RADIOGRAPHIC PATTERN FINDINGS OF CERVICAL SPINE INJURIES AMONG
PATIENTS ATTENDING TENWEK HOSPITAL
BY
KIPLANGAT RONALD
TM 215-5675/2013
A PROPOSAL SUBMITTED TO THE COLLEGE OF HEALTH SCIENCES DEPARTMENT
OF JOMO KENYATTA UNIVERSITY OF AGRICULTURE AND TECHNOLOGY IN
PARTIAL FULFILMENT OF THE REQUIREMENT OF THE AWARD OF BSc
RADIOGRAPHY.
JOMO KENYATTA UNIVERSITY OF AGRICULTURE AND TECHNOLOGY,
P.O BOX
THIKA
DECLARATION
I hereby declare that this project is my original work achieved through personal reading. This
work has not been submitted in any other institution for any academic purposes. I acknowledge
all information from other sources and from whom I have worked with.
Name: KIPLANGAT RONALD
Signature……………………………………………………….
Date…………………………………………..
LIST OF ABREVIATIONS
AP View
: Anteroposterior view.
C1, C2
: First cervical vertebrae, Second cervical vertebra etc.
CT
: Computer Tomography.
H.D.U
: High Dependency Unit.
I.C.U
: Intensive Care Unit.
I.V
: Intravenous.
CSI
: Cervical Spine Injuries.
MRI
: Magnetic Resonance Imaging.
RTA
: Road Traffic Accidents
CHAPTER 1:
STUDY JUSTIFICATION
Patients with Cervical spine injuries are frequently seen at Tenwek Hospital Emergency
department. Cervical spine injuries are a serious co-morbidity likely to influence the critical care
and outcome of head injured patients.
There is no study in the past that has specifically targeted cervical spine injuries in head injury
Tenwek. Therefore, there is need to do a study on this injury and its unique relationship with
head injury and, its role in emergency and critical care.
It is the aim of this study to determine the radiographic pattern findings of cervical spine injury
in head injured patients as seen at Tenwek Hospital.
RESEARCH QUESTION
What are the common radiographic pattern findings of cervical spine injury in trauma patients
and as related to the cause of the injury?
MAIN OBJECTIVE
The purpose of this study is to determine the radiographic pattern findings of cervical spine
injuries among patients attending Tenwek Hospital Radiology Department
SPECIFIC OBJECTIVES
To determine the relative frequency and severity of cervical spine injury in head injured
patients as seen at Tenwek Hospital.
To determine sociodemographic features of the patients.
To determine relationship between the cause of head injury and the pattern of cervical
spine injury.
To establish the type of pre-hospital care given to protect the cervical spine of the
patients before they arrive at the emergency department.
1
CHAPTER 2: LITERATURE REVIEW
The cervical spine injurie are among the most common and potentially devastating injuries
involving the axial skeleton. It is a commonly associated injury in patients with head trauma. The
force producing a serious head injury (e.g. a road traffic accident or a fall from a height onto the
head) may also injure the neck. One should assume a cervical spine injury is present until proven
otherwise in patients presenting at an emergency medical facility with a history of a highvelocity motor vehicle accident, significant head or facial trauma, a neurological deficit, or neck
pain (American college of surgeons committee on trauma. Advanced trauma life support
(ATLS).1997: 215-230) While assessment of airway, breathing, and hemodynamic stability (A B
C’s of trauma) continue to be the highest priority in caring for the patient with multiple traumatic
injuries, central nervous system evaluation follows closely behind. The central nervous system
assessment begins in the field. The cervical spine should be protected until work-up proves that it
is not injured.
The incidence of cervical spine injuries is on the increase in many countries. This has been
especially so in the last 40yrs due to an increase in both use and volume of motor vehicles
(Gerhrig R et al 1968 and Michelis L.S). There is a proportional loss in valuable manpower as
most of the injured patients are in the most productive years of their life.
RELEVANT ANATOMY
According to Gardner E et al, 1975, the human spine comprises 24 movable presacral vertebrae,
a sacrum and a coccyx. The 24 movable presacral vertebrae comprise of 7 cervical, 12 thoracic,
and 5 lumbar. The five vertebrae immediately below the lumbar are fused in the adult to form
the sacrum. The lowermost four, fused in later life, form the coccyx.
Vertebrae of each group can usually be identified by special characteristics. Furthermore,
individual vertebrae have distinguishing characteristics of their own.
The vertebral column is flexible because it is composed of many slightly movable parts-the
vertebrae. Its stability however depends largely upon ligaments and muscle. Strength, however,
is provided by the structure of the column and its constituent parts (Gardner E et al, 1975).
A typical vertebra consists of a body, a vertebral arch and several processes for muscular and
articular connections. There are two transverse processes and one spinous process. Each lever is
acted upon by several muscles or muscle slips.
The body of the vertebra is the part that gives strength and supports weight. It consists mostly of
spongy bone that contains red marrow. The body is separated from that above and below it by
the intervertebral disc
2
The seven cervical vertebrae consist of 3 atypical and 4 typical vertebrae. The first cervical
vertebra is called the atlas (named after Atlas, who, according to a Greek mythology, was
reputed to support the heavens). The skull rests on it and articulates through the atlanto- occipital
joint. The second cervical vertebra is called the axis, because it forms a pivot around which the
atlas turns and carries the skull, and the seventh (C7) is a transitional vertebra. The third to the
sixth cervical vertebrae are regarded as typical.
