Preventing motor vehicle crashes related spine injuries in children

Effectiveness of road safety interventions: An evidence and gap map

Background

Road Traffic injuries (RTI) are among the top ten leading causes of death in the world resulting in 1.35 million deaths every year, about 93% of which occur in low- and middle-income countries (LMICs). Despite several global resolutions to reduce traffic injuries, they have continued to grow in many countries. Many high-income countries have successfully reduced RTI by using a public health approach and implementing evidence-based interventions. As many LMICs develop their highway infrastructure, adopting a similar scientific approach towards road safety is crucial. The evidence also needs to be evaluated to assess external validity because measures that have worked in high-income countries may not translate equally well to other contexts. An evidence gap map for RTI is the first step towards understanding what evidence is available, from where, and the key gaps in knowledge.

Objectives

The objective of this evidence gap map (EGM) is to identify existing evidence from all effectiveness studies and systematic reviews related to road safety interventions. In addition, the EGM identifies gaps in evidence where new primary studies and systematic reviews could add value. This will help direct future research and discussions based on systematic evidence towards the approaches and interventions which are most effective in the road safety sector. This could enable the generation of evidence for informing policy at global, regional or national levels.

Search Methods

The EGM includes systematic reviews and impact evaluations assessing the effect of interventions for RTI reported in academic databases, organization websites, and grey literature sources. The studies were searched up to December 2019.

Selection Criteria

The interventions were divided into five broad categories: (a) human factors (e.g., enforcement or road user education), (b) road design, infrastructure and traffic control, (c) legal and institutional framework, (d) post-crash pre-hospital care, and (e) vehicle factors (except car design for occupant protection) and protective devices. Included studies reported two primary outcomes: fatal crashes and non-fatal injury crashes; and four intermediate outcomes: change in use of seat belts, change in use of helmets, change in speed, and change in alcohol/drug use. Studies were excluded if they did not report injury or fatality as one of the outcomes.

Data Collection and Analysis

The EGM is presented in the form of a matrix with two primary dimensions: interventions (rows) and outcomes (columns). Additional dimensions are country income groups, region, quality level for systematic reviews, type of study design used (e.g., case-control), type of road user studied (e.g., pedestrian, cyclists), age groups, and road type. The EGM is available online where the matrix of interventions and outcomes can be filtered by one or more dimensions. The webpage includes a bibliography of the selected studies and titles and abstracts available for preview. Quality appraisal for systematic reviews was conducted using a critical appraisal tool for systematic reviews, AMSTAR 2.

Main Results

The EGM identified 1859 studies of which 322 were systematic reviews, 7 were protocol studies and 1530 were impact evaluations. Some studies included more than one intervention, outcome, study method, or study region. The studies were distributed among intervention categories as: human factors (n = 771), road design, infrastructure and traffic control (n = 661), legal and institutional framework (n = 424), post-crash pre-hospital care (n = 118) and vehicle factors and protective devices (n = 111). Fatal crashes as outcomes were reported in 1414 records and non-fatal injury crashes in 1252 records. Among the four intermediate outcomes, speed was most commonly reported (n = 298) followed by alcohol (n = 206), use of seatbelts (n = 167), and use of helmets (n = 66). Ninety-six percent of the studies were reported from high-income countries (HIC), 4.5% from upper-middle-income countries, and only 1.4% from lower-middle and low-income countries. There were 25 systematic reviews of high quality, 4 of moderate quality, and 293 of low quality.

Authors' Conclusions

The EGM shows that the distribution of available road safety evidence is skewed across the world. A vast majority of the literature is from HICs. In contrast, only a small fraction of the literature reports on the many LMICs that are fast expanding their road infrastructure, experiencing rapid changes in traffic patterns, and witnessing growth in road injuries. This bias in literature explains why many interventions that are of high importance in the context of LMICs remain poorly studied. Besides, many interventions that have been tested only in HICs may not work equally effectively in LMICs. Another important finding was that a large majority of systematic reviews are of low quality. The scarcity of evidence on many important interventions and lack of good quality evidence-synthesis have significant implications for future road safety research and practice in LMICs. The EGM presented here will help identify priority areas for researchers, while directing practitioners and policy makers towards proven interventions.

