCI was 3 per 10000 people. The mortality rate due to TSCI was 3.9% (95% CI: 0.02 to 0.06; P<0.05). Conclusion: Based on the findings of this meta-analysis, the pooled incidence and prevalence of TSCI in the Iranian population were 10.5/1000.000 people and 4.4/10.000 people, respectively. TSCIs had occurred more frequently in males follow- ing MVCs, and in the age group under 30 years. The pooled mortality rate due to TSCI was 3.9% (95% CI: 0.02 to 0.06; P<0.05). Keywords: Spinal Cord Injuries; Epidemiology; Prevalence; Incidence; Iran Cite this article as: Saheban Maleki M, Khedri B, Ebrahimpour Roodposhti M, Askari Majdabadi H, Omolbanin Seyedrezaei S, et al. Epi- demiology of Traumatic Spinal Cord Injuries in Iran; a Systematic Review and Meta-Analysis. Arch Acad Emerg Med. 2022; 10(1): e80. https://doi.org/10.22037/aaem.v10i1.1720. ∗Corresponding Author: Farahnaz Khajehnasiri, Department of Commu- nity Medicine, School of Medicine, Tehran University of Medical Sciences, Tehran, Iran. E-mail: khajenasiri@tums.ac.ir, TeleFax: 98.21-88962357, ORCID: https://orcid.org/0000-0002-4217-3685. This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Downloaded from: http://journals.sbmu.ac.ir/aaem M. Saheban Maleki et al. 2 1. Introduction Spinal cord injuries are classified into two types, traumatic and non-traumatic (1). Traumatic spinal cord injuries (TSCI) are one of the most severe conditions in terms of morbidity and disability (2, 3). The mortality rate in people with TSCI is higher than that of normal people (4). The in-hospital mor- tality rate of spinal cord injuries varies from region to region (4). The most common causes of TSCI are motor vehicle colli- sions (MVCs), falls, violence, and sports/leisure activities (5). TSCIs predominantly occur in males younger than 30 years old (6), and most frequently at the level of the cervical spine, followed by thoracic, and lumbosacral (7). In 2016, there were 0.93 million (0.78-1.16 million) new cases of SCI, with age-based standardized incidence rates of 13 (11-16) per 100 000 people for SCI (8). The incidence rate is different from one country to another (9). TSCI is a costly injury for patients as the average cost for the initial injury and recovery phase of SCI can be $142,366 (10). The most common symptoms in patients with TSCI include pain, weakness, fatigue, and numbness (11). The most common outcomes after TSCI are paralysis (12), de- pression (13), anxiety (14), osteoporosis (15), adverse events, including urinary tract infections, pneumonia, neuropathic pain, delirium, pressure ulcers (16), hydronephrosis, bladder stones, vesicoureteral reflux (17), Hypothermia (18), cardio- vascular complications, and autonomic dysreflexia (19). Given that TSCIs vary by country and region (20), and there is no meta-analysis regarding these injuries in Iran, there is an urgent need to determine the epidemiological characteristics of TSCIs in order to implement appropriate control and pre- vention strategies. This study aimed to investigate the epi- demiological characteristics of TSCI in the Iranian popula- tion. 2. Methods The Meta-analysis of Observational Studies in Epidemiol- ogy (MOOSE) guidelines (21) were used when writing the re- port, and the Preferred Reporting Items for Systematic Re- views and Meta-Analyses (PRISMA) checklist was used when preparing the report (22). 2.1. Literature search strategy Two authors, independently, carried out a systematic litera- ture search in the most important electronic databases, in- cluding PubMed, Scopus, Web of Science, Google Scholar, † Corresponding Author: Roya Amiri; Department of Intensive Care Nursing, Kish Free Zone, Kish Specialty &Sub Specialty Hospital, Kish, Iran. E-mail: r.a_amiri@yahoo.com, Tel: 98-76-44459400-10, Fax: 98-76-44459409, ORCID: https://orcid.org/0000-0003-3153-7778. SID, Iranmedex, and Magiran to identify the studies pub- lished in English or Persian languages up to January 2022 us- ing keywords. Furthermore, the list of references of records included in the final analysis was scanned for more articles. The key search terms included traumatic spinal cord injuries, epidemiology, prevalence, incidence, risk factors, and Iran. The search strategy by database was: PubMed #1. Spinal Cord Injur* [Title/Abstract] OR Spinal Cord In- juries [MeSH Terms] #2. Epidemiolog* [Title/Abstract] OR Epidemiology [MeSH Terms] #3. Incidence [Title/Abstract] OR Incidence [MeSH Terms] #4. Risk factor* [Title/Abstract] OR Risk factor [MeSH Terms] #5. Prevalence [Title/Abstract] OR Prevalence [MeSH Terms] #6. Iran [Title/Abstract] #7. 2 OR 3 OR 4 OR 5 #8. 