CERVICAL SPINE INJURIES & HEAD INJURY
The head is very vulnerable to injury, often with severe consequences. It is particularly
susceptible to acceleration -deceleration and rotational forces because it is heavy in relation to its
size.
The cervical spine is important to consider in positioning the head in space. The dominant
motion in the lower cervical spine is flexion-extension, but the cervical spine's anatomy permits
a fair amount of motion in all planes .It is freely mobile in 3 dimensions and occupies a relatively
unstable position, being secured only by the neck muscles and ligaments. This section of the
spine connects the base of the head to the thorax and, with the help of soft tissues, supports the
head. In high-speed injuries, the head can act as a significant lever arm on the cervical spine
and, depending on the mechanism, can create a wide array of injury patterns (Goodrich J et al,
2002)
The cervical spine is therefore very vulnerable and injury occurs when the forces it is subjected
to exceed its ability to dissipate energy.
Regardless of the cause, cervical spine fractures are serious injuries; they may involve spinal
cord damage that can result in partial or complete paralysis or even death, especially in high
cervical cord lesions.
Most Cervical spine injuries occur during motor vehicle accidents when the head is violently
jerked either backwards or forwards. This type of accident may not cause a fracture but instead
injure the muscles and ligaments of the neck. The resulting injury is a neck sprain, which is
commonly called whiplash.
Another common cause is violent collision that compresses the cervical spine against the
shoulders. This force can be so great that a vertebra fractures or even bursts into small fragments
e.g., striking the head against the bottom of a pool in shallow water diving or “spear”" tackling
during contact games like rugby and American football. This mechanism is implicated is most
sports injuries involving the neck (Harries M et al, 1996)
Cervical spine injury can have devastating consequences. If present or if not ruled out, the
patient’s neck will be immobilized and this may hinder emergency measures like intubation.
Krista et al in 1998 out found that intubation with a cervical collar on can be unsuccessful in up
3
to 46% of cases, even when multiple attempts were found to have been made, this was especially
so in pre-hospital attempts. Securing an air way is important as some studies have found the
incidence of hypoxia at 22% at the time of evaluation (Chesnutt R et al, 1993) .Unterberg A et al
in 1991 reported higher figures of 30% to 40% in patients with severe head injury. For patients
with head injury hypoxia increases the mortality by 85%, with survivors having a higher rate of
permanent disability ( Chesnutt R et al, 1995) Thus a lot of effort has been put to trying to make
protocols on the handling of the cervical spine in emergency situations especially when there is
head trauma. This is because the patient will usually have a decreased level of consciousness and
thus not amenable to clinical clearance of cervical injury.
INCIDENCE OF CERVICAL SPINE INJURY IN HEAD TRAUMA
Olson D et al in 2002 defined the head injury as any alteration in mental or physical functioning
related to a blow to the head. Loss of consciousness does not need to occur. Severity of head
injuries most commonly is classified by the initial post resuscitation Glasgow Coma Scale (GCS)
score, which generates a numerical summed score for eye, motor, and verbal abilities. A score of
13-15 indicates mild injury, a score of 9-12 indicates moderate injury, and a score of 8 or less
indicates severe injury (Olson D et al, 2002)
The Advanced trauma life support (ATLS) course manual gives the incidence of cervical spine
injury in head injured patients at around 5-10%. It also states that any injury above the clavicle
should prompt a search for cervical spine injury, which may be present in up to 15% of such
patients.
The incidence of spinal injury increases with severity with most studies showing an incidence of
between 7% to 10% in severe head injuries, (Hills M et al 1993) and around 2%-4% for
moderately head injured patients.
As per Shrago G 1973, most head injury related cervical spine injuries occur at the upper levels
C1-C3.Shrago found 56%in upper cervical 34%mid cervical 10% lower cervical. At least 25% to
30 % of patients with cervical spine or cord injury will have will have at least a mild head injury.
AETIOLOGY
Most cervical spine injuries in patients with head trauma are secondary to RTA (road traffic
accidents). With an average of 52% of the above injuries being secondary to RTAs associated
trauma ( Shrago G 1973 and Holly T et al 2002) ,falls constitute around 33% with the rest being
attributed to sports and other causes (Shargo G 1973). Gunshot wounds to the head have a very
low incidence of cervical spine injury (Krista L et al, 1998).
In general the cervical spine is the site of injury in 37 % to 55 % of all spine injuries. Causes
include RTAs 50%, fall 20%, Sports15% and 10% other causes. RTAs are implicated in most of
the severe forms of injury.
4
In a retrospective study by Musau C et al in 1988, he found that locally at the KNH and Spinal
Injury unit, RTAs accounted for 54.1%, fall from a height 31.8%, assaults +gunshots 7.9%,
falling objects5.3%. Peak age was found to be 20-40 years with a male: female ratio at 4.5:1.
Other figures given show the following distribution the age frequency peaks are 15-39 years. The
type of accidents included motor vehicle accidents (50%-70%), falls (6%-10%), diving
accidents, blunt head and neck traumas, penetrating neck injuries and contact sports injuries
taking the rest (George D, 1999)
The majority occur at the C1 to C2 or C5 to C7 level 1. C1- C2 level is more common in
pediatrics ( Canale S T Cambells textbook of operative orthopedics).This is due to shifting of
the fulcrum effect in the cervical spine from the upper cervical spine i.e. C1- C2 in children to
the C5 –C7 level in the adult .