Incidence, prevalence and disability of spinal cord injury in China from 1990 to 2019: a systematic analysis of the Global Burden of Disease Study 2019

PURPOSE

We aimed to estimate the incidence, prevalence and years lived with disability (YLDs) of spinal cord injury (SCI) in China in 2019 and temporal trends from 1990 to 2019.

METHODS

The Global Burden of Disease Study 2019 was used to obtain data. Outcome measures included age-standardized incidence rate (ASIR), prevalence rate (ASPR) and YLDs rate (ASYR). A Bayesian meta-regression tool, DisMod-MR 2.1, was used to produce the estimates of each value after adjustments.

RESULTS

In 2019, there were 234.19 [95% uncertainty interval (UI) 171.84-312.87] thousand incident cases of SCI in China, with an ASIR of 13.87 (95% UI 10.15-18.66) per 100,000. ASIR and ASYR increased by 40.81% (95% UI 32.92-49.14%) and 11.44% (95% UI 5.16-17.29%) compared with 1990, individually. Males had higher ASIR and ASYR in each year from 1990 to 2019, but the incidence and YLDs rates of females exceeded males after 70 years old. Incidence and YLDs rates both ascended with age. SCI at neck level had slightly higher incidence rate but much higher YLDs rate than that below neck level. The average incidence age increased from 38.97 in 1990 to 54.59 in 2019. Falls were the leading cause of SCI.

CONCLUSION

The incidence and burden of SCI in China increased significantly during the past three decades. The age structure of SCI patients showed a shift from the young to the elderly as population aging. Urgent efforts are needed to relieve the health pressure from SCI.

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

Objectives:

To describe the patterns of cervical spine injuries in an adult population in a major trauma center in Riyadh, Saudi Arabia.

Methods:

A retrospective cohort study including all adults with cervical spine injuries from 2014 to 2018 was conducted. All patient data with radiological evidence of injury involving the cervical spine were collected.

Results:

The final sample size realized as 257 patients. Majority of the sample (85.6%) were male and the age ranged from 14-90 years (mean of 36.6 years±18.5 SD). Motor vehicle accidents were the most frequent mechanism of injury (92.6%, n=238). Single level of injury of the cervical spine was encountered in 52.9% (n=136) and 2 or more levels of injury were encountered in 47.1% (n=122) of patients. In total, 442 cervical spine injury levels were identified. At these levels, 559 fractures were observable radiologically. Associated head injury was present in 125 patients (48.6%). Only a small proportion (22.2%, n=57) had neurological sequelae.

Conclusion:

It reflects the impact of this injury on younger male patient population.

Safer Roads to School

Any and all advances made by medical science cannot solve the problem of road traffic injuries (RTIs) in school-going children, especially if the only concerned people are those of the medical fraternity. Children are a vulnerable part of the traveling population and thus have been persistent due to the callous nature of the citizens and policy makers toward road safety and injury prevention. In our multicultural and multilingual country, there is a need for multistakeholder initiative with a countrywide presence if we are to stem the rise of mortality and morbidity due to these accidents. The first question we need to ask is how to prevent road traffic accidents and improve the condition of our roads. Pediatric RTIs are eternal problem of industrial revolution with complications and effects that may affect individual and society with increase in the number of motorized communications. Dedicated capacity building is urgently need who should be able to provide the necessary care to the injured children at the road crash spot as well as should be informed where to take the injured child and whom to contact in the dedicated injury care center while transporting the victims of situations.

Cervical and thoracic spine injury in pediatric motor vehicle crash passengers

OBJECTIVE

Motor vehicle occupants aged 8 to 12 years are in transition, in terms of both restraint use (booster seat or vehicle belt) and anatomical development. Rear-seated occupants in this age group are more likely to be inappropriately restrained than other age groups, increasing their vulnerability to spinal injury. The skeletal anatomy of an 8- to 12-year-old child is also in developmental transition, resulting in spinal injury patterns that are unique to this age group. The objective of this study is to identify the upper spine injuries commonly experienced in the 8- to 12-year-old age group so that anthropomorphic test devices (ATDs) representing this size of occupant can be optimized to predict the risk of these injuries.

METHODS

Motor vehicle crash cases from the National Trauma Data Bank (NTDB) were analyzed to characterize the location and nature of cervical and thoracic spine injuries in 8- to 12-year-old crash occupants compared to younger (age 0-7) and older age groups (age 13-19, 20-39).

