1. Introduction
pinal Cord Injury (SCI) is defined as a direct damage to the spinal cord, causing temporary or permanent damage to its performance. SCI can be divided into two main categories: traumatic and non-traumatic [1, 2]. Traumatic SCI occurs due to automobile crash, falling down, sports, etc., while the non-traumatic SCI is secondary to other complications, as tumors, infections, and degenerative disc disease. Chronologically, patients with SCI form four subgroups: i) acute phase patients; who got injured within last 48 hours, ii) subacute phase patients; who got injured between 48 hours to 14 days ago, iii) intermediate phase patients; who got injured between 14 days to 6 months ago, and iv) chronic phase patients; who injury occurred to them 6 months ago and earlier. SCI includes two steps. Primary injury arises from a mechanical force to the nervous tissue resulting in direct damage and a secondary insult which deteriorates the condition [3].
Neuron and glial cell deaths occur directly following SCI, or as a result of the liked ischemia and infection. These changes and associated glial scar compromise internal architecture of the spinal cord, and accompanying with the slow rate of axonal regeneration and remyelination, are factors determining the weak potential of spinal cord for self-regeneration [4]. Hence, it can be expected that regardless of the injury mechanism, SCI is almost always associated with permanent neurological damage.
The cost of care of a patient bearing SCI is estimated to be approximately 1.1 to 6.4 million dollars during his/her lifetime, highlighting the necessity of placing the prevention before the treatment. It has been reported that men have a higher chance (79.8%) to suffer from SCI, compared with women (20.9%) [5] and the risk for morbidity and mortality is higher when the site of the injury is close to the head. Traumatic SCI occurs mostly in the cervical spinal cord (60%) and the risk for its occurrence in thoracic and lumbosacral spinal cord is rather low (32% and 6%, respectively) [5].
Elderly, multi-system trauma, and accident severity are other factors correlated with morbidity and mortality [6, 7]. Although today with advances that have been made in medical sciences the survival rate in SCI patients seems to be promising, these patients still experience a shorter lifespan when compared to age-matched healthy individuals [8]. During hospital stay, the mortality rate in SCI patients has been estimated to be 4-14%. After being discharged, the mortality rate for the patients was estimated to be 3.8% in the first year and 1.6% in the second year following the accident [9].
Depending on the mechanism and type of the injury, traumatic damage to the spine can cause SCI at cervical, thoracic, or lumbosacral spinal levels in spinal cord, which are almost always detectable by one of the medical imaging techniques. SCI includes fractures, tensions, dislocations, etc., which most of the times are accompanied by Traumatic Brain Injury (TBI), burning, fractures of the limbs, and internal organs damage. Damage to the spinal cord could result in complete or incomplete SCI in different levels. International standards for neurological classification of spinal cord injuries, mostly referred to as the ASIA Impairment Scale (AIS), is a scale classifying spinal cord injuries according to motor and sensory functions and the severity of the injury [10].
Regarding the physical, mental, emotional, social, and economic impacts on the patient, her/his family, and the health system, it is necessary to put prevention as the first line treatment for SCI. But in some cases that it is impossible to prevent the injury, providing efficient health care in the shortest possible time frame is of the utmost importance as it turned out to be correlated with successful outcome [9].
The differences in culture and climate and also urban texture can have a direct impact on the incidence of SCI and even their types and levels. Due to the existence of various gardens and building sites, the risk of falling down is high in Guilan province. Additionally, its mild climate attracts passengers from all over the country in holidays such as Nowrouz and summer holidays, making it a province with a somehow custom-built traffic pattern with increased risk of car accidents. There are studies on the traumatic SCI in Guilan province, but either their focuses are on the regions of the spinal cord involved in the injury or they are assessing results in a short period of time. Thus, this study was aimed to investigate not only the anatomical site of the SCIs, but also the types and levels of these injuries and the associated injuries in patients admitted to the Guilan trauma center.
2. Methods & Materials/ Patients
Study design
The present cross-sectional study was based on a survey carried out on patients with spine trauma admitted to the Poursina hospital trauma center in Rasht and registered to Guilan trauma center spinal cord injuries’ registry during 2015 to 2019. Medical records of patients with confirmed CT-scan and/or MRI signs of SCI were enrolled in the study. Demographic information including age, sex, anatomical site of the injury, type of the injury, type of the injury to the C1-C2 vertebrae, type of the associated injuries, presence of locked facet, and neurological defects ASIA (The American Spinal Injury Association) impairment scale [10] were extracted from the registry.
Statistical analyses
Absolute and relative percentage abundance of the variables were calculated via SPSS statistical software V. 22 (IBM Corp, Armonk, NY, USA). 
3. Results
A total of 274 medical records of patients were reviewed. Seventy-six patients were females (27.7%) and 198 patients were males (72.3%). The mean±SD of patients’ age was 42.27±16.83 years. All patients had non-penetrating traumatic injuries. Based on this survey, 120 patients (43.8%) suffered from SCI in lumbar region of the spinal cord, 76 patients (27.7%) had cervical SCI, and 50 patients (18.2%) had thoracic SCI. Also, 14 patients (5.1%) were reported with both thoracic and lumbar injuries, 10 patients (3.6%) with both thoracic and cervical injuries, 1 patient (0.4%) with both lumbar and sacral injuries, 2 patients (0.7%) with both lumbar and cervical injuries, and 1 patient (0.4%) with cervical and thoracic and lumbar injuries. Tables 1, 2, and 3 represent a summary on the type of fractures and/or displacements in the cervical, thoracic and lumbar regions of the spine, respectively. Locked facet was reported in 12 patients (4.4%).