According to Allen B et al in 1982, at least 20% of the patients will have more than one cervical
spine fractures. 20% to 75% of cervical spine fractures are considered unstable and 30%-70% of
these have associated neurologic injuries to the spinal cord.
Injuries of the cervical spine produce neurological damage in approximately 40% of patients.
Approximately 10% of traumatic cord injuries have no obvious roentgenographic evidence of
vertebral injury, this type of injury is called Spinal Cord Injury without Radiological
Abnormality (SCIWORA).
In traumatized patients, 3%-25% of spinal cord injuries occur during field stabilization, transit to
the hospital, or early in the course of therapy. This implies that, in order to prevent additional
neurologic disability, care of any severely injured patient must include neck stabilization until
cervical fracture is ruled out.
FRACTURES OF C-SPINE
Common injuries include fracture of the atlas, atlantoaxial subluxation, odontoid fracture, and
hangman fracture. Less common injuries include occipital condyle fracture, atlanto-occipital
dislocation, and atlantoaxial rotary subluxation.
Atlas (C1) fractures
Four types of atlas fractures (I, II, III, IV) result from impaction of the occipital condyles on the
atlas, causing single or multiple fractures around the ring. The first 2 types of atlas fracture are
stable and include isolated fractures of the anterior and posterior arch of C1, respectively.
Anterior arch fractures usually are avulsion fractures from the anterior portion of the ring and
have a low morbidity rate and little clinical significance. The third type of atlas fracture is a
fracture through the lateral mass of C1. Radiographically, asymmetric displacement of the mass
from the rest of the vertebra is seen in odontoid view. This fracture also has a low morbidity rate
and little clinical significance. The fourth type of atlas fracture is the burst fracture of the ring of
5
C1 and also is known as a Jefferson fracture. This is the most significant type of atlas fracture
from a clinical standpoint because it is associated with neurologic impairment.
Atlantoaxial subluxation
When flexion occurs without a lateral or rotatory component at the upper cervical level, it can
cause an anterior dislocation at the atlantoaxial joint if the transverse ligament is disrupted.
Because this joint is near the skull, shearing forces also play a part in the mechanism causing this
injury, as the skull grinds the C1- C2 complex in flexion. Since the transverse ligament is the
main stabilizing force of the atlantoaxial joint, this injury is unstable. Neurologic injury may
occur from cord compression between the odontoid and posterior arch of C1. Radiographically,
this injury is suspected if the predental space is more than 3.5 mm (5 mm in children).
Computerized tomography to confirm the diagnosis. These injuries may require fusion of C1 and
C2 for definitive management.
Atlanto-occipital dislocation
When severe flexion or extension exists at the upper cervical level, atlanto-occipital dislocation
may occur. Atlanto-occipital dislocation involves complete disruption of all ligamentous
relationships between the occiput and the atlas. Death usually occurs immediately from
stretching of the brainstem, which causes respiratory arrest. Radiographically, disassociation
between the base of the occiput and the arch of C1 is seen. Cervical traction is absolutely
contraindicated, since further stretching of the brainstem can occur (Belavo E et al, 2002).
Odontoid process fractures
The 3 types of odontoid process fractures are classified based on the anatomic level at which the
fracture occurs.
Type I odontoid fracture is an avulsion of the tip of the dens at the insertion site of the alar
ligament. Although a type I fracture is mechanically stable, it often is seen in association with
atlanto-occipital dislocation and this must be ruled out because it is life threatening.
Type II fractures occur at the base of the dens and are the most common odontoid fractures. This
type is associated with a high prevalence of nonunion because of the limited vascular supply and
a small area of cancellous bone.
Type III odontoid fracture occurs when the fracture line extends into the body of the axis.
Nonunion is not a major problem with these injuries because of a good blood supply and the
greater amount of cancellous bone.
With type II and III fractures, the fractured segment may be displaced anteriorly, laterally, or
posteriorly. Since posterior displacement of segment is more common, the prevalence of spinal
cord injury is as high as 10% with these fractures.
6
Initial management of a type I dens fracture is use of a cervical orthosis. Types II and III
fractures are managed by applying traction.
Occipital condyle fracture
Occipital condyle fractures are caused by a combination of vertical compression and lateral
bending. Avulsion of the condylar process or a comminuted compression fracture may occur
secondary to this mechanism. These fractures are associated with significant head trauma and
usually are accompanied by cranial nerve deficits. Radiographically, they are difficult to
delineate, and CT scan may be required to identify them.
These mechanically stable injuries require only orthotic immobilization for management, and
most heal uneventfully. These fractures are significant because of the injuries that usually
accompany them.
CERVICAL SPINE CLEARANCE AND ASSESMENT
Non-Radiographic ("clinical") Spine Clearance
Only when all five of the following criteria have been met can a patient's cervical spine be
cleared clinically:
No peripheral neurologic deficit or complaint on history or examination.
No posterior neck pain or tenderness.
No recent use of intoxicants (cocaine, opiates, ethanol, benzodiazepines, etc.)