RESULTS

Spinal injuries in this trauma center data set tended to occur at more inferior vertebral levels with older age, with patients in the 8- to 12-year-old group diagnosed with thoracic injury more frequently than cervical injury, in contrast to younger occupants, for whom the proportion of cases with cervical injury outnumbered the proportion of cases with thoracic injury. With the cervical spine, a higher proportion of 8- to 12-year-olds had upper spine injury than adults, but a substantially lower proportion of 8- to 12-year-olds had upper spine injury than younger children. In terms of injury type, the 8- to 12-year-old group's injury patterns were more similar to those of teens and adults, with a higher relative proportion of fracture than younger children, who were particularly vulnerable to dislocation and soft tissue injuries. However, unlike for adults and teens, catastrophic atlanto-occipital dislocations were still more common than any other type of dislocation for 8- to 12-year-olds and vertebral body fractures were particularly frequent in this age group.

CONCLUSIONS

Spinal injury location in the cervical and thoracic spine moved downward with age in this trauma center data set. This shift in injury pattern supports the need for measurement of thoracic and lower cervical spine loading in ATDs representing the 8- to 12-year-old age group.

Evidence-based prevention and treatment of osteoporosis after spinal cord injury: a systematic review

PURPOSE

Spinal cord injury (SCI) results in accelerated bone mineral density (BMD) loss and disorganization of trabecular bone architecture. The mechanisms underlying post-SCI osteoporosis are complex and different from other types of osteoporosis. Findings of studies investigating efficacy of pharmacological or rehabilitative interventions in SCI-related osteoporosis are controversial. The aim of this study was to review the literature pertaining to prevention and evidence-based treatments of SCI-related osteoporosis.

METHODS

In this systematic review, MEDLINE, EMBASE, PubMed, and the Cochrane Library were used to identify papers from 1946 to December 31, 2015. The search strategy involved the following keywords: spinal cord injury, osteoporosis, and bone loss.

RESULTS

Finally, 56 studies were included according to the inclusion criteria. Only 16 randomized controlled trials (involving 368 patients) were found. We found following evidences for effectiveness of bisphosphonates in prevention of BMD loss in acute SCI: very low-quality evidence for clodronate and etidronate, low-quality evidence for alendronate, and moderate-quality evidence for zoledronic acid. Low-quality evidence showed no effectiveness for tiludronate. In chronic SCI cases, we found low-quality evidence for effectiveness of vitamin D₃ analogs combined with 1-alpha vitamin D₂. However, low-quality inconsistent evidence exists for alendronate. For non-pharmacologic interventions, very low-quality evidence exists for effectiveness of standing with or without treadmill walking in acute SCI. Other low-quality evidences indicated that electrical stimulation, tilt-table standing, and ultrasound provide no significant effects. Very low-quality evidence did not show any benefit for low-intensity (3 days per week) cycling with functional electrical stimulator in chronic SCI.

CONCLUSIONS

No recommendations can be made from this review, regarding overall low quality of evidence as a result of high risk of bias, low sample size in most of the studies, and notable heterogeneity in type of intervention, outcome measurement, and duration of treatment. Therefore, future high-quality RCT studies with higher sample sizes and more homogeneity are strongly recommended to provide high-quality evidence and make applicable recommendations for prevention and treatment of SCI-related bone loss.

Epidemiology, causes and prevention of car rollover crashes with ejection

Rollover crashes (ROCs) are responsible for almost a third of all highway vehicle occupant fatalities. Although ROCs are common and serious mechanism of injury, ROCs are under-reported. To analyze the causes, mechanism, impact and prevention of ROCs, we reviewed the literature between 1984 and 2013. By utilizing the search engines PubMed, MEDLINE and EMBASE by using key words “ROCs” “Ejection” and “vehicle” the initial search yielded 241 abstracts, of which 58 articles were relevant. Most of the articles were either retrospective or experimental studies funded by automobile companies. All vehicles are susceptible to rollovers to certain extents. Despite continuing innovation in vehicles’ safety, human factor is pivotal in prevention of ROCs. Distracted driving, speeding and drinking escalate the chances of rollover crashes. Wearing a seatbelt greatly improves the chances of surviving a ROC.