Accompanying injuries was reported in 75 patients (27.4%) of which 55 patients (73.3%) had limb fractures, 11 patients (14.7%) had TBI, 4 patients (5.3%) represented with internal bleeding, and 5 patients (6.7%) suffered from both TBI and limb fractures. Fifty-seven patients (20.8%) complained about having pain. Table 4 summarizes Visual Analogue Scores (VAS score) [11], assessed in conscious patients who had accompanying injuries, as well as spine trauma. The median of VAS score was 6 (range=6). Of the 103 patients with SCI, according to ASIA impairment scale, 3 patients (2.9%) had score A, and 100 patients (97.1%) had score E neurological defects. Twenty-eight patients (10.2%) were not able to control their urine and 24 of them (8.8%) had no control over excretion.

4. Discussion
In the present study, most of the patients showed normal neurological characteristics (E) according to ASIA. Locked facet was not a frequently observed event in the patients with spine trauma. Limb fracture was the most important associated disease in these patients, in contrast to pain. Safaei et al. studied 174 patients with spine injury in our hospital between 2001 and 2003 and reported that 71.8 % of the patients were male with an average age of 40.75±15.55 years [12]. Moreover, lumbar (L1), thoracic (T12), and cervical (C7) spine injuries of spine were found in 54.6, 33.9, and 11.5 percent of the patients with spine injury.
In our study, we observed that 198 patients (72.3%) were males. The mean of patients’ age was 42.27 years. One hundred-twenty patients (43.8%) suffered from SCI in lumbar region of the spinal cord, 76 patients (27.7%) had cervical SCI, and 50 patients (18.2%) had thoracic SCI. Furthure, 14 patients (5.1%) were reported with both thoracic and lumbar injuries, 10 patients (3.6%) with both thoracic and cervical injuries, 1 patient (0.4%) with both lumbar and sacral injuries, 2 patients (0.7%) with both lumbar and cervical injuries, and 1 patient (0.4%) with cervical and thoracic and lumbar injuries.
In 2015, Yousefzadeh et al. investigated 74 patients with spine injury and found that 88.2 of the patients were male [13]. Moreover, 34 patients (44.7%) experienced cervical spine injury. Thoracolumbar injuries resulted in SCI in 23 patients (30.3%). 29.7% of the patients had paraplegia and 10.8% of the patients suffered quadriplegia. Complete SCI was reported in 25 patients (38.5%).
In our study, of the 103 patients with SCI, according to ASIA impairment scale, 3 patients (2.9%) had score A, and 100 patients (97.1%) had score E neurological defects. Ramezani et al. [14] carried out a cross-sectional investigation on all 15-80 years old patients with trauma in Poursina Hospital of Guilan Province from 2015 to 2017 and reported that 70% of all the patients with spinal fractures were male and 30% were female. In addition, the mean age of patients with spinal fractures was 40.2. Lumbar (47.64%), cervical (30.58%) thoracic (21.76%) spine fractures were found to be the most prevalent.
An Icelandic retrospective study assessed hospital admissions owing to traumatic spinal fracture during a 5-year period [15]. The authors reported a total of 487 patients were diagnosed with a spinal fracture in which the mean age was 56 years Of these patients 9% developed SCI. A Spanish observational study on 282 traumatic SCI patients in the Canary Islands between 2001 and 2015 showed that 80.1% of the patients were males [16]. Additionally, the most frequently affected level was the cervical spine (50.9%), and incomplete tetraplegia (29.8%) was the most prevalent group.
5. Conclusion
The most telling reiteration is that men mostly had spine trauma. Lumbar region was the most susceptible place of SCI. Moreover, most of the patients experienced score E (normal neurological defects) according to ASIA.

Ethical Considerations
Compliance with ethical guidelines
The study was approved by institutional ethics committee (Code: IR.GUMS.REC.1397.517).
Funding
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
Authors contributions
Sasan Andalib and Zahra Mohtasham Amiri (co-first authors) contributed equally to the paper. All authors met ICMJE criteria.
Conflict of interest
Authors declare no conflict of interest.
Acknowledgements
We thank Guilan Road Trauma Research Center for the support provided.


References