No closed head injury (GCS must be > 13)
No major distracting injuries (e.g.: open femur fracture, multiple rib fractures)
If all five of the above criteria are reliably met, cervical spine precautions may be discontinued
without any further testing (Goth P et al 1993).
George C. Velmahos et al 1996 on 540 alert patients with negative clinical examination found no
radiological abnormality. Thus patients meeting above criteria can have their cervical spine
cleared clinically and do not need radiological exam.
Roentgenographic Evaluation of a Suspected Cervical Spine Injury
In the conscious patient the following three-step approach is followed:
Standard 3-view series (AP + lateral + open-mouth odontoid).
Swimmer's view when lower spine (C7 to T1) cannot be adequately seen on lateral view
If above are normal but patient complains of neck pain, obtain lateral flexion/extension
views. This is best done under fluoroscopic control, Robert I et al 2000 showed that it is
easy effective and devoid of complications.
7
In the unconscious patient the following steps are followed:
Standard 3-view series (AP + lateral + open-mouth odontoid).
Swimmer's view when lower spine (C7 to T1) cannot be adequately seen on lateral view.
CT scan with thin axial cuts through C1 - C2.
Any neurologically impaired patient, with the deficit attributable to cervical cord injury should
remain in full spine protection and undergo immediate evaluation by the neurosurgical service.
The standard 3 view films are obtained initially.
ROENTGENOGRAPHIC ASSESMENT
The views required to radiographically exclude a cervical spine injury include an anteroposterior
view, a lateral view, and an odontoid view. However an oblique view and/or a swimmers view
may also be done when above views are not adequate. The lateral view must include all seven
cervical vertebrae as well as the C7-T1 interspace, allowing visualization of the alignment of C7
and T1. The most common reason for a missed cervical spine injury is a cervical spine
roentgenographic series that is technically inadequate.
Lateral view
Three aspects of the cervical spine lateral view should be carefully analyzed namely:
1. Cervical spine curvature; if normal lordotic curvature is replaced with kyphotic flattening, this
may be due to spasm secondary to injury.
8
Schematic lateral view of the cervical spine. Note the odontoid (dens), the predental space and
the spinal canal. (A=anterior spinal line; B=posterior spinal line; C=spinolaminar line; D=clivus
base line)
The anterior margin of the vertebral bodies, the posterior margin of the vertebral bodies, the
spinolaminar line and the tips of the spinous processes (C2-C7) should all be aligned. Any
malalignment should be considered evidence of ligamentous injury or occult fracture, and
cervical spine immobilization should be maintained until a definitive diagnosis is made. After
ensuring that the alignment is correct, the spinous processes are examined to be sure that there is
no widening of the space between them. If widening is present, a ligamentous injury or fracture
should be considered. In addition, if angulation is more than 11 degrees at any level of the
cervical spine, a ligamentous injury or fracture should be assumed. The spinal canal should be
more than 13 mm wide on the lateral view. Anything less than this suggests that spinal cord
compromise may be impending.
2. Intervertebral disc interspaces; Variation in interspace thickness or variation in alignment of
prevertebral, postvertebral and anterior spinal tissues may suggest injury. Atlanto-occipital
disassociation can be very difficult to diagnose and is easily missed. The distance from the
occiput to the atlas should not exceed 5mm anywhere on the film.
3. Soft tissue; The retropharyngeal soft tissue thickness is normally 4 to 7 mm at C3 with a
smooth widening to 18 to 20 mm at C7. Retropharyngeal soft tissue swelling (more than 6 mm
at C2, more than 22 mm at C6) is highly specific for a fracture but is not very sensitive. Soft
tissue swelling in symptomatic patients should be considered an indication for further
radiographic evaluation. A simple mnemonic is 6mm at C2 and 22mm at C6 (Graber M e al
1999)
Odontoid view
The dens is next examined for fractures. If it is not possible to exclude a fracture of the dens,
thin-section CT scans or plain film tomography is indicated.
The lateral aspects of C1 are examined next; these should be symmetrical, with an equal amount
of space on each side of the dens. Any asymmetry is suggestive of a fracture. Finally, the lateral
aspects of C1 should line up with the lateral aspects of C2. If they do not line up, there may be a
fracture of C1.
The Open Mouth (OM) view of the odontoid peg is usually difficult to obtain and of poor quality
in unconscious patients, especially if intubated. A CT Scan of C1- C2 should be performed in
these patients, as well as scanning areas found to be abnormal on the plain films. Sagittal and
coronal reconstructions may help in cases of suspected odontoid injury (Graber M e al 1999)
9
Anteroposterior view
The height of the bodies of the cervical vertebrae should be approximately equal on the
anteroposterior view. The spinous processes should be in midline and in good alignment. If one
of the spinous processes is off to one side, a facet dislocation may be present.
CT scan imaging
This is indicated where unclear imaging on plain radiography is not obtained, where burst
fractures are suspected and where bone fragment protrusion into the neural canal is suspected,
CT-scanning provides an excellent imaging of bone ( Daffner R et al 2001)
This new, faster and more versatile type of CT scanning has revolutionized critical care in
trauma centers (where available) as it has high resolution and fast acquisition thus allowing
expeditious radiologic diagnosis of cervical spine fractures, and other traumatic injuries
(LeBlang S et al 1999 and Flanders A et al 1999). Selective use of helical CT increases the
accuracy of diagnosis of cervical spine injuries to 100% (Barbra C et al 2001).
