Introduction
Traumatic spinal cord injury (TSCI) is a very burdensome incidence which occurs unexpectedly. It can be really destructive and costly (1) since usually causes long-term and lifelong morbidity and many a time changes the life conditions of the injured one’s and his/her family (2). In this type of injury, the spine structure is damaged and its function are impaired. This leads to disorder in motor skills, sense, sphincters, and autonomic nerves below the damaged area (3). The cause of traumatic spinal cord injuries can be either traumatic or non-traumatic (NTSCI), which includes various degrees based on nerve damage (4). According to international standards of American Spinal Injury Association (ASIA), the severity of an injury can be classified into two types, complete and incomplete. Complete injury is defined as absence of sensory and motor function in lowest parts of sacral segment (3) while in incomplete injury, sensory or motor function below the injured plane including the lowest sacral segments is maintained. The prevalence of traumatic SCI is different based on economic, social, political and cultural structure of each region (5). The incidence rate of spinal injuries in developed countries varies from 12.1 to 57.8 cases per million population and in developing countries from 12.7 to 29.7 (6). In US, the annual incidence of SCI is about 40 cases per million population (7). There are scarce reports on incidence of SCI in Iran (8). The most SCI cases are young men in age range of 21 to 30 years old (3). Moreover, the studies revealed that within two previous decades, motor vehicle accidents, violence and falling in the elderly have been the most leading-to-death mechanisms in youths (9). Patients with SCI put a burden on heath care system because their condition necessitates much more care and higher costs not only in the acute phase but also in early years after injury due to secondary physical and mental outcomes (10)(11). With regard to the abovementioned points, knowing the prevalence and incidence of SCI is of high importance since the statistics have shown the necessity of prevention (10). Considering the importance of topic and the fact that various life styles, socio-economic class and time of study lead to different epidemiologic statistics (12), much more research should be performed in this field in Iran in order to discover the groups at risk and preventive strategies. As a matter of fact, in prior studies, there has been no emphasis on types of spinal injuries. Therefore, the high importance of this topic in recent years and people’s different lifestyles made us to conduct our study in a trauma referral center in Guilan province on epidemiology and types of traumatic spinal injuries.

Methods & Materials
This is a descriptive study which was performed by census method on patients with spine trauma who had referred to Emergency Department of Poursina Hospital. Over this period, data of 76 patients were collected prospectively using a questionnaire consisting of demographic characteristics and the injured spine area, injury mechanism, type of neural injury based on ASIA scale and clinical examinations and records and para-clinical findings. Data were analyzed using SPSS (version 18) and descriptive statistics.

Results
In this study, 68 of 76 patients admitted with neurologic disorder due to spine trauma were men (88.2%). The male-to-female ratio was 7.4:1. The mean age of men was 35.2±1.45 years and 80% of them were under 45 years. Mean age of women was 47.1±1.16 years (Figure 1). MVA (48.7%) and falling (42.1%) were the most common causes of SCI in this study, respectively. Causes of SCI based on age are shown in figure 2. 
43 patients (56.6%) with SCI had burst fracture and 17 patients (22.3%) of these fractures had facet dislocation (type B3 and C1 to 3 in Magerl classification). The unusual fractures like Odontoid and posterior element fracture were the least types. 10 SCI patients (31.1%) had no fracture in spinal column. One of them had SCI in C1-C2 due to stab wound which caused Brown-Sequard. One of the patients had SCI due to gun shut but had no pellet in spinal cord. 8 patients (10.5%) had central cord syndrome due to the previous degenerative canal narrowing. Results of this study indicated that 29.7% of patients had Paraplegia and 10.8% Quadriplegia.
In 34 patients (44.7%), cervical spine trauma and in 23 patients (30.3%) lumbar trauma led to SCI. No sacral trauma in these patients led to SCI. 25 patients (38.5%) had complete SCI (A in ASIA categorization). Figure 3 shows spine lesion in different levels. 
7 patients with SCI (9.2%) died during hospitalization. Mean age of dead patients was 49.42±1.32 years. In this study, increased age was assigned as a risk factor for death. In 4 of these patients (57.1%) cervical SCI led to death. 3 of deaths were due to organ injuries such as brain or sepsis. Falling was the mechanism of trauma due to SCI in 3 deaths (75%).
 

