Flat panel detector-CT with endovenous injection. Description of a novel technique for obtaining cerebral arteries imaging: Technical note


Romanian Neurosurgery  |  Volume XXXI  |  Number 4 |  2017  |  October-December 

 
Article 

 
Traumatic spinal cord injuries – epidemiologic 

and medico-legal issues  

 

Bianca Hanganu, Andreea Alexandra Velnic, Valentin Petre-Ciudin, Irina Manoilescu, Beatrice Gabriela Ioan 
ROMANIA 

 

 

 

DOI: 10.1515/romneu-2017-0075 
 



 
 
 
 
 
484 | Hanganu et al - Traumatic spinal cord injuries 

 

 
 
 
 
 
 

DOI: 10.1515/romneu-2017-0075   

Traumatic spinal cord injuries – epidemiologic and 
medico-legal issues 

Bianca Hanganu, Andreea Alexandra Velnic, 
Valentin Petre-Ciudin, Irina Manoilescu, Beatrice Gabriela Ioan 

“Grigore T. Popa” University of Medicine and Pharmacy, Institute of Legal Medicine, Iași, 
ROMANIA 

 
Abstract: Spinal cord injuries represent a special category of injuries in traumatic 
pathology, with high morbidity and mortality, which justify their analysis with the aim 
to identify useful aspects in order to prevent and treat them. We therefore performed a 
retrospective study on 426 cases in order to analyze epidemiology and medico-legal 
issues related to spinal cord injuries. The studied items regarded socio-demographic 
aspects (gender, age, home region), type of lesions (vertebral, spinal cord, association 
with other trauma), circumstances leading to trauma (cause of the injury, season), data 
regarding hospitalization (medical condition at the hospital admission, number of days 
of hospitalization, clinical diagnosis, imaging exploration level) and data resulting from 
autopsy (diagnosis, toxicological examination). Most of our results are consistent with 
literature data, except for some epidemiological items, which might be explained with 
cultural differences, life style and inhomogeneous population. Based on our results, the 
general conclusion is the need for prevention campaigns, focusing on road traffic 
accidents and falls (especially in elderly) as the main causes of spinal cord injuries. 
Key words: spinal cord trauma, death, epidemiology, legal medicine 

 
Introduction 

Spinal cord injuries represent a special 
category in traumatic pathology, both 
regarding the high morbidity and mortality 
and dysfunctions leading to low quality of 
patient’s life [4]. Mostly important is the 
cervical region, the most frequently affected 
[1], as it is associated with head trauma, 

difficulties in intubation and its major 
consequence, quadriplegia [5]. 

The incidence of spinal cord trauma varies 
largely among reported studies worldwide, 
mainly because of inclusion criteria, 
identification procedures and treatment 
possibilities, both before and after the 
admission to the hospital or owing to 
geographical and cultural factors [4]. Thus, 



 
 
 
 
 

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the lowest reported annual incidence was 2.3 
per million in Canada and the highest 83 per 
million in Alaska [4]. Soopramanien in a 
study conducted in 1994 reported an annual 
incidence for Romania of at least 28.5 per 
million inhabitants [11]. 

Aim and objectives 
The aim of our aim was to identify the 

epidemiological and medico-legal aspects 
which may be useful in preventing and 
treating spinal cord injuries. The main 
objectives are as follows: highlighting the 
causative and contributing factors in spinal 
cord trauma, identifying the most common 
injuries and the most frequent mechanisms of 
injury.  

Material and methods 
We performed a retrospective study using 

the data collected from the autopsy reports 
issued by the Institute of Legal Medicine of 
Iasi and the medical records during a 6 year 
time frame. Inclusion criteria of the cases 
were: the presence of spinal cord injury, alone 
or associated with injuries in other segments 
of the body and admission to the hospital 
prior to death, immediately after trauma. 

The analyzed items were: socio-
demographic factors (gender, age, home 
region), sustained injuries (spinal, spinal 
cord, association with other injuries), 
circumstances leading to trauma (cause of 
trauma, season), data mentioned in the 
medical files (medical condition at admission, 
number of days of hospitalization, clinical 
diagnosis, imaging exploration) and data 

acquired during autopsy (diagnosis, 
toxicological examination). 

Results 
Socio-demographic factors 

We analyzed 426 cases of spinal cord 
trauma which fulfilled the inclusion criteria 
mentioned above.  

Analysis of the gender revealed male 
predominance- 337 (79%) as opposed to 
female- 89 (21%), with male:female ratio 
3.5:1. 

Mean age was 55.3 years, most of the cases 
over 60 years (38% of the cases), while the 
least were under 20 years (5.1% of the cases).  

Rural to urban ratio revealed almost twice 
higher the number of cases in rural area than 
in urban area, respectively 281:145. 

Circumstances leading to trauma 
Seasonal distribution showed a relatively 

equal distribution in summer (26.5%), 
autumn (28.6%) and winter (27.9%), the 
minimum number of cases recorded during 
spring (16.9%). 

Circumstances leading to trauma 
correlated with the gender of the victim 
revealed the first place in women for road 
traffic accidents (52% versus 37% in male), 
while the falls hold the first place in male 
victims (49% versus 31% in female). 