GENERAL MANAGEMENT
Management can be divided into the acute, delayed and long-term. It is important however to
emphasize that the eventual outcome and prevention of further injury is dependent on proper
handling of the patient from the site of the accident, during transport to hospital, at the accident
and emergency units and eventually at the specialized unit where definitive management will
take place.
Immobilization
Any patient with suspected cervical spine injury should be immobilized below and above the site
until injury is ruled out clinically and through x-rays. This should be done in the neutral position
without bending or rotating the patient. Cervical spine collars and sand bags are the usual mode
of immobilization. Hard cervical collars however should not be left on for too long a duration as
they are known to cause pressure sores and in a recent study have actually been shown to cause
intracranial hypertension (Mobbs R et al 2002).
A patent airway is of critical importance in spinal cord injured patients and especially so where
there is head injury1. Intubation has however been found to be difficult when attempted with a
cervical collar and this further emphasizes the importance of early cervical spine clearance.
Of special concern is the maintenance of adequate immobilization in the restless agitated or
violent person. This condition may be due to pain or confusion associated with hypoxia or
hypotension, alcohol or drug intoxication or even a personality disorder. The cause if possible
should be found. Sedatives or a paralytic agent may be used ensuring that other vital parameters
e.g. airway control and ventilation are maintained.
10
CHAPTER 3: STUDY METHODOLOGY
STUDY DESIGN
This will be a retrospective study.
AREA OF STUDY
The study will be undertaken at the Tenwek Hospital. Tenwek receives and deals with most of
the acute trauma patients around South Rift and part of Nyanza Province. Patients will be
recruited to the study at the casualty department, the surgical wards, the intensive care unit (ICU)
and the high dependency unit (HDU).
STUDY POPULATION
All patients admitted to Tenwek Hospital with head and cervical spine injuries during the study
period will be recruited into the study.
STUDY PERIOD
The study covered a two year period of recruitment from January 2014 to April 2016.
STUDY INSTRUMENTS AND METHODS
The admissions register at the radiology department will be used to identify all patients admitted
with a diagnosis of head and cervical spine injury.
The following features will be taken and recorded;
History of the pre-hospital events was taken where available.
Details of the cause and time of head injury were recorded.
Demographic indices such as age and sex were recorded.
Note of evidence of intoxication
Radiographic views taken
The questionnaire will be used to record all other parameters relevant to the study.
Investigations will be mainly plain radiography and CT scan. Cervical spine x-rays will be taken
with three basic views, a cross table lateral, an AP view and open mouth view. All the x-rays
showing any abnormality will be discussed by with a radiologist from the x-ray department.
Specialized investigations will be sought where available including, CT scanning of cervical
spine.
11
ELIGIBILITY CRITERIA.
All patients sent to Tenwek Hospital Radiology department with head and cervical spine injury
during the period of study. Patients referred from other institutions with cervical spine injury and
concomitant head injury will also be included.
DATA MANAGEMENT
Data will be extracted from the questionnaire using dummy tables .The data will then be
analyzed using SPSS version 22 (2014). The information will then be presented as tables, graphs
and charts. Where indicated, test of significance was applied using Chi-Square (X2) analysis.
Statistical significance will be defined as a p-value less than 0.05.
ETHICAL CONSIDERATIONS.
Permission to carry out the study will be sought from the Tenwek Hospital Administration.


All information obtained from the study was treated with outmost confidentiality and will
be available only to the university and the medical fraternity.
Consent was sought from the patient or next of kin where available. Where next of kin
was not available and patient was confused or unconscious, consent was sought from the
consultant in the respective unit.
12
CHAPTER 4: DATA ANALYSIS AND INTERPRETATION
4.1 Introduction
This chapter presents study findings in form of tables and charts for purposes of discussion and
final recommendations. The chapter is thus ordered according to findings and presented
according to the specific objectives of the study. Key emphasis is placed on the need to handle
the specific objectives upon which this study is pegged upon.
4.2 Socio-demographic factors
4.2.1 Age distribution
In table 1 below, the age of respondents is categorized into six categories. As evident from the
analyzed data, it is positive to say that majority of the respondents 28% (28) were of the ages
between 21 and 30 years. Respondents between the ages of 11 to 20 years exhibited the lowest
frequency of 9 (9%). The age group of 0 to 10 years recorded 10% (10), those between 31 and 40
years recording 20% (20), those between 41 and 50 years being 20% (20) while those above the
age of 51 years being 13% (13).
Age group (years)
Frequency
Percentage
0-10
10
10%
11-20
9
9%
21-30
28
28%
31-40
20
20%
41-50
20
20%
51 and above
13
13%
Table 1: Age of respondents
The figure below illustrates the frequency distribution of age of the respondents captured in the
study. The age groups are plotted against the frequency of case occurrence from a total sample of
100 respondents.
13
Age of respondents
30
28
25
20
20
Frequency
20
15
13
10
9
10
5
0
0-10
11-20
21-30
31-40
Age group
41-50
above 51
Figure 1: Frequency distribution of respondents’ age.
4.2.2 Gender distribution
Figure 2 below shows gender distribution of the respondents in the study. Males posted the
highest percentage of 56% with a frequency of 56 males while female respondents recorded 44%
representing a frequency of 44 females of the total respondents.