 

 

 

Discussion
Mean age of patients in this study was 36.64±14.61 years. In similar studies in Canada and America, the mean age of patients was 35 (13) and over 33 years, respectively (12). Asian papers have reported mean age of SCI patients in range of 26.8 to 56.6 years. This estimation was similar to world statistics which displays that most SCI traumatic incidences occur to adult individuals since they are the most active members of society (14). In Iran, a similar study was performed in Tehran in which the mean age of patients with traumatic SCI victims was 31±7 years (8). In our project, 88% of subjects under study were men. In another study by Dryden et al. 71.6% of patients were men (13). Brojeni et al. had 18 men (90%) and 2 women (10%) of 20 subjects in their study (15). In a research by Jackson et al. the number of SCI men was four times more in men than women (12), based on a report by Ning et al, men were more at risk of SCI than women (14). These findings emphasize the fact that younger men are more involved in works and activities in open environments while most women work at home or perform less riskful activities (3)(14). In this effort, the most common cause of SCI was motor vehicle accidents (48.7%) followed by falling (42.1%). In parallel studies, it was suggested that MVC (Motor Vehicle Collision) and falling were the causes leading to SCI, respectively (12)(13)(14). In a study in Iran, traffic accidents (54.11%) and falling (42.35%) were the most common causes of SCI (16). In ongoing study, 44.7% of patients had traumatic spine in cervical area and 30.3%  in the thoracolumbar area. In a research by Dryden et al. 61.5% of patients in cervical and 17.3% in thoracic,17.1% lumbosacral area suffered trauma (13). Broojeni et al. reported the anatomical area of injury as follows; cervical in 8 cases (40%), thoracic in 7 cases (35%), and lumbar in 5 cases (25%) (15) whereas in a study by Erdoğan and colleagues, the most prevalent injury location was attributed to lumbar (48%) followed by thoracic (29.3%) (17). All in all, severity of traumatic SCI is often assessed by the neurologic level of injury (tertraplegia) or extent of injury (complete or incomplete) (14). In a study by Jackson, 54.1% of patients had tetraplegia who occupied a higher number compared to 
paraplegia (12). In this study, 38.5% of patients had complete SCI (A grade in ASIA), 9.2% B, 16.9% C, 35.4% D. A study by Feng et al. suggested 32.6% A, 12.1% B, 16.3 C, and 38.9% D (5). In another study, Jackson et al. cited 55.6% A level injury (complete injuries) which was more than incomplete (44.4%) (12). Furthermore, Ning et al. who worked on traumatic SCI epidemiology in Asia concluded that in most countries, most patients were at A level of AISA/Frankel (except China & Japan), B level comprised 10 to 30% of patients. A similar number were at C (14) in our project, 7 patients (9.2%) died during hospitalization. In most patients with cervical SCI death was the direct cause of death. Our study revealed that the most causes of death in patients with SCI was injury in cervical area (5) while in a study conducted by Dryden et al. 32% of dead victims had SCI in cervical area, and 68% of them had SCI and injury in other areas (13). 

Conclusion
According to this study, men were more at risk and the most injury mechanism leading to SCI was MVA. In fact, these victims are source of income in family and human resource in society. As a result, these injuries lead to serious damages in diverse dimensions. In most cases, they make patients unable to accomplish their personal matters. Often these traffic accidents are preventable; thus, we suggest more attention be paid to education on safety issues considering at risk groups. Governments and organizations in charge should devise comprehensive plans with clear aims to increase safety. 

Acknowledgment
Hereby, the authors would like to thank Clinical Research Development Unit of Poursina Hospital, Guilan University of Medical Sciences. 

Funding
None declared

Conflicts of Interest 
The authors have no conflict of interest. 

References