ORIGINAL ARTICLE

A Nationwide Review of the Associations Among Cervical Spine Injuries, Head Injuries, and Facial Fractures
Ryan Patrick Mulligan, Jonathan A. Friedman, MD, and Raman Chaos Mahabir, MD, MS, FRCSC

Background: Several small studies have investigated the relationship among facial fractures, c-spine injuries, and head injuries with varying results. Determining this correlation at a national level would be the rst step in updating the trauma imaging protocol. The purpose of this study was to review the incidence of facial fractures, c-spine injuries, and head injuries at trauma centers across the United States. Methods: The design was a retrospective chart review of International Classication of Disease, Ninth Revision, diagnosis and procedure codes from the National Trauma Data Bank between the years 2002 and 2006. This included data on more than 2.7 million reported traumas. Results: The incidence of facial fracture was 13.5% in patients with a c-spine injury, 21.7% in patients with a head injury, and 24.0% of patients with a combined c-spine and head trauma. Head injuries were found in 40.2% of patients with a c-spine injury, 67.9% of patients with a facial fracture, and 71.5% of patients with a combined c-spine injury and facial fracture. C-spine injuries were reported in 6.7% of facial fractures, 7.0% of head injuries, and 7.8% of patients with a combined facial fracture and head injury. Conclusions: This is the largest review in history documenting these associations. Pending cost-benet analysis, the current trauma imaging protocol may be challenged. Key Words: Trauma, Facial fracture, Head injury, C-spine injury. (J Trauma. 2010;68: 587592)

assess the head and cervical spine.2 Similarly, in head and neck trauma, it is important to rule out facial fractures. Swelling and distortion of the anatomy can impede clinical examination, again forcing trauma services to rely on the CT scans. Although the cuts for a CT scan of the head or cervical spine can detect facial fractures, they do not have enough detail to completely evaluate the facial skeleton. The reconstructive surgeon requires a dedicated CT of the facial bones, including coronal and axial cuts, which are not captured with the standard c-spine and head series. The purpose of our study was to establish the incidence of and association among facial fractures, c-spine injuries, and head injuries with the NTDB. A review at the national level would be the rst step in an update of trauma imaging protocol.

MATERIALS AND METHODS

The NTDB uses the International Classication of Disease, Ninth Revision (ICD-9) to code for diagnoses and the ICD-9 Clinical Modication (ICD-9-CM) for procedure coding. The dataset used in our analysis contained 1,309,311 incidents with 4,893,319 diagnosed injuries, as well as 1,297,067 incidents with 5,944,599 procedures performed between the years 2002 and 2006. The complete dataset is organized by 21 relational tables with each incident listed by a unique incident identier key that is consistent for all tables. An incident identier key number can be used more than once if a patient has more than one injury or procedure, therefore a unique incident identier key could be thought of as a single patient. The ICD-9 diagnosis codes and ICD-9-CM procedure codes for each incident were located in separate tables. For analysis, new tables were created in Microsoft Access by paring down an original table to contain only codes for a certain injury or procedure. The table was then ltered to contain only unique incident keys to represent each patient. Injury and procedure tables were then compared to determine which incident keys were concurrently present. For the purposes of our study, a facial fracture diagnosis was dened as any fracture of the frontal, parietal, orbit, maxilla, nasal, ethmoid, zygomatic, palate, alveolus, and mandible. Cervical spine injuries included fracture, dislocation, and spinal cord injury in the cervical region. Head injury was dened as any injury commonly requiring a CT scan. These injuries included skull fracture, brain contusions or lacerations, intracranial hemorrhage, and concussion with loss of consciousness. Table 1 con587