Gender distribution
female
44%
male
56%
Figure 2: Gender distribution of respondents.
14
4.3 Case occurrences and characteristics.
4.3.1 Victims of road traffic accidents
Road traffic accidents claim lives and inflict injuries on victims. Of all the respondents who
participated in the study, passengers recorded the largest majority of 50 cases (50%) while the
least being pedestrians with a frequency of 17 (17%) having injuries related to the head and
cervical spine. Cyclists (motorcycle and bicycle) posted 33 cases (33%).
Road traffic accidents injuries
cyclist
33%
passanger
50%
pedestrian
17%
Figure 3: Road traffic accidents victims.
4.3.2: Passenger sitting position
Of all the victims who were passengers, a larger percentage were in the front seat. This is
represented by 48% reflecting 27 persons out of the total 50. Those in the back seat were 34%
(17) while those on the back of a pick-up or lorry were the least with a percentage of 18%,
representing 9 persons out of the total 50 passengers. Figure 4 below gives more insight.
15
Passanger sitting position
back of p/u
or lorry
18%
front seat
48%
back seat
34%
front seat
back seat
back of p/u or lorry
Figure 4: Passenger sitting position.
4.3.3 Use of helmet
Passenger protection especially on bicycles and motor cycles is vital in terms of safety in case of
accidents. Of all the passengers using the above means of transport, only 34 passengers (34%)
wore a helmet while a larger majority of 66 passengers (66%) did not wear a helmet. This had
implications on the individuals during road traffic accidents. The figure below illustrates the
percentage distribution of the use of helmets.
Passenger wearing helmet
yes
34%
yes
no
no
66%
Figure 5. Use of helmets by passengers.
16
4.3.4 Injury due to fall from height
Head and cervical spine injuries have also been attributed to persons falling from height. From
the study, 50 of the respondents (50%) reported to have fallen from a height of 3 to 10 meters
high. This was the highest number posted while the least was fall from a height of less than 3
meters, with a record 22 persons (22%). Fall from height of more than 10 meters was evident
among 28 of the total respondents holding 28% of the total sample.
Frequency distribution chart below shows the distribution of the above statistics.
Injury due to fall from height
above 10m
28
3-10m
50
less than 3m
22
0
10
20
30
Frequency
40
50
60
Figure 5: Injury due to fall from height.
4.3.5 Pre-hospital care.
Pre-hospital care is paramount in preventing further injury, pain and damages such as blood loss
and secondary injury. Of all the respondents who participated in the study, 44% had a cervical
collar administered to them after the accident. This represents 44 of the total 100 respondents.
Patients who did not receive any pre-hospital care in the form of cervical collar being
administered were 56, representing 56%.
Figure 6 below shows the percentage distribution of cervical collar being administered to head
and cervical spine injury patients.
17
Cervical collar administered
yes
44%
yes
no
56%
no
Figure 6: Cervical caller being administered.
4.3.6 Type of collar administered
Of all the 44 respondents who admitted to have received a cervical collar administered, 17 of
them (39%) received a soft collar while a larger proportion of 27 respondents (61%) received a
hard collar. The figure below shows percentage distribution of the type of collar of collar
administered.
Type of collar administered
hard
39%
soft
61%
soft
hard
Figure 7: Type of collar administered.
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4.3.7 Neck pain during unaided head movement
Head and spine injured patients experience pain during movements that are unaided. Of all the
respondents, 56% admitted to experiencing neck pains during head movements while 44% did
not experience or record any experience of neck pain during unaided head movements. The
figure below shows percentage distribution of neck pain experience.
Neck pains
no
44%
yes
56%
yes
no
Figure 8: Neck pains during head movements (unaided)
4.3.8 Influence of alcohol and other intoxications.
Alcohol and other forms of intoxication (drug use) have been attributed to cause road traffic
accidents as well as falling from heights. A majority 53% attributed the cause of accident and
subsequent injury to alcohol and other intoxication. On the other hand, 47% did not relate the use
of alcohol and other forms of intoxication to accidents and injury. The figure below gives a
detailed illustration of the percentage distribution of influence of alcohol related accidents.
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Influence of alcohol and other intoxication
no
47%
yes
53%
yes
no
Figure 9: Influence of alcohol and other forms of intoxication
4.3.9 Severity of head injury
Head injury as a result of road traffic accidents, fall from height, assault or object falling on head
can be very severe to the point of immobility and no response at all. Verbal response was evident
in 46 of the total respondents, representing 46%. Motor response was the least with a frequency
of 26 individuals (26%) while eye opening was evident in 28 cases (28%). The figure below
show percentage distribution of severity of head injuries.
Percentage
Severity of head injury
50
45
40
35
30
25
20
15
10
5
0
46
28
26
eye openning
motar response
Response
Figure 10: Severity of head injury.
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verbal response
4.3.10 Fracture at base of skull
Severity of head injury can also be an element of fracture at base of skull. A total of 61
respondents (39%) had fracture at the base of the skull while 39 respondents (39%) had no or did
not exhibit fracture at base of skull. This is summed up in the chart below.
Fracture at base of skull
no
39%
yes
61%
yes
no
Figure 11: Fracture at base of skull in patients.