Causes and patterns of spine trauma in children and adolescents in Saudi Arabia: implications for injury prevention

BACKGROUND AND OBJECTIVES

Knowledge regarding traumatic spine injuries (TSIs) is essential for effective prevention strategies, particularly in the developing world, where majority of the population is younger and organized prevention programs are scarce. Therefore, our objective was to describe TSI mechanisms, demographics, patterns, and outcomes in children and adolescents.

DESIGN AND SETTINGS

Retrospective chart review in a major trauma center from May 2001 to May 2009 in Riyadh, Saudi Arabia.

PATIENTS AND METHODS

Detailed chart reviews were done for all consecutive TSI patients ≤18 years old.Cases were identified through the trauma database registry that included admitted patients.

RESULTS

Of the 3796 cases identified, 120 cases (3.2%) sustained 141 TSIs (mean age: 13.5 years; males:83.8%). TSI was most common among children from 16 to 18 years old. Overall, motor vehicle collision (MVC)was the most common injury mechanism (60.8%). However, younger patients (<12 years) sustained more pedestrian injuries (40.6%). Among MVC cases with known seat belt statuses (43.8%), 90.6% were not wearing seat belts. The cervical spine level was the most commonly affected (55.8%) region, especially in children <12 years old (88%). More than 1 affected spinal level was found in 23.3% cases. Spinal cord injuries were found in 19.2% cases. Overall, mortality was 8.3%, and half of these mortalities were secondary to pedestrian injuries. A total of 22.7% of cases were discharged with neurological deficits.

CONCLUSION

The high frequency and severity of MVC and pedestrian injuries observed in the present study raise significant concerns regarding the safety of children on the roads. Spine involvement was age specific;younger patients tended to have more cervical injuries, and older patients exhibited more thoracic spine involvement.

Motor vehicle crash-related injury causation scenarios for spinal injuries in restrained children and adolescents

OBJECTIVE

Motor vehicle crash (MVC)-related spinal injuries result in significant morbidity and mortality in children. The objective was to identify MVC-related injury causation scenarios for spinal injuries in restrained children.

METHODS

This was a case series of occupants in MVCs from the Crash Injury Research and Engineering Network (CIREN) data set. Occupants aged 0-17 years old with at least one Abbreviated Injury Scale (AIS) 2+ severity spinal injury in vehicles model year 1990+ that did not experience a rollover were included. Unrestrained occupants, those not using the shoulder portion of the belt restraint, and those with child restraint gross misuse were excluded. Occupants with preexisting comorbidities contributing to spinal injury and occupants with limited injury information were also excluded. A multidisciplinary team retrospectively reviewed each case to determine injury causation scenarios (ICSs). Crash conditions, occupant and restraint characteristics, and injuries were qualitatively summarized.

RESULTS

Fifty-nine cases met the study inclusion criteria and 17 were excluded. The 42 occupants included sustained 97 distinct AIS 2+ spinal injuries (27 cervical, 22 thoracic, and 48 lumbar; 80 AIS-2, 15 AIS-3, 1 AIS-5, and 1 AIS-6), with fracture as the most common injury type (80%). Spinal-injured occupants were most frequently in passenger cars (64%), and crash direction was most often frontal (62%). Mean delta-V was 51.3 km/h±19.4 km/h. The average occupant age was 12.4±5.3 years old, and 48% were 16- to 17-year-olds. Thirty-six percent were right front passengers and 26% were drivers. Most occupants were lap and shoulder belt restrained (88%). Non-spinal AIS 2+ injuries included those of the lower extremity and pelvis (n=56), head (n=43), abdomen (n=39), and thorax (n=36). Spinal injury causation was typically due to flexion or lateral bending over the lap and or shoulder belt or child restraint harness, compression by occupant's own seat back, or axial loading through the seat pan. Nearly all injuries in children<12 years occurred by flexion over a restraint, whereas teenage passengers had flexion, direct contact, and other ICS mechanisms. All of the occupants with frontal flexion mechanism had injuries to the lumbar spine, and most (78%) had associated hollow or solid organ abdominal injuries.

CONCLUSIONS

Restrained children in nonrollover MVCs with spinal injuries in the CIREN database are most frequently in high-speed frontal crashes, of teenage age, and have vertebral fractures. There are age-specific mechanism patterns that should be further explored. Because even moderate spinal trauma can result in measurable morbidity, future efforts should focus on mitigating these injuries.