he National Trauma Data Bank (NTDB) is the largest trauma registry ever assembled and contains more than 2.7 million records from the United States and Puerto Rico since 1988. Nearly half a million incidents were reported to the NTDB last year alone.1 Identication and assessment of head and cervical spine injury are key components of the initial trauma evaluation. Neurologic examination may be limited because of the extent of other injuries, endotracheal intubation, or confounding medications with sedative effects. Trauma services increasingly rely on imaging, particularly computed tomography (CT) scans, to
Submitted for publication November 3, 2008. Accepted for publication May 22, 2009. Copyright 2010 by Lippincott Williams & Wilkins From the Divisions of Neurosurgery and Plastic Surgery (R.P.M.), Texas A&M Health Science Center and Scott and White, Temple, Texas; Departments of Surgery, Neuroscience, and Experimental Therapeutics (J.A.F.), Texas A&M Health Science Center College of Medicine, College Station, Texas; and Division of Plastic Surgery (R.C.M.), Scott and White/Texas A&M Health Science Center College of Medicine, Temple, Texas. Address for reprints: Raman C. Mahabir, MD, Division of Plastic Surgery, Scott and White Memorial Hospital, 2401 South 31st Street, Temple, TX 76508; email: rmahabir@swmail.sw.org. DOI: 10.1097/TA.0b013e3181b16bc5

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TABLE 1.
Injury

Injuries and ICD-9 Codes

ICD-9 Codes 805.00805.18 806.00806.19 839.00839.18 952.00952.09 800.1800.4 800.6800.9 801.0801.9 803.0803.9 804.0804.9 850.1852.5 853.0853.1 854.0854.1 800.0800.9 802.0802.9 804.0804.9 805.00805.18 806.00806.19 839.00839.18 806.00806.19 952.00952.09 800.1, 800.6 801.2, 801.6 803.2, 803.6 804.2, 804.6 851.0851.9 800.2, 800.3 800.7, 800.8 801.3, 801.4 801.7, 801.8 803.3, 803.4 803.7, 803.8 804.3, 804.4 804.7, 804.8 852.0852.5 853.0853.1 801.0801.9 803.0803.9 804.0804.9 850.1850.9 Injury Details Fracture of cervical vertebral column with/without mention of spinal cord injury, cervical vertebra dislocation, cervical spinal cord injury without evidence of spinal bone injury

C-spine injury

Head injury

Fractures of vault of skull with intracranial injury, fractures of base of skull, other and unqualied skull fractures, multiple fractures involving skull and face with other bones, concussion with loss of consciousness, cerebral laceration and contusion, subarachnoid, subdural, and extradural hemorrhage following injury, other and unspecied intracranial hemorrhage after injury, intracranial injury of other and unspecied nature

Facial fracture

Fractures of frontal and parietal bones, fractures of facial bones, multiple fractures of skull and face with other bones Fracture of cervical vertebral column with/without mention of spinal cord injury Cervical vertebra dislocation Fracture of cervical vertebral column with mention of spinal cord injury, cervical spinal cord injury without evidence of spinal bone injury Brain contusion or laceration with and without skull fracture

C-spine fracture C-spine dislocation C-spine cord injury Brain contusion/laceration

Intracranial hemorrhage

Cerebral, subarachnoid, subdural, or extradural hemorrhage with and without skull fracture

Skull fracture

Fractures of base of skull, other and unqualied skull fractures, multiple fractures involving skull and face with other bones Concussion with loss of consciousness

Concussion with loss of consciousness

tains the ICD-9 diagnosis codes used and a detailed denition of each subset. ICD-9-CM procedure codes were less descriptive by anatomic location. Facial fracture reductions included procedures on the orbit, maxilla, nasal bone, malar bone, alveolus, and mandible. Procedures to reduce fractures of the frontal and parietal bones are coded as skull fracture reductions with the ICD-9-CM method, and therefore were included with head injury procedures. Spine level is not differentiated with ICD-9-CM coding, so that procedures on the spine at all levels, not just cervical, were used. Because of the specicity of spine and head procedure codes, it was difcult to rule out any of the listed procedures in a trauma situation. To ensure all possibilities were accounted for, all operation
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codes for the spine were included in spine procedures and all operation codes for the skull, brain, and cerebral meninges were included in head procedures. However, the level vertebral fracture reduction is not specied with ICD-9-CM coding, so that procedures rarely associated with head or face injury, such as reduction of thoracolumbar fractures and dislocations, were unnecessarily included. Table 2 contains the ICD-9-CM codes and procedure details.