1 AND 7 AND 6 Web of Science #1. TI= (Spinal cord injur*) #2. TI= (Epidemiolog *) #3. TI= (Incidence) #4. TI= (Prevalence) #5. TI= (Risk factor*) #6. TI= (Iran) #7. 2 OR 3 OR 4 OR 5 #8. 1 AND 7 AND 6 Scopus #1. TITLE-ABS-KEY (Spinal cord injur*) #2. TITLE-ABS-KEY = (Epidemiolog *) #3. TITLE-ABS-KEY = (Incidence) #4. TITLE-ABS-KEY = (Prevalence) #5. TITLE-ABS-KEY = (Risk factor*) #6. TITLE-ABS-KEY = (Iran) #7. 2 OR 3 OR 4 OR 5 #8. 1 AND 7 AND 6 2.2. Study selection Epidemiological studies conducted on the Iranian popula- tion with TSCI were included, and those conducted on in- dividuals with non-traumatic spinal cord injuries, with irrel- evant outcomes, case series, case reports, and the letters to the editor were excluded. 2.3. Data extraction and quality assessment The methodological quality of included studies was assessed using ROBINS-I tool (23). Two authors extracted the epi- demiological and demographic data, independently, using the same extraction form. The extracted information in- cluded 1) study characteristics (first author, year, place, pe- riod, and type), demographic characteristics (sample size, mean age, and sex), and epidemiological outcomes (preva- This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Downloaded from: http://journals.sbmu.ac.ir/aaem 3 Archives of Academic Emergency Medicine. 2022; 10(1): e80 Table 1: Characteristics of included studies Study Province Period N Ratio (M:F) Mean age Incidence /1000000 Prevalence /10000 Leading causes Second causes Andalib, 2018 (24) Guilan 2015-2018 127 3.5: 1 38.27 NR NR MVCs - Derakhshanrad, 2016 (25) Tehran 2011-2015 1137 3.8:1 29.1 NR 2.36 MVCs falling Fakharian, 2004 (27) Isfahan 1995-1999 225 3.6:1 39 NR NR falling MVCs Fakharian, 2019 (26) Isfahan 2014-2017 986 3.3:1 39.5 NR NR MVCs falling Ghajarzadeh, 2019 (28) Tehran 2013-2017 830 4.3:1 29 NR NR MVCs falling Haddadi, 2015 (29) Mazandaran 2012-2014 906 1.3:1 NR NR NR MVCs falling Jazayeri, 2015(30) Tehran, Alborz 2015 NR NR NR NR 2.96 NR NR Kamravan, 2014 (31) Fars 2009-2012 261 3:1 37.2 NR NR MVCs falling Khazaeipour, 2017 (32) Tehran 2012-2013 140 2.5:1 NR NR NR MVCs falling Rahimi-movaghar, 2009 (35) Tehran 2007-2008 4 1:1 31.7 NR 4.4 MVCs falling Ramezani, 2019 (36) Guilan 2015-2017 170 2.3:1 40.2 NR NR MVCs falling Rasouli, 007 (33) Southeastern Iran 1994-2005 64 18:1 27.42 NR NR MVCs - Saatian, 2020 (37) Hamadan 2007-2017 3219 2:1 41.7 NR NR MVCs falling Sharif-Alhoseini, 2014 (38) Tehran 2010-2011 138 5.5:1 33.2 10.5 NR falling MVCs Tabesh, 2018 (34) Isfahan 2012-2018 510 2.3:1 42.31 NR NR MVCs falling Yousefzadeh-Chabok, 2010 (41) Guilan 2005-2006 245 2.5:1 38.2 NR NR MVCs falling Yousefzadeh-Chabok, 2015 (42) Guilan 2015 76 8.5:1 35.2 NR NR MVCs falling Yadollahi, 2018 (39) Fars 2017 171 4.9:1 38.2 NR NR MVCs falling Yazdani, 2021 (40) Hormozgan 2017 207 2.5:1 40.2 NR NR MVCs falling N: number of participants, M: male, F: female, NR: not reported, MVCs: motor vehicle collisions. Table 2: Risk of bias (ROBINS-I) Study Confounding Selection Intervention Measurement Missing Data Outcome Measurement Reported Result Overall Andalib, 2018 Moderate Low Low Low Low Moderate Moderate Derakhshanrad, 2016 Moderate Low Low Low Low Moderate Moderate Fakharian, 2004 Moderate Low Low Low Low Moderate Moderate Fakharian, 2019 Moderate Low Low Low Low Moderate Moderate Ghajarzadeh, 2019 Moderate Low Low Low Low Moderate Moderate Haddadi, 2015 Moderate Low Low Low Low Moderate Moderate Jazayeri, 2015 Moderate Low Low Low Low Moderate Moderate Kamravan, 2014 Moderate Low Low Low Low Moderate Moderate Khazaeipour, 2017 Moderate Low Low Low Low Moderate Moderate Rahimi-movaghar, 2009 Moderate Low Low Low Low Moderate Moderate Ramezani, 2019 Moderate Low Low Low Low Moderate Moderate Rasouli, 2007 Moderate Low Low Low Low Moderate Moderate Saatian, 2020 Moderate Low Low Low Low Moderate Moderate Sharif-Alhoseini, 2014 Moderate Low Low Low Low Moderate Moderate Tabesh, 2018 Moderate Low Low Low Low Moderate Moderate Yousefzadeh-Chabok, 2010 Moderate Low Low Low Low Moderate Moderate Yousefzadeh-Chabok, 2015 Moderate Low Low Low Low Moderate Moderate Yadollahi, 2018 Moderate Low Low Low Low Moderate Moderate Yazdani, 2021 Moderate Low Low Low Low Moderate Moderate Note: Moderate=the study is sound for a non-randomized study with regard to this domain but cannot be considered comparable to a well-performed randomized trial; Low=the study is comparable to a well-performed randomized trial with regard to this domain. lence and incidence rate, risk factors, level of injuries, and mortality rate). 