Abstract
Introduction
Accidents are common with moving vehicles when they come into contact with either a rider or another vehicle. During the collision, there is an exchange of force between the objects, which results in the deformities. Incidentally, if a person is involved in such an accident, the resultant impact causes injuries in the person. Two-wheelers are no exception for such accidents. In fact, the resultant injuries are much severe than injuries sustained by the occupants of closed cabin vehicles.
Aim
To study the pattern of spinal injuries in a victim of road traffic accident, who died of a two-wheeler accident.
Material and Methods
The present study is made on the deaths which occurred after two-wheeler accidents which are subjected to post mortem examination in the mortuary of Gandhi Medical College, Secunderabad, during the period January 2014 to July 2015.
Results
Cervical spine is the most common area to be involved among spinal column, followed by lumbar and thoracic. Mortality is more highly associated with cervical spine involvement. Among all spinal cord injuries hemorrhage and contusion were more observed. Almost all of the spinal injuries cases were also associated with other injuries and most of them were associated with head injuries.
Introduction
Death is an inevitable event in the life of a human being. It may occur in any form. The most miserable form it is an accident. A person who was hale and healthy, who was present with us a few hours before, may come as a cadaver. Most of the time, it is the negligence, which results in an accident. The negligence may be on the part of the victim or may be on the part of the other person who occupied the opposite vehicle. Sometimes innocent pedestrians are also victimized by such accidents.
An accident, for all practical purposes, is preventable, provided it is anticipated and proper preventive measures are adopted. The driver of the vehicle must be awake, alert, alcohol free, and aware of the surroundings to prevent the accidents. If he fails to adopt any one of the above measures, it definitely results in a fatal outcome either to himself or to others.
A wake in the sense that he must not be sleepy, or he must not drive overnight without proper rest to the body and mind.
Alert means he must control the movement of his vehicle by anticipating the movement of other vehicles or pedestrians on the road.
Alcohol as such reduces the reflexes by increasing the latent period for reflexes. Alcohol also causes incoherence and confusion. There is a motor in coordination which increases the vulnerability to accidents.
Aware of surroundings, as even the best driver cannot anticipate the roads, which are too bad at some places, where it becomes difficult to control the vehicular movement. Rain damages the roads, and no matter how familiar the drivers are with the road, they can be caught unaware by the newly forming pits and potholes. Many times, the sign boards are not properly displayed. In the nights, especially the glazing lights of the oncoming vehicle compromise visibility.
The effect of the above factors is more pronounced in the riders of two-wheelers. The rider has to maintain the balance when the bike moves slowly, apart from observing all of the above.
The two-wheelers which are introduced into the Indian market are not designed for these roads and the environment, as they have great pickup and high speed. The riders of these bikes are young individuals who have an inclination towards fast and rash driving. Apart from this, the advertisements shown in the electronic media are so tempting that even girls are provoked to ride these two-wheelers.
Theoretically speaking, the chances of getting injuries are more in two-wheeler riders than other vehicle drivers or occupants. Even though the fatalities are more with two-wheeler accidents than the other vehicles, since in two-wheelers there is not much protection.
The number of two-wheelers is increasing day by day, hence the accident rate is also increasing proportionately.
The advent of increased medical facilities is causing the decrease in the mortality rate after these two-wheeler accidents, however, the morbidity is still on a higher side.
Hence, it is found necessary to make an observation on these fatal outcomes after two-wheeler accidents occurring in twin cities, in regard to their pattern and other variables. And it is also found necessary to observe the role of helmets in providing protection.
The present study is done on those deaths which occurred due to two-wheeler accidents and subjected to post mortem examination in the Mortuary of the Gandhi Medical College, Secunderabad from January 2014 to July 2015.
Aims and Objectives
The present study is made on the deaths which occurred after two-wheeler accidents which are subjected to post mortem examination in the mortuary of Gandhi Medical College, Secunderabad, during the period January 2014 to July 2015.
The aims of the present study include:
To study the pattern of spinal injuries in a victim of a road traffic accident, who died of a two-wheeler accident. To study the cause of death. To enlist the factors which are responsible for the causation of accident and death in the twin cities. To know the factors which hampered the protection of the helmet and caused the death. To suggest steps to prevent spinal injury and reduce the mortality.
Material and Methods
The present study is made on those dead bodies which are subjected to post mortem examination in the mortuary of the Department of Forensic Medicine, Gandhi Medical College, Secunderabad, from January 2014 to July 2015. Total 100 cases examined.
Inclusion criteria:
The dead bodies with a history of death due to an accident from a two-wheeler. Both riders and pillion riders died in the two-wheeler accidents. All age groups from both sexes are selected for this study. Deaths which occurred without treatment or after the treatment for injuries are selected.
Exclusion criteria:
Deaths occurring from accidents by other vehicles are excluded.
Inquest reports, first information report, statements made by the relatives, hospital record, and panchanamas of scene of offence, etc. are collected from the police, apart from the post-mortem examination report from the department, to get the data for analysis purposes.
The present study is not a complete one, because of the lack of other investigation procedures at the end. However, an effort is made to compare the material with the literature.
Observations
Variation in number of incidents during different months of the year. More number of deaths occurred in May (16) followed by January (15), April (13), February (12), March (11), July (11), June (7), December (5), September (3), October (3), August (2), November (2).
Variation in accidents depending upon the age group. More number of deaths occurred in between age group of 31–40 years (28), followed by 21–30 years (23), 41–50 years (22), 51–60 years (17), above 60 years (9), below 20 years (1).
Sex distribution of victims. Out of 100, 94 were male and six were female.
Variation in religion among victims. In the present study, 95 were Hindus and five were Muslims.
Distribution of cases according to geographical area: 40 cases from urban, 40 cases from rural, and 20 from semiurban.
Distribution of cases according to socioeconomic status: 69 belongs to the middle class and 31 belongs to the lower class.
Distribution of victims according to marital status: 92 were married and eight were unmarried.
Time of incident: The majority of accidents occurred in the night (34) followed by morning (25), evening (23), and afternoon (18).
Number of victims admitted in hospital. Out of 100, 93 cases were admitted in the hospital.
Time of survival of cases: Spot death occurred in seven cases, 54 persons survived for one day, 36 were one day to one month, three were more than one month.
Influence of alcohol intoxication on the cases. Smell of alcohol present in 37 cases.
Distribution of cases based on position of victim over the two-wheeler: 79 riders were died and 21 pillion riders were died.
Distribution of cases based on area of spine injury. Cervical injury noted in 96 cases, thoracic injury in one case, lumbar in three cases.
Distribution of cases based on pattern of spinal cord injury. Spinal card contusion and hemorrhage seen in 43 cases, compression seen in 32 cases, hemorrhage in one case, laceration and hemorrhage in two cases.
Number of cases of spinal injuries associated with head injury: In 66 cases, head injury noted apart from spinal injury.
Number of cases of spinal injuries associated with other injuries. All cases were shown other injuries apart from spinal injury.
Number of cases with history of helmet for protection: Three persons had helmets at the time of accident.
Discussion
The present study was done to know the pattern of spinal injuries in two-wheeler road traffic accidents, for which a sample of one and a half year deaths were taken from January 2014 to July 2015.
Variation in number of incidents during different months of the year.
In the present study, a period of 19 months was taken, the first seven months show a higher number of cases when compared to the remaining five months. According to data, the highest number of cases were recorded in the month of May, followed by January, and the least number of cases were recorded in the months of August and November.
There were no studies available that compared seasonal variations in traffic accidents involving spinal injuries. The first half of the year that showed a higher number of cases is due to a study done twice for the months during the first half of the year.
Taking into consideration the above views, there were not many seasonal variations and the deaths due to spinal injuries in two-wheeler road traffic accidents were more or less uniform throughout the year.
Age and sex distribution.
In the study, males predominated over females in the ratio of 94% male to only 6% female. The vulnerable age group in both males and females are 31–40 years.
Findings similar to present study were observed Robertson 11 where most victims belong to 31–40 years age group and by S. Lalwani 1 where most of the victims belong to age group of 25–40 years, by A. Amin 2 where most of the victims belonged to age group 31–40 years and by S. Ankarath 3 most of victims belonged to 31–40 years age group.
Contrast was seen in the studies conducted by Harnam Singh, 4 where most victims belonged to the age group of 21–30 years in both male and female. In Zarir Hafiz Zulkipli’s 5 studies, the most common age group is 21–30 years. In a study conducted by Hashim H. H., Sarani R., 6 and Green R. N. 7 most victims belonged to the 20–32-year age group.
Among the individuals who are victims of two-wheeler accidents, the males outnumbered females with a ratio being almost 94% males and 6% females, similar to the present study conducted by Robertson, 8 the male ratio predominated the female ratio, the males were 88.9% involved whereas females 11.1%. Similarly, the study conducted by Ankarath 3 and Harman Singh 4 showed that males were 90% involved and females were only 10%. The study conducted by Zarir Hafiz Zulkipli 5 showed that 87.5% of males were involved whereas females were only 12.5%. Study in neighboring countries like Malaysia 9 and China 10 detected a male predominance similar to our study. Studies conducted in Australia 11 suggested male predominance and the most susceptible age group was 21–40 years.
The causes of male predominance may be because there are more males riding two-wheelers compared to females, and most of the working sections in our region are males. The lower incidence of females is mainly attributed to custom, social values and preference of females to stay indoors.
Distribution of cases based on the religion: In this study, Hindus were 95% and the rest of the religions, like Muslims and Christianity, account for 5%, similar to studies in India.12–15 This may be explained by the fact that the religion of most of the population of this locality is Hinduism.
Distribution based on geographical area: In the present study, it is observed that people from more urban and semi-urban areas are more involved, that is 40% in urban and 40% in semi-urban regions when compared to 20% from rural areas. Thus, it can be attributed to a greater number of movements of vehicles or more number of vehicles in both urban and semi-urban areas.
Distribution based on socioeconomic status and marital status: In the present study most of the victims belonged to middle class, that is, 69% and lower class 31% and none from upper class, thereby inferring that people from middle class socioeconomic status were involved in more accidental deaths by two wheelers as two wheelers are used by these people in majority. The accidents occurred in 92% of married people when compared to 8% of unmarried people, this can be attributed to the most common age group involved being above 25 years in our study. So marital status is not a barrier for accidents.
Based on time of incident: In our study, the incidents occurred in the night 34% and in the early morning 25% were more when compared to afternoon 18% and evening 23%. This can be attributed to the poor lighting during the night. Deaths were also seen more in evening due to overcrowding on roads. Similar to our studies, the studies conducted by Zarir Hafiz Zulkipli, 5 most of the cases occurred at night and early morning, which were accounted for 43.8% of total cases.
In contrast to our study, studies conducted by Norman, 16 most of the cases were seen during the evening and afternoon.
Based on the number of victims admitted to hospital and time of survival of cases: In the present study, out of all two-wheeler accidents, only 7% of people were not admitted to hospital and 97% of people were admitted to hospital. Out of the 7% all were spot dead at the time of accident. 54% of people died within 24 hours of accident, 36% survived more than 24 hours, only 3% survived for more than a month.
In contrast to studies conducted by Harnam Singh 4 altogether, 39.5% victims had succumbed within one hour, 2/3rd (67.8%) by 12 hours, 3/4th (77.1%) by 48 hours and 90% by one week and 97.7% within two weeks. The longest survival period was 30 days and 15 hours.
Influence of alcohol intoxication: In most of the deceased alcohol was not detected, except in 37% of people of entire study. Alcohol intoxication history or detection of alcohol was not properly made out as the viscera were not preserved in all cases to confirm presence of alcohol.
Based on the position of rider: In the present study, the deceased is not always the rider of the vehicle. In our study, 78% of males and 1% of females were riding the vehicle. Rest of the people 11% were pillion riders.
Distribution of cases based on area of spine and pattern of spinal cord injury: In the present study, the most number of deceased received injuries more in cervical spine region 96%, whereas in 1% of cases only thoracic spine is involved. In 3% of cases, only lumbar spine is involved, whereas there is no case which involves sacral spine. In the present study, the most frequently injured spine region for all the road accident victims was the cervical spine. The predominance of cervical spine injury in motorcyclists in the study was most likely due to the occurrence of head injuries in virtually every victim for each group. Studies have shown that head injuries usually yield concurrent neck injuries in motorcyclists.17, 18 It is postulated that these cervical spine injuries result from the transfer of energy from direct axial loading to the head. 19 Moreover, the energy transfer can occur from a hyper motion in which the relatively slender neck is strained by disconjugate motion between the larger masses of the head and torso. 20 These mechanisms offered an explanation for the occurrence of cervical spine injuries in victims who had no direct contact trauma to the neck. While it has been suggested that a helmet protects the cervical spine by preventing hyper flexion,1, 21 we were unable to substantiate the same from this study due to insufficient information on helmet usage. Similar data where cervical spine injury was most commonly involved was seen in the study by Zarir Hafiz Zulkipli. 5
In addition, the differences in the patterns of injuries for motorcyclists between the current findings and earlier studies may be attributed to regional differences. 22 Previous studies were from developed countries, such as in Europe and the USA, in which most of the motorcycles are big and high-powered, and therefore could move very fast. 23 Thus, accidents often involve high-energy transfer. This may not be reflective of developing countries such as India because most of the motorcycles are small, low-powered and usually used for commuting in the cities. The accidents usually involved less energy transfer due to low speed. This factor may determine the injury outcomes because of the spine biomechanics. Unlike the cervical spine, the thoracic spine, especially the mid-section, is always associated with high-energy injury because great force is required to injure the thoracic spine, which is well-protected by the rigid rib cage. 24
In contrast, studies conducted by Robertson, 8 thoracic spinal injury predominated in this series of injured motorcyclists. Previous smaller reports concentrating on selected groups of patients with spinal injury have also demonstrated a thoracic or thoracolumbar predominance in motorcyclists.25–28 This injury pattern is thought to occur as a result of hyperflexion of the spine of the unrestrained motorcyclist on impact with objects. 19 Axial loading is concentrated at the point of maximal flexion and results in injuries predominantly in the midthoracic spine (T4–T7). 28
Similarly, studies conducted by Lass Uhrenholt of the 129 (10.4%) patients with spinal injuries, 87 (67.4%) involved the lower thoracic and 17 (13.2%) upper lumbar levels. Two patients had complete paraplegia on initial presentation, both following fracture dislocation of the thoracic spine. Mortality was seen only in 15% (13 out of 87) of thoracic spine fractures when compared to 53.3% (8 out of 15 patients) in cervical spine injuries, which supports the present study.
In our present study of the deceased, who had compression injuries to spinal cord, which led to paraplegia in most cases, 32% most of them had both contusion and hemorrhage to spinal cord, 43%. Only 2% had both hemorrhage and laceration. 1% only hemorrhage, whereas 22% of the deceased had no visible injury to spinal cord.
11. Number of spinal injuries associated with head injury and other injuries: In our present study, almost 66% of the cases are associated with head injuries. only in 34% cases there are no visible head injuries. whereas all 100% cases of spinal injuries are associated with other injuries.
12. Number of cases seen with helmet protection: Once again in our study the information given in the inquest and the information collected from relatives was incomplete regarding the presence of the helmet at the time of accident. It was found that 66% of people not wearing helmets sustained both head injuries and spinal injuries, and 34% people without head injury only, whereas in 3% of people wearing helmets, it was known, whereas in others, the history of wearing helmets could not be found.
Conclusion
Two-wheeler accidents pose severe risks of spinal and head injuries, particularly in the cervical region. Effective preventive measures include:
Promoting helmet use. Enforcing traffic rules. Improving road conditions.
Comprehensive policies and educational initiatives are crucial to reducing fatalities and improving overall road safety.
Footnotes
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article.
Ethical Approval
The ethical approval has been obtained from the institutional Ethics Committee.
Funding
The authors received no financial support for the research, authorship and/or publication of this article.
Informed Consent
Not applicable.