RESULTS
Of the 1,309,311 people diagnosed with an injury, there were 117,417 with one or more facial fractures, 58,272 with a cervical spine injury, and 334,864 with a head injury (Fig. 1).
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Spine and Head Injuries and Facial Fractures

TABLE 2.
Procedure

Procedures and ICD-9 CM Codes

ICD-9 CM Codes 3.003.99 1.002.99 21.71, 21.72 Procedure Details All operations on spinal cord and spinal canal structures All procedures of the skull, brain, and cerebral meninges Nasal bone fracture reduction, maxilla/zygomatic fracture reduction, mandibular fracture reduction, alveolar fracture reduction, orbit fracture reduction, unspecied facial fracture reduction

DISCUSSION
This is the largest study of the association among head injury, c-spine injury, and facial fractures ever reported. More than 1.3 million individuals with injuries from 700 hospitals across the United States and Puerto Rico were analyzed by using the NTDB. The extremely large sample size may allow meaningful generalization with regard to best imaging protocols and resolve discrepancies in previously published data. The incidence of cervical spine injury in the setting of facial fracture has been reported to be between 0% and 7.3%.317 Alvi et al.18 reported the highest incidence, but that report had a relatively small sample of 151 facial fractures. Of 676 facial fractures, Williams et al.19 found 4.2% with a c-spine injury but reported a similar incidence in all traumas with or without facial fracture. In one of the larger and most recent studies, Elahi et al.20 found the incidence to be 3.7%, however, in the setting of multiple facial fractures the incidence jumped to 8.9%. Davidson and Birdsell7 found the incidence to be 1.3%, but in the setting of a motor vehicle crash this increased to 5.5%. The only reviews of the need for c-spine imaging are with mandibular fracture and both Andrew et al.21 and Bayles et al.22 reported it was unnecessary after nding the incidence to be 1%. Despite this, it remains common practice to obtain c-spine imaging for those with any facial fracture. Given our nding of a 6.7% incidence and the devastating consequences of a missed C-spine injury, this practice is likely best left unchanged. The incidence of facial fracture in the setting of c-spine or head injury may be of more importance to the trauma surgeon, with respect to the indications for a dedicated facial CT scan at the time of standard head and neck CT. The highest reported incidence of facial fracture with cervical spine injury was 8.6% by Lewis et al.23 Hackl et al.24 reported an incidence of 2.1%, but saw the incidence increase with severity of cervical spine injury. In the setting of c-spine fracture, Oller et al.11 reported the incidence of facial fracture to be 1.7%, and in the setting of c-spine cord injury, the incidence was 0.8%. We found the incidence of facial fracture in the setting of c-spine to be 13.5%, signicantly higher than previously reported. Facial fracture in the setting of c-spine injury is twice as likely as the reverse, yet facial CT scans in patients with c-spine trauma are not routinely acquired. This is one area that could potentially be improved on. The necessity of facial CT scans in c-spine or head trauma victims is debated in the literature. In support, facial fracture specic to head injury was reported to be about 12%.25,26 In 116 trauma victims, Rehm and Ross27 saw 46 facial fractures of which more than half were clinically unsuspected and required CT scans for diagnosis. Studies by Weider et al.29 and Press et al.28 argued against the need for facial CT scanning in trauma victims by showing no significant differences in complication rate, infection rate, or total hospital stay between those who were treated early or days later. Our study found the incidence of facial fracture to be 21.7%. Studies on the incidence of head injury in patients with facial fracture have shown wildly varying results ranging from 5.0% to 85%.1315,17,28,30 41 The variation in results may be attributed to different population samples and varied
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Spine procedure Head procedure Facial fracture reduction

76.7076.79

Figure 1. Summary of the injuries reported to the NTDB during the study period.