4.3.11 Radiological findings
After undergoing examination by radiographers, findings were recorded according to specific
severity and characteristics. Depressed characteristics were the highest, recording a total of 35
cases (35%) while none was the least, being represented by 17 cases (17%). Linear had a total of
28 cases (28%) while stellate was evident in 20 cases (20%). The frequency distribution table
below shows frequency and percentage distribution of the characteristics.
Radiological Findings
Frequency
Percentage
Linear
28
28%
Depressed
35
35%
Stellate
20
20%
None
17
17%
Table 2: Radiological findings
21
The figure below is a frequency distribution chart showing radiological findings from
radiographers concerning respondents’ condition.
Radiological findings
stelate
20
depressed
35
linear
28
non
17
0
5
10
15
20
Frequency
25
30
35
40
Figure 12: Radiological findings.
4.3.12 Loss of normal lordosis
Loss of normal lordosis is also a characteristic of head and cervical spine injury. From the total
sample of respondents, 52 of them (52%) experienced loss of normal lordosis while 48
respondents (48%) did not show or exhibit loss of normal lordosis. The figure below is an
illustration of the above observation.
Loss of normal lordosis
no
48%
yes
52%
yes
no
Figure 13: Loss of normal lordosis.
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4.3.13 Level of sublaxacation
The level of sublaxacation is a vital characteristic of head and cervical spine injuries.
Respondents who exhibited a level of sublaxacation less than 25% were 56, being representative
of 56% of the total sample size. Respondents who exhibited a level of sublaxacation more than
25% were 44 (44%).
The figure below shows the percentage distribution of the levels of sublaxacation.
Level of sublaxacation
more than 25%
44%
less than 25%
56%
less than 25%
more than 25%
Figure 14: Level of sublaxacation
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CHAPTER 5: DISCUSIONS, CONCLUSIONS AND RECOMMENDATIONS
5.1 Introduction
Pursuant to the inferences from the analyzed data above, discussion and conclusions can be made
in relation to the frequency and severity in head and cervical spine injuries in patients, the sociodemographic features of the patients, the relationship between the cause of head injury and
pattern of cervical spine injury and the type of pre-hospital care given to patients. A summary of
the discussions or each of the above aspects is outline as below.
5.2 Age distribution and gender
From the frequency distribution table, it is evident that most of the victims or rather patients of
head and cervical spine injuries at Tenwek Hospital are between the ages of 21 to 30 years. This
could be attributed to the fact that this age group is aggressive and youthful and thus, they are
involved in activities such as construction where objects could fall on their head, alcoholism and
other intoxications that can lead to one falling from a height for example in ditches or cliffs and
road traffic activities (boda boda business and the use of the same as a means of transport).
Those between the ages of 11 to 20 years are the least in terms of cases reported at the hospital.
The study furthermore reveals that most of those who fall victims of head and cervical spine
injuries are males while the least are females. One reason for the above observation is that men
are involved - to a larger proportion, in activities that pre-dispose them to head and cervical spine
injuries. For example, it is mostly men who operate motor cycles and bicycles as well most
transport mechanisms (vehicles) and this pre-disposes them to road traffic accidents as
passengers or cyclists. While most culture consider a woman’s place to be the homestead while a
man has to be in public domain, males are to a larger extend exposed to road traffic and
accidents as pedestrians. Additionally, most construction sites employ males and thus, more
males are pre-disposed to injuries arising from objects falling on their heads as well as falling
from heights.
5.2 Road traffic accidents
Road traffic accidents are highly associated with head and cervical spine injuries. From the
study, it is true to say that most of those affected were passengers while the least were
pedestrians. This is because of the less pre-disposing factors available for pedestrians. Passengers
are highly pre-disposed because they are directly present in the vehicles that are involved in road
traffic accidents. Additionally, most of the passengers affected were seated in the front seat while
24
the least affected are those seated in the back of pickups and lorries. Sitting in the front seat thus,
proves to be highly risky than sitting in the back seat and thus, can be attributed to the high
number of head and cervical spine injuries.
Most of the passengers were not wearing a helmet. This is most applicable incases of motor
cycles and bicycles. Helmets are vital in protection of the head from harm in case of an accident.
However, from the study, a small proportion took the measure of wearing a helmet. This is
because of the knowledge they have on the use and importance of wearing a helmet. Those who
did not wear a helmet cited reasons such as absence of a helmet and ignorance due to short
distance being travelled.
5.3 Pre-hospital care
Pre-hospital care is very important in preventing further injuries and damage such as loss of
blood and increased severity of the injuries sustained. Such care can be in form of first aid. Most
respondents cited having received a cervical collar prior to arriving at the hospital. This can be
attributed to lack of information on the need and importance of this care by the handlers of the
patients at the time of accident. Moreover, such cases can also be linked to unavailability of
equipment or materials as well as trained persons to administer pre-hospital care.
Soft collar was the most used cervical collar for those patients who had a cervical collar
administered to them. A soft collar is mostly preferred to a hard collar due to the ease of
administering and it does not hinder the patient from moving or breathing.
5.4 Influence of alcohol and other forms of intoxication
Alcohol and other drugs and abused substances cause poor judgment and coordination of the
body and mind and thus, results in road traffic accidents as well as falling into ditches and cliffs.