After 60 years of age the leading 
circumstances for spinal trauma are the falls 
(51.5% of these cases), followed by road traffic 
accidents (36.8% of these cases), while under 
20 years of age, the leading circumstance is 
road traffic accidents (72.72% of these cases), 
followed by falls (18.18% of these cases). 



 
 
 
 
 
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For 55% of all the victims toxicological 
analysis revealed the presence of alcohol in 
the blood samples collected during the 
autopsy,  21% showing a blood alcohol 
concentration above  2g%o, this being the 
case for 15.38% of the road traffic victims and 
7.32% of the fall victims. 

Level and type of injuries 
The most affected was the cervical level, 

both in isolation (52%) and associated 
injuries in other segments of the spine, 
comprising 70%, in one case being affected 
the entire spine. 

The most frequent recorded injuries were 
dislocations, caused by falls (31%) as well as 
by road traffic accidents (18.2%), followed by 
simple fractures, produced during road traffic 
accidents (14.2%) and fall (10.2%). 

Data regarding hospital admission 
27.81% of the road traffic accident victims 

and 43.97% of the fall victims have died in 
less than 24 hours after admission, while 
5.32% of the road traffic accident cases and 
26.7% of the fall cases have died after more 
than 30 days following admission in the 
hospital. 

At admission, 17.37% of the victims were 
in coma (22.48% of the road traffic accident 
victims and 18.84% of the fall victims), 
20.18% of the victims had an influenced state 
of consciousness (6.5% of the road traffic 
accident victims and 39.26% of the fall 
victims), while the remaining victims of the 
road traffic accidents and falls were conscious 
(16 cases, 2 of which sustained spinal trauma 
during road traffic accidents and 14 after a 
fall). 

Discussions 
The main objective of our study was to 

analyze the epidemiological factors in spinal 
cord trauma which have led to death, in order 
to identify the most common mechanisms 
and circumstances of injuries, the risk factors, 
causative and contributing factors, as well as 
the people most exposed to be the victims of 
this type of injuries, in order to prevent and 
effectively treat them.  

During the time frame of our study, 426 
cases have been identified, most of the victims 
being in the group over 60 years of age, which 
could be explained by the degenerative 
changes characteristic to elderly people [1], 
with a mean age of 55.3 years. On the 
contrary, Das et al. (2013) identified in their 
study conducted in India that the most 
affected age group, with more than 60%, 
people between 20-39 years of age- the 
productive age group of a society, 
highlighting the alteration of the productivity 
of that country due to spinal cord trauma [1]. 
Shingu et al. (1994) report the main affected 
age group in Japan- 55.8% as people between 
40-69 years [10], so as Kamravan et al. (2014) 
who report the mean age being 37.2±15.9 
years [5]. Hagen et al. (2012) identified in 
their review, after analyzing the cases with 
traumatic spinal cord injuries until 2011, the 
lowest mean age in Turkey- 26.8 years, and 
the highest in Oklahoma- 55.5 years, noting 
also an increase of the incidence for people 
over 60 years- from 5% to 13% [4]. Along 
with aging, the prognostic becomes poorer, 
recovery potential decreases and the risk for 
complications increases [4], specific anatomy 



 
 
 
 
 

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features concurring to a higher incidence of 
these injuries in elderly: calcification of the 
ligaments, decreased elasticity and increased 
bone demineralization [1].  

Males are generally more affected than 
females, male to female ratio in our study 
being 3.7:1, alike with the results of Kamravan 
et al. 2014, who identified a 3:1 ratio [5] and 
with another Romanian study which 
identified a 3.35:1 ratio for the southern part 
of the country [11]. Instead, Das et al. (2013) 
identified a higher ratio, of 8.43:1, in a study 
regarding cervical spinal cord injury in 
eastern India, this difference being ascribed to 
the mainly household activity of the women 
[1]. An equal frequency was identified in 
studies conducted in Taiwan and Iran [4].  

Regarding the circumstances of injury in 
spinal trauma, in our study prevail road 
traffic accidents (52% of the women and 37% 
of the men) and falls (49% of the men and 
31% of the women). By comparison, a study 
made in the south of Romania more than 20 
years ago revealed the falls from height as the 
major cause of spinal trauma, 59%- with 19% 
falls from horse-drawn carts, while 13% 
involved road traffic accidents [11]. 
Comparing these results with the findings of 
our study we note a marked increase of the 
road traffic accidents, most probably as a 
consequence of the general development of 
the country and road infrastructure and 
important increase of the road traffic. 
Another study published in the same period 
of time, i.e. 1994, in Japan, reveals the 
contrary- the predominance of the road 
traffic accidents in 44.6% of the cases 
followed by falls in 29.2% of the cases [10]. A 

different situation is observed in India, where 
it is seen a lower risk for women to be victims 
of road traffic accidents as their main activity 
involves the house [1]. Road traffic accidents 
represented the main cause of spinal injury in 
the study performed by Kamravan et al. 
(2014), while Fredo et al. (2012) identified 
60% of the cases being the victims of falls and 
21% the victims of road traffic accidents [3]. 
Hagen et al. (2012) identified the highest 
percent of road traffic accidents related to 
spinal cord injuries in the West Africa- 89%, 
and the lowest in Greenland- 4%, Pakistan 
and Nepal- both with 7% [4]. Regarding the 
spinal cord injuries produced after falls, data 
published by Hagen et al. (2012) showed the 
highest percent in Pakistan and Nepal- 82% 
and the lowest in South Africa- 3% [4]. These 
differences in reported number of cases might 
be explained by the geographical factors, 
disparity in defining the terms and methods 
for data collection [4], as well as differences in 
the level of development of the countries 
where the studies were performed [1].  