The incidence of facial fracture was 13.5% in patients with a c-spine injury, 21.7% in patients with a head injury, and 24.0% of patients with a combined c-spine and head trauma. The incidence of facial fracture requiring reduction was 2.8% in patients with a c-spine injury, 3.9% in patients with a head injury, and 4.9% in patients with a c-spine and head injury (Table 3). Head injuries were found in 40.2% of patients with a c-spine injury, 67.9% of patients with a facial fracture, and 71.5% of patients with a combined c-spine injury and facial fracture. A neurosurgical procedure was performed on 10.8% of patients with a facial fracture, 13.1% of patients with a c-spine injury, and 19.0% of patients with a facial fracture and c-spine injury. C-spine injuries were reported in 6.7% of facial fractures, 7.0% of head injuries, and 7.8% of patients with a combined facial fracture and head injury. A spine procedure was performed on 1.5% of patients with a facial fracture, 1.6% with a head injury, and 1.7% with a facial fracture and head injury. Table 3 also contains the incidences of specic head and c-spine injuries in the setting of facial fracture, c-spine injury, and head injury.
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TABLE 3.

Results
N 117,417 Injury C-spine injury C-spine fracture C-spine dislocation C-spine cord injury Head injury Skull fracture Brain contusion/laceration Intracranial hemorrhage Concussion with loss of consciousness Facial fracture Head injury Skull fracture Brain contusion/laceration Intracranial hemorrhage Concussion with loss of consciousness Facial fracture C-spine injury C-spine fracture C-spine dislocation C-spine cord injury Head injury C-spine injury Facial fracture N (%) 7,883 (6.7) 7,128 (6.1) 654 (0.6) 987 (0.8) 72,612 (61.8) 34,603 (29.5) 19,810 (16.9) 33,598 (28.6) 13,156 (11.2) 7,883 (13.5) 23,449 (40.2) 5,922 (10.2) 4,758 (8.2) 9,483 (16.3) 6,894 (11.8) 72,612 (21.7) 23,449 (7.0) 20,781 (6.2) 2,492 (0.7) 3,491 (1.0) 5,633 (71.5) 5,633 (7.8) 5,633 (24.0) Procedure Spine procedure N (%) 1,712 (1.5)

In the Setting of Facial fracture

Head/brain procedure

12,720 (10.8)

C-spine injury

58,272

Facial fracture reduction Head/brain procedure

1,607 (2.8) 7,648 (13.1)

Head injury

334,864

Facial fracture reduction Spine procedure

13,114 (3.9) 5,366 (1.6)

Facial fracture and c-spine injury Facial fracture and head injury C-spine injury and head Injury

7,883 72,612 23,449

Head/brain procedure Spine procedure Facial fracture reduction

1,498 (19.0) 1,264 (1.7) 1,144 (4.9)