Most respondents alluded to cases of alcohol and other form of intoxications as part of the main
causes of accidents that led to their injuries.
5.5 Severity of injuries
Most patients experienced severe injuries as a result of the accidents that they were involved in.
First, most patients admitted to experiencing pains during unaided head movements. This is a
sign that the injuries were severe. Pain can be used as a measure of severity of an injury or
symptom and thus, the pain experienced by this patients suggest that the injuries were severe.
Secondly, the below 50% for verbal response, motor response and eye opening suggest that the
injuries were severe. Indeed, when there is minimal or no motor response, verbal and eye
25
opening, then a patient is deem to be under severe suffering. Thus, the study suggest that most of
the patients who reported to the hospital with head and cervical spine injuries had severe injuries
resulting from the accidents or causes of injuries they encountered.
Thirdly, the radiological findings suggest that the injuries reported were really severe. This is
from the findings that portray depressed, stellate, none and linear characteristics of the patients.
Loss of normal lordosis was high too, thus, showing unstable conditions in the patients. Normal
lordosis is vital for proper body functioning but when it is lost then the condition can be termed
as severe. Fracture at base of skull was reported in most patients. Thus, it is true to say that the
injuries sustained by the patients were severe. The presence high percentage of level of
sublaxacation below 25% is worrying and points to the fact that patients sustained severe injuries
during accidents. Therefore, it is true, from the study, to say that most of the head and cervical
spine injuries sustained by the patients were severe as a result of the causes (road traffic
accidents, falling from a height, assault and objects falling on the head).
5.6 Validity and significance.
From the analysis of the data, the p-value for the entered data stood at 0.623 and this is the level
of significance. This value being above 0.05, therefore, it is true to say that there is minimal or
no relation between the relative frequency and the severity of cervical spine injury in head
injured patients at Tenwek Hospital.
5.7 Conclusions
Cervical spine injuries resulting from head injury is not common, having 100 valid cases only
exhibited and confirmed at Tenwek Hospital during the period of the study. This estimation
accounts for patients who denied their consent of being part of the study. Therefore, cervical
spine injuries are in most cases severe and there is need for top notch, specialized adequate care
and treatment. Tenwek hospital is well placed to receive patients of head injury and thus, from
the study, there is need for equipping in terms of personnel and equipment.
5.6 Recommendations
26
27
APPENDIX 1
QUESTIONNAIRE
DATE OF DATA COLLECTION -----/-----2016
1. Study code number; -----------------2. Date and time of accident; Date ---- /------ / -------------Time --------------------- (24hrs)
3. Tenwek Hospital
Referral from other hospital
4. Demographic characteristics:
5. Sex
Male
Female
6. Age
7. Cause of head injury:
(i) R.T.A;
(ii) If RTA: - PASSENGER
PEDESTRIAN
(iii)If RTA: - Passenger: Front seat
CYCLIST
Back seat
(iv) Wearing helmet? Yes
Back of P/U or Lorry
No
(v) Fall from height
(vi) If fall – Height: <3 Meters
3-10 Meters
>
10 Meters
(vii) Object falling on head
(viii) Assault:
(ix) Other; Specify -------------------------------------------------------------------------------------------8. Cervical collar applied Yes
If YES
Soft collar-
No
Hard collar
9. Drug/Alcohol intoxication: Yes
None
10. Neck pain on movement (unaided) Yes
No
11. Severity of head injury (G.S.C) - eye opening
- Motor response
- Verbal response
- Total
28
12. Radiological findings of skull:
No #s
Linear #s
Depressed #s
Stellate #s
-
Region of skull specify ---------------------------------------------------------------------------------
-
Fracture base of skull: Yes
No
13. CT Scan findings of head -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------14. Radiological examination of C-Spine [X-Ray]
a) Loss of normal lordosis: Yes
No
b) Retropharygeal space widening:Width at c2 in mm -------------- width at c7 in millimeter---------------Width in mm at level of injury -------------------------------c) Subluxation ----below 25% of vertebral width -
Above 25%
d) Wedge collapse
e) Loss of vertebral height
f) Fracture of dens
g) Vertebral spine fracture
h) X- Ray report by radiologist------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------15. C.T Scan findings (C-Spine): ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
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APPENDIX 2
INFORMED CONSENT FORM
I (patient)/Parent/Guardian/next of kin (delete as applicable) of --------------------------------------of --------------------------------------------------------, do hereby freely consent to participate in this
research study on RADIOGRAPHIC PATTERN FINDINGS OF CERVICAL SPINE INJURIES
AMONG PATIENTS ATTENDING TENWEK HOSPITAL, by KIPLANGAT RONALD. He
has explained to me the nature of the study to me. I also understand that participation in this
study will not affect my medical care in any way whatsoever. I also understand that I can
withdraw from the study at any time if I so wish, without giving any explanation, again without
any adverse consequences. I also understand that all information about myself/my child/my next
of kin (delete as applicable) will be treated with the strictest of confidence.
Signed ---------------------------------------------- Date -----------------------------------------------------Witnessed ----------------------------------------I KIPLANGAT RONALD, confirm that I have clearly explained to the patient the nature of this
study and the contents of this consent form.
Signed --------------------------------------------- Date -------------------------------------------------------
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WORK PLAN
BUDGET
BIBLIOGRAPHY/REFEENCES
31