Accepted Manuscript

Risk Factors for Cervical Spine Injury in Patients with Mandibular fractures

Esa M. Färkkilä, DDS, MD, Zachary S. Peacock, DMD, MD, R.John Tannyhill, DDS,
MD, Laurie Petrovick, MSc, Alice Gervasini, RN, PhD, George C. Velmahos, MD,
PhD, Leonard B. Kaban, DMD, MD

PII: S0278-2391(18)30853-X
DOI: 10.1016/j.joms.2018.07.032
Reference: YJOMS 58408

To appear in: Journal of Oral and Maxillofacial Surgery

Received Date: 14 June 2018

Revised Date: 31 July 2018
Accepted Date: 31 July 2018

Please cite this article as: Färkkilä EM, Peacock ZS, Tannyhill RJ, Petrovick L, Gervasini A, Velmahos
GC, Kaban LB, Risk Factors for Cervical Spine Injury in Patients with Mandibular fractures, Journal of
Oral and Maxillofacial Surgery (2018), doi: 10.1016/j.joms.2018.07.032.

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 ACCEPTED MANUSCRIPT
Risk Factors for Cervical Spine Injury in Patients with Mandibular Fractures

Esa M. Färkkilä, DDS, MD1,2, Zachary S. Peacock, DMD, MD1,2, R. John Tannyhill, DDS,

MD1,2, Laurie Petrovick, MSc1, Alice Gervasini, RN, PhD1, George C. Velmahos, MD, PhD 1,3,

Leonard B. Kaban, DMD, MD1,2

From the: Departments of Oral & Maxillofacial Surgery and Surgery Massachusetts General

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Hospital1, Harvard School of Dental Medicine2 and Harvard Medical School3, Boston, MA

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Esa M. Färkkilä, Research Fellow, Oral & Maxillofacial Surgery

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Zachary S. Peacock, Assistant Professor, Oral & Maxillofacial Surgery

R. John Tannyhill, Instructor, Oral & Maxillofacial Surgery

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Laurie Petrovick, Program Manager, Division of Trauma, Critical Care and Emergency
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Surgery
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Alice Gervasini, Nurse director, Trauma & Emergency Surgery Service

George C. Velmahos, Professor of Surgery and Chief, Trauma and Emergency Surgery
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Leonard B. Kaban, WC Guralnick Distinguished Professor, Chief, Emeritus, Oral &

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Maxillofacial Surgery
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Address Correspondence to:

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Dr. Leonard B. Kaban

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Department of Oral & Maxillofacial Surgery

Massachusetts General Hospital

Boston, MA 02114

kaban.leonard@mgh.harvard.edu

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Abstract

Purpose: Patients with mandibular fractures are known to be at risk for concomitant cervical spine

injuries (CSI). The purpose of this study was to determine the incidence and risk factors for CSI in

these patients.

Patients and Methods: We conducted a retrospective cohort study of adult trauma patients with

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mandibular fractures from June 1, 2007 through June 30, 2017. Patients were identified through the

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Massachusetts General Hospital Trauma Registry and were included as subjects if they had a

mandibular fracture and computed tomography (CT) or magnetic resonance imaging (MRI) of the

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cervical spine. Primary predictor variable was site of mandibular fracture; outcome variables were

presence of CSI and mortality. Other variables were: Demographic (age, gender, alcohol and drug

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use, Injury Severity Score (ISS), Glasgow Coma Scale (GCS), presence of mid-face and extra-
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craniofacial injuries and etiology. Data analysis consisted of univariate correlations and
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construction of a multivariate model to determine independent risk factors for CSI.

Results: Of 23,394 patients, in the Trauma Registry, 3950 (17%) had craniomaxillofacial fractures
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(CMF) and 1822 (7.7%) CSI. The frequency of CSI in the overall cohort of mandibular fracture
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patients (n=1147) was 4.4% and for admitted patients (n=495) 10%. Mean age of patients with

mandibular fractures + CSI was 40 years (19-93); 84% were male. Subjects with a ramus-condyle
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unit fracture, mandible + any mid-face fracture, non-CMF injuries and motor vehicle crash (MVC)

etiology had the highest frequency of CSI. Ramus-condyle unit fracture and chest injury were
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independent risk factors for CSI in the multivariate model (p=0.0334 and 0.0013, respectively).