281 of the total number of cases in our 
study came from rural areas and 145 from 
urban area, with a ratio of almost 2:1. Dryden 
et al. (2003) detected a 2.5 times higher risk 
for spinal cord injuries in people from villages 
in relation to people from urban areas [2]. 
Hence the risk for spinal trauma is higher in 
rural regions, where most of the people 
perform rough activities or farming [11] as 
opposed to intellectual activities in cities. 

Analysis of seasonal repartition of cases 
revealed relatively equal frequencies in our 
study in summer, autumn and winter, with 
the fewest cases in spring. These results differ 



 
 
 
 
 
488 | Hanganu et al - Traumatic spinal cord injuries 

 

 
 
 
 
 
 

from those reported by Karamehmetoglu et 
al. (1995), who found the highest frequency 
during spring- mainly as a result of falls, 
followed by summer- mainly road traffic 
accidents [7]. Sharif-Alhoseini and Rahimi-
Movaghar (2014) reported the repartition of 
falls and road traffic accidents as follows: 
summer, spring, autumn and winter, 
assigning the road traffic accidents more 
frequently in spring, while the falls in winter 
[9] and Karacan et al. (2000) reported the 
highest frequency of road traffic accidents 
during summer [6]. Mondal et al. (2011) 
identified the predominance of road traffic 
accidents occurring during May-June [8]. The 
hypothesis of the present study take into 
account the fact that during winter and 
summer the spinal trauma might be 
attributed at least in part to extreme sports. 

Given the fact that cervical injuries are the 
most frequent causes of death [1] it is justified 
the high incidence of the injuries in this 
segment- 52% isolated injuries and 70% 
associated with injuries in other segments. 
However, studies performed in China show 
only 5% cervical injuries, as opposed to 
Turkey, with 92% of the injuries, the difference 
being explained either as a consequence of 
different causal patterns or geographical and 
financial factors which may contribute to 
underreporting of spinal injuries [4]. Shingu et 
al. (1994) reported 74.3% of cases involving the 
cervical segment [10].  

The most frequent recorded injury in our 
study was dislocation, comprising 31% in falls 
and 18.2% in road traffic accidents, followed 
by simple fracture in 14.2% of the road traffic 
accidents and 10.2% in falls. Das et al. (2013) 

reported the prevailing of fractures in 
combination with dislocation in 53.7% of 
cases, while simple fractures were recorded 
for 34.3% and isolated dislocation in 10.8% of 
cases [1]. Data regarding the frequency and 
level of injuries may contribute for the 
improvement of the work environment in 
spinal surgery, both by training the surgeons 
and adjustment of surgical instruments and 
techniques [1] and by training specialists 
from related fields: occupational therapists, 
physiotherapists and rehabilitation doctors 
[11]. 

Alcohol ingestion highly influences the 
occurrence of traumatic injuries. More than 
half of the victims were under the influence of 
alcohol at the moment of the trauma, for 21% 
blood alcohol concentration being more than 
2%o, of which 26 were victims of road traffic 
accidents and 14 victims of falls. Shingu et al 
(1994) reported the presence of alcohol in 
32.2% of bicyclists and 8.9% of car accidents 
victims [10]. Alcohol represented a main risk 
factor for the association of spinal cord 
injuries with head trauma, as reported by 
Hagen et al. (2012) [4].  

Conclusions 
The rate of spinal cord injuries varies 

largely in the identified studies, although the 
predominance of cervical segment was a 
general rule. Given the serious consequences 
of these injuries, it is therefore necessary to 
provide suitable medical and rehabilitation 
services, followed by supporting services and 
appropriate life style which might lead to 
minimization of the impact these injuries 
have on the victims and their families.  



 
 
 
 
 

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Differences detected across studies 
performed in this field regarding 
circumstances, age and gender may be 
explained by differences in culture, life style 
and inhomogeneous study population. 
However the results of our study as well as 
those of other similar studies emphasize the 
need for prevention campaigns especially 
regarding road traffic accidents and falls 
(mostly in elderly) and reducing alcohol 
ingestion. Regarding this last aspect, the high 
incidence of blood alcohol ingestion suggests 
the need for a moderate ingestion, alerting the 
people about the risks they expose especially 
before driving a car or bicycle, or when they 
need to perform highly risky activities.  
 
Correspondence 
Andreea Alexandra Velnic 
E-mail: andreea.velnic@yahoo.com 
Irina Manoilescu 
E-mail: manoilescuirina@yahoo.com 

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