Comment on: Patterns of cervical spine injuries in adults at a major trauma center in Saudi Arabia

To the Editor

In a study about cervical spine injuries, Dr. Alharbi described the patterns of cervical spine injuries affecting adults in a major trauma center in Riyadh, Saudi Arabia.¹ This retrospective collaborative study comprised adults with cervical spine injuries from 2014 to 2018, excluding patients 13 years of age and below. However, as per the United States Food and Drug Administration Class III classification, the adolescent age group is up to 18 years of age,² whereas the skeletal maturation is more advanced in girls than boys of the same age because the early pubertal bone ages of 11 years old girls and 13 years old boys are equivalent stages of bone maturation by the hand-wrist method.³ Accordingly, the exclusion of pediatric age 13 years and below was somehow vague, whether based on institutional level or a specifically followed classification of pediatric age.

Studies that focus on cervical spine injuries usually consider including more accurate imaging modalities as magnetic resonance imaging (MRI) to not miss patients with normal computerized tomography (CT) scans. In a study conducted by Holmes et al⁴ to describe the performance of adjunctive radiologic imaging in patients with a cervical spine injury, it was found that most patients with cervical spine injury undergo MRI or CT imaging. However, in clinical practice, MRI is superior at identifying soft tissue injuries, whereas CT performs better in identifying bony injuries. Accordingly, the current study only included CT that was abnormal excluding patients with normal CT. This might disregard clinical situations that could indicate cervical injures diagnosed on superior imaging modality as MRI.

Limited literature is available on our local experience regarding the patterns of cervical spine injuries. And it is noteworthy that motor vehicle accidents were the most frequent causative of injury (92.6%) which was higher than the international reports (25-50%). Therefore, additional emphasis on the seat position of passengers and the differences of vehicles could yield more accurate results, availing a clear understanding of the patterns of injures. Two retrospective studies comparing motorcycle trauma with all-terrain vehicles trauma have shown similar mortality. All-terrain vehicles riders were found to be significantly younger and more severely injured with a higher incidence of head and neck injury (56% vs. 30%, p<0.001).⁵ Another article evaluated the differences in injury patterns according to seat position: i) Victims who were front seated passengers had the highest mortality. ii) Rear seat passengers were found to be at greater risk for serious traumatic brain injuries (BTIs).⁶ This pattern of injuries correlated with TBIs, which was in the current study addressed solely with Glasgow coma scale (GCS) scores. Contrarily, Chieregato et al⁷ found a consensus of Italian anesthetists with the classification of TBI severity that includes CT findings and pupil reactivity besides GCS scores. In another study, conducted by Malec et al,⁸ a single TBI severity classification system based on commonly used TBI severity measures was developed. This system classified TBI according to death due to TBI, trauma-related neuroimaging abnormalities, GCS, PTA, loss of consciousness, and specified post-concussive symptoms. For the moderate-severe (definite) TBI classification, the estimated sensitivity was 89% and the estimated specificity was 98%.⁸ This highlights the importance of the details associated with this kind of injury to reach to a more accurate description of the patterns of cervical spinal injuries, especially in our local population.