denitions of head injury. Sinclair et al.14 found the incidence to be 85%, but with a broad denition of head injury and a population of strictly blunt trauma victims of which more than 70% were the result of a motor vehicle crash. On the lower end of the spectrum, Lim et al.13 dened head injury as moderate to severe neurosurgical injury and reported an incidence of only 5.4%. Studies that focused on trauma victims, such as those by Press et al.28 (59%) and Davidoff et al.30 (55%), reported incidences closest to our nding of 61.8%, which argues strongly for a CT head in all patients with a c-spine fracture. Several studies looked at specic types of head injuries in patients with facial fracture. The incidence of skull fracture was reported to be between 1.9% and 19%.16,40 43 Concussions were present in 2% to 70% of facial fractures, depending on severity of the concussions included in the study.16,18,44 Pappachan and Alexander44 reported a higher incidence of cerebral contusion (26.4%) than intracranial hemorrhage (2.7%), whereas Alvi et al.18 reported a higher incidence of intracranial hemorrhage (43.7%) than cerebral contusion (15.9%). Our results reect the large sample size and used widely accepted denitions of injury subsets. The incidence of c-spine injury in the setting of head injury has been reported between 1.7% and 9%, depending on the severity of injuries included.3,19,4552 Michael et al. supported the view of assuming concomitant injury in both settings until proven otherwise. In addition to reporting an incidence of 6% c-spine injury with head injury, they found the incidence of head injury in the setting of c-spine injury to
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be 24%.52 Iida et al.53 reported an incidence of 35% moderate to severe head injury with c-spine injury along with an observation of increased frequency of brain damage in upper cervical injury compared with middle and lower regions of the c-spine. In all studies of this kind, the incidence of head injury specic to c-spine injury has been reported between 6% and 63%.5255 Our ndings fall within both reported ranges and are most similar to the values reported by studies supporting a comprehensive imaging protocol. Examination of the literature found differing opinions on the need for a CT scan of the c-spine or head when the other was being performed. Gbaanador et al.56 concluded that there was no association between c-spine and head injury. More recently, however, Holly et al.46 found the incidence to be 5.4% and called for a more effective protocol in determination of c-spine injury with head injury. Our 7% incidence of c-spine injuries in the setting of head injuries would in fact support their proposal. The incidences of head, spine, or face procedures were only a fraction of their respective injuries, but this was expected as only a proportion of any injury that requires surgical intervention. Indicated in our Methods section, all procedures on the spine were included in our analysis, including thoracolumbar fracture reductions unrelated to head or face injury. As a result, our incidence of spine procedure with head injury or facial fracture is a slight overestimate. Worth noting was the incidence of a head procedure after c-spine injury (13.1%) or facial fracture (10.8%). Little has been published on the rate of neurosurgical intervention in
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this setting, but the incidence may be high enough to warrant necessary CT scans at an earlier time. As anticipated, the incidence of head, c-spine, or face injury rose when the other two were involved. Although the situation was rare (5,633 cases), procedure rate was also increased. The literature pertaining to such traumatic incidents is sparse, but more precautionary measures are expected in events of this nature (Fig. 1). The NTDB is the largest trauma registry available and is a popular source for correlation studies. However, its limitations and biases with respect to our study are worth noting. The NTDB consists mostly of data from larger trauma centers, thus skewing the population sample toward younger and more severely injured patients.1 Therefore, the data should be interpreted as an estimate for a trauma center referral population, and not the general population. Some of our ndings for incidence of concomitant injury were either higher than the previously reported range or higher than the generally accepted number. This could be attributed to the increased severity of injury of our sample population, as well as the rigorous reporting requirements by the NTDB accounting for all associated injuries. In addition, our data are being compared with some studies performed nearly 30 years ago. Although the true incidence has not likely changed, imaging technology has improved such that associated injuries are more likely to be found and accounted for. While performing our analysis, we also encountered the issue of a reporting bias. The NTDB is meant to include an ICD-9 diagnosis code and ICD-9-CM procedure code (when applicable) for each incident. However, there were several patients coded for a procedure without the appropriate diagnosis code. ICD-9 diagnosis and procedure codes did not always translate for some injuries, so that accurate corrections could not be made for unreported diagnosis codes. Our injury incidence was underestimated and procedure incidence was overestimated, assuming that all procedure codes were correctly entered for billing purposes. Finally, because of the manner in which the data are collected and the variability in the practices at different trauma centers, the data in the NTDB does not allow for comment on how the decisions were made to obtain imaging at each center, which would clearly affect the likelihood of identifying injuries. Instead, it gives an overall picture of the national trends and this article gives a general overview and attempts to clarify imaging protocols for the injuries. Based on these data, implementing routine facial CT in patients with head or c-spine trauma should be considered and analyzed further. The efcacy of early detection of facial fracture in patients with head or c-spine trauma is needed. In addition, cost-benet analyses of the increased CT utilization mandated by such a protocol would be of value. A look into the severity and specicity of injuries may be needed to develop a prediction rule for the necessity of specialized facial CT scans. Our study reports the incidences of broadly dened injuries, but a similar analysis of specic facial bone fractures and head injuries or c-spine injuries by vertebral level may reveal even stronger associations from which imaging decisions can be made. In addition, clinical criteria
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such as mechanism of injury, age, Glasgow Coma score, and presence of injuries not including head, c-spine, or face could be taken under consideration. The NTDB also has Abbreviated Injury Score data for each incident. If higher incidences were present with increased Abbreviated Injury Scale, changes could be made to the trauma imaging protocol based on injury severity. Future studies will focus on specic injury associations, as well as take a more comprehensive approach to the incident data so further conclusions can be made. REFERENCES
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