Mortality was four-fold higher in subjects with CSI versus those without CSI.

Conclusion: The presence of ramus-condyle unit fractures and chest injury were independent risk

factors for CSI. Oral and maxillofacial surgeons should be diligent in ruling out CSI in mandibular

fracture patients.

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Introduction

It has been recognized that patients sustaining mandibular fractures are at moderate to high

risk for concomitant cervical spine injuries (CSI) [1-5]. The presence or absence of a CSI in

association with a facial fracture of any type is a critical factor to consider during immediate

emergency management or when planning definitive operative correction. Early diagnosis of CSI is

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therefore imperative. In large tertiary care or university hospital settings, trauma surgeons may be

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the first to see patients with facial trauma. As part of the primary survey, they will secure the

airway, control bleeding and rule out life-threatening injuries. Inherent in this survey is maintaining

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cervical immobilization and ensuring timely interventions to rule out CSI. In the community and

outpatient hospital setting, oral and maxillofacial surgeons (OMSs) may be the first to definitively

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evaluate patients with facial fractures and therefore, they need to be well informed of injuries
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associated with CSI and protocols for assessment of the cervical spine.
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The incidence of concomitant CSI in patients with mandibular fractures is most frequently

reported to be 1 to 7%. [1, 3, 4, 6, 7]. However, in a study of over 1.3 million trauma patients,
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Mulligan and Mahabir [8] report rates of 5.1 percent in patients with isolated mandibular fractures
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and 9.1 percent in patients with mandible plus another facial fracture [8]. Motor vehicle crashes

(MVCs) are reported to be the major cause of craniomaxillofacial (CMF) fractures and
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simultaneous CSI [4, 9-11]. The influences of site of mandibular fracture and etiology of injury have
[4, 12, 13]
not been frequently analyzed in relation to concomitant CSI. . Although improved safety
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features in automobiles (shoulder harnesses, safety glass, collapsible peripheral parts of the auto

body), stricter alcohol laws, laws requiring seat belt compliance and lower speed limits have

improved survival in MVCs, it is not clear if these have had an impact on the incidence of CSI in

association with facial fractures [14-17].

The effect of wide-spread use of computed tomography (CT) and magnetic resonance

imaging (MRI) on the diagnosis of CSI has not been thoroughly investigated. However, in a recent

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multi-center study involving American College of Surgeons verified Level I trauma centers, 767

trauma patients were enrolled and had cervical spine MRI scans if they had persistent posterior

cervical pain, were not evaluable or both and had negative cervical spine CT scans[18]. The MRI

scans identified additional cervical spine injuries in 23.6% of patients despite a normal cervical

spine CT scan. In this group the additional injuries identified were: ligamentous injuries (16.6%),

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soft tissue swelling (4.3%), vertebral disk injury (1.4%) and dural hematoma (1.3%)[17].

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The purpose of this study was to determine the incidence and risk factors for cervical spine

injuries (CSI) in patients with mandibular fractures. The authors hypothesized that the incidence of

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CSI in association with mandibular fractures would be higher than previously reported due to the

reported increased survival in MVCs and improved imaging techniques (CT and MRI). Second, it

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was hypothesized that the mandibular fracture sites most at risk for associated CSI would be the
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symphysis/parasymphysis and ramus/condyle unit.
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The specific aims of this study were: 1) to estimate the incidence of CSI in patients

diagnosed with mandibular fractures at Massachusetts General Hospital (MGH), 2) to measure the
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association between sites of mandibular fractures and CSI, 3) to estimate the incidence of CSI in
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patients with mandibular plus any mid-face fracture 4) to document the most common associated

injuries and mortality and 5) to report the etiology of injury in patients with mandibular fractures
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and CSI[19].
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Materials and Methods

Study design and variables

This was a retrospective cohort study of all patients, evaluated and treated at MGH, from

June 1, 2007 through June 30 2017, with mandibular fractures and/or cervical spine fracture or

ligamentous injury. MGH is a tertiary referral hospital with an American College of Surgeons

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verified Level I Trauma Center. The study was approved by the Institutional Review Board,

(Protocol #2017P001797)

Patients were identified based on International Classification of Diseases, Ninth Revision

(ICD-9, 2007-2014) codes 802.0—802.99; 805.0-805.18; 806.00-806.19; 847.0; 900.0-900.9;

952.0-953 and International Classification of Diseases, Tenth Revision (ICD-10, 2015-2017) codes

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S02-S02.04; S02.6-S026.9; S07; S12-S19. These codes correspond to fractures involving the skull,

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nasal bones, orbit, zygoma, maxilla, mandible and cervical spine injuries, respectively.