2.4. Evidence synthesis The epidemiological and demographic findings of included studies were summarized. The Comprehensive Meta- Analysis software was used to analyze the data. The mean difference (MD) and the risk ratio (RR) with a 95% confidence This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Downloaded from: http://journals.sbmu.ac.ir/aaem M. Saheban Maleki et al. 4 interval (CI) were used for continuous and dichotomous vari- ables, respectively. The random-effect model was used for studies with I2>50% or P <0.1. Otherwise, the fixed-effect model was used. 3. Results 3.1. Search results PRISMA flow diagram of the study selection process is shown in Figure 1. In total, 265 records were identified after dupli- cate removal by searching the databases and resources. After screening the records by their titles and abstracts, 36 studies were screened for eligibility. Finally, nineteen studies (24-42) involving 9416 cases were included in our analysis. The main characteristics of the included studies are presented in Table 1. 3.2. Assessment of risk of bias The results of assessing risk of bias of included studies are presented in Table 2. The methodological quality of included studies was acceptable. 3.3. Demographic characteristics The included studies reported the mean age of TSCI patients in the range of 27.42 to 42.31 years. The pooled mean age of the participants was 35.80 ± 1.07 (CI: 33.69 to 37.91) years. A small number of studies reported the frequency of TSCI by age groups. According to the findings of the studies, the largest age group was under 30 years. The majority of partic- ipants were male (69%; 95% CI: 68% to 70%) and the male- to-female ratio was 2.4:1. The lowest and highest male-to- female ratios were 1.3:1 and 18:1 in the North and South-East of Iran, respectively. 3.4. Etiology MVCs were the leading cause of TSCI in Iran (57.9%; CI: 25% to 63%), followed by falls (32 %; CI: 26% to 38%), assaults (7%; CI: 3% to 14%), and other causes (8% CI: 6% to 11%), respec- tively ((Figure 2). However, in two studies (27, 38), falls were presented as the main cause of TSCI. 3.5. Prevalence and incidence Three studies (25, 30, 35) reported the prevalence of TSCI in the Iranian population. The meta-analysis result showed the prevalence of TSCI in the Iranian population was 4.4 per 10000 people (Figure 3). Only one study (38) examined the incidence of TSCI, according to which the incidence rate of TSCI among the Iranian population was estimated at around 10.5 per million people. 3.6. Mortality rate Nine studies involving 6744 cases reported the mortality rate among people with TSCI. The findings of meta-analysis re- vealed that mortality rate due to TSCI was 3.9 % (95% CI: 0.02 to 0.06; P<0.05) (Figure 4). 3.7. Injury level Anatomical most common sites of TSCI were thoracolumbar (27%; CI: 10% to 55%), cervical (23%; CI: 16% to 31%), tho- racic (20%; CI: 9% to 40%), lumbar (20%; CI: 12% to 31%), and other multiple traumas (16%; CI: 7% to 32%), respec- tively (Figure 5). 3.8. Sensitivity analysis A sensitivity analysis was performed to compare the fixed- and random-effect estimates of the effect size. The result showed no change in the effect size. 4. Discussion According to the present study’s findings, the overall mean age of TSCI in the Iranian population was 35.80 ± 1.07 years. The results of a systematic review conducted in the Middle East and North Africa showed that the mean age of the pa- tients with TSCI was 31.32 years (43), which was similar to our finding. In addition, the most commonly affected people were in the 20-29 years age group (43). This result is also in line with our findings. A systematic review of the epidemiol- ogy of TSCI in Asian countries indicated that the mean age of injured people ranged from 26.8 to 56.6 years (44). Our study also revealed that most TSCIs (69%) occurred in males, and TSCI rate in men was almost 2.4 times greater than women. The pooled proportion of male gender in the Middle East and North Africa (43) was 77% of all cases, which was similar to our results. The evidence showed that in developing coun- tries (45), males comprised most TSCI cases. Furthermore, a global study showed that the majority of TSCI occurred in males and mostly in individuals aged under 30 years (9). Our study demonstrated that MVCs were the leading cause of TSCI in Iran. A similar pattern was found in the Mid- dle East and North Africa regions (43), in which MVCs were introduced as the main cause of injuries, followed by falls. Moreover, a systematic review (45) conducted in developing countries showed that MVCs and falls were the most com- mon mechanisms of TSCI. Similar findings were observed in Asia (44) and around the world (9), which were in line with our results. However, in Europe, the most common causes of injuries were falls and MVCs, respectively (46). The incidence and prevalence of TSCI varied between de- veloping and developed countries (9). Based on the present study, the prevalence of TSCI in Iran was 4.4 per 10000 peo- ple, and the incidence rate of TSCI among the Iranian popu- This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Downloaded from: http://journals.sbmu.ac.ir/aaem 5 Archives of Academic Emergency Medicine. 2022; 10(1): e80 lation was estimated at 10.5 per million people. The pooled annual incidence of TSCI in the Middle East and North Africa (43) was 23.24 per million people, which was higher than that of Iran. According to the meta-analysis, the mortality rate due to TSCI among the Iranian population was 3.9%. A meta- analysis (4) conducted by Chamberlain et al. showed that TSCI-related mortality rates ranged from 2.1%, 7.0%, 7.6%, to 24.1% in the WHO regions of Western Pacific, Europe, the Americas, and Africa, respectively. The result of research conducted in Europe (46) showed that most deaths occurred in the older age groups, especially in the female popula- tion. The most common causes of death were falls (53%) and MVCs (23%) with the same proportions in both sexes. Gen- erally, older age, injuries related to TSCI, tetraplegia, and tra- cheostomy have been suggested as the risk factors associated with mortality due to TSCI (47, 48). Since environmental, be- havioral, and health factors can play a key role in mortality after TSCI (49), intervention strategies focusing on these fac- tors may lead to reduction in mortality due to TSCI (50). Based on the findings of the current study regarding injury levels, most participants had thoracolumbar cord and cervi- cal injuries. A literature review of worldwide epidemiology (51) showed that cervical level of the spine was the most com- mon part to get injured. It seems that appropriate prevention and control strategists for TSCI in Iran should focus on males, MVCs, and the age group under 30 years. These findings can be helpful for health researchers and policymakers to plan strategies for controlling and preventing these injuries. How- ever, further detailed studies with large sample sizes and sub- group data are required to investigate the factors affecting TSCI in Iran. 5. Limitations This study had some limitations. First, not all studies in the meta-analysis reported the outcomes of interest, including standard deviation of mean age, male to female ratio, in- jury mechanisms, and injury levels. Second, most studies have been conducted in the central part of Iran, which can be considered as a problem for the generalizability of our findings. Finally, we could not perform a meta-analysis on TSCI-related mortality rates based on injury mechanisms, age groups, and sex due to lack of data. 6. Conclusion Based on the findings of this meta-analysis, the pooled in- cidence and prevalence of TSCI in the Iranian population was 10.5/1000.000 people and 4.4/10.000 people, respec- tively. TSCIs had occurred more frequently in males following MVCs, and in the age group under 30 years. The pooled mor- tality rate due to TSCI was 3.9% (95% CI: 0.02 to 0.06; P<0.05). 7. Declarations 7.1. Acknowledgments None. 7.2. 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This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Downloaded from: http://journals.sbmu.ac.ir/aaem M. Saheban Maleki et al. 8 Figure 1: The PRISMA flow diagram of study selection process. This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Downloaded from: http://journals.sbmu.ac.ir/aaem 9 Archives of Academic Emergency Medicine. 2022; 10(1): e80 Figure 2: Forest plot of mechanism of injury: motor vehicle collisions (A), falls (B), assault (C), other causes (D). This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Downloaded from: http://journals.sbmu.ac.ir/aaem M. Saheban Maleki et al. 10 Figure 3: Forest plot of prevalence rate of traumatic spinal cord injuries. Figure 4: Forest plot of rate of mortality due to traumatic spinal cord injuries. This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Downloaded from: http://journals.sbmu.ac.ir/aaem 11 Archives of Academic Emergency Medicine. 2022; 10(1): e80 Figure 5: Forest plot of the level of the injury: cervical (A), thoracic (B), thoracolumbar (C), lumbar (D), multiple traumas (E). This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Downloaded from: http://journals.sbmu.ac.ir/aaem Introduction Methods Results Discussion Limitations Conclusion Declarations References