Patients were included as subjects if they were 18 years of age or older and had complete

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medical records including in-patient and out-patient charts and complete imaging data. Exclusion

criteria were the presence of craniocerebral injuries without any mandibular fractures and/or

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diagnosis codes listed in the registry not supported by clinical or radiographic data. The primary
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predictor variable was site of mandibular fracture (symphysis/para-symphysis, body, ramus/condyle
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unit, angle). The primary outcome variables were CSI and mortality. Other predictor variables

included demographic data (age, gender, alcohol, drug use), Injury Severity Score (ISS), Glasgow
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Coma Scale (GCS), presence other CMF fractures, presence of extra-craniofacial injuries
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(intracranial hemorrhage, extremity, chest, pelvis, abdomen) and etiology (fall, MVC, bicycle

accident, assault, gunshot wound, pedestrian hit by motor vehicle, sports injury).
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Hospital charts were reviewed for demographics, injury related data (bones involved,

mechanisms of injury, associated injuries including ISS and clinical findings). Mandibular fracture
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sites were categorized based on plain radiographs (panoramic or standard mandibular series) and/or

CT scans. Sites were defined as follows: 1) para-symphysis or symphysis region, between the

canines, 2) body, from canines to second molars, 3) angle, 3rd molar area to angle of the mandible

and 4) ramus-condyle unit, including coronoid process, the proximal portion of the mandibular

bone. Other CMF fractures and sites were also confirmed on imaging. Associated injuries were

divided into 6 categories; 1) intracranial hemorrhage including hematomas and contusion, 2)

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extremities, 3) chest including thorax, lung, and thoracic-spine injuries, 4) pelvis including lumbar-

spine injuries, 5) abdomen including kidney, spleen and liver injuries and 6) eye/globe injuries.

Cervical Spine Clearance Protocol

The MGH protocol for CSI clearance among adult trauma patients is as follows: (1) Patients

can be cleared clinically with no imaging if they are conscious, neurologically intact, and if they

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have had no major distracting injuries. They must be able to participate in a comprehensive

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cervical spine clinical examination where they have no pain or cervical tenderness on palpation,

neck rotation or axial loading and no restriction of motion. (2) Patients with an index of suspicion

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for a CSI, demonstrating any neurologic finding, or distracting injury, undergo a cervical spine CT

and comprehensive cervical spine clinical examination. Usually, with a negative clinical exam and

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normal CT scan, as read by an Emergency Department attending radiologist and an attending
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Trauma Surgeon, the cervical spine is cleared. (3) Patients who are obtunded and unable to
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participate in a comprehensive cervical spine clinical examination, undergo a cervical spine CT.

Usually, with a completely normal CT scan, the trauma surgeon will remove a cervical collar and a
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comprehensive cervical spine clinical exam will be completed when the patient can participate. In
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the presence of abnormal CT findings, an MRI is performed depending on the nature of the findings

(e.g. simple spinal process fractures may not be imaged further, whereas a major body fracture or a
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dislocation will require an MRI). Similarly, patients with peripheral neurologic deficits that could

be attributed to CSI, are typically imaged by MRI, even if the CT is normal.

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CT scans were done on a General Electric Lightspeed 64 Scanner (General Electric,

Fairfield, CT) and Siemens Somotom Force Scanner (Erlangen, Germany). Craniomaxillofacial and

C-spine scans were composed of 0.625mm and 2.5mm slices, respectively on both machines. MRI

scans were obtained on General Electric MRI 1.5 Tesla scanner (General Electric, Fairfield, CT)

with 3mm thick slices.

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Data analyses

Statistical analyses were conducted with JMP pro 13.0. (SAS Institute, Cary, NC) software.

Continuous variables were analyzed for normal distribution using the Shapiro-Wilks test and

compared with categorical variables using the Mann-Whitney test. The univariate analyses of

categorical variables were analyzed by the x2 test. Multivariate analyses were performed using

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nominal logistic regression. To assess independent risk factors for CSI, a multivariate model was

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constructed selecting variables statistically significant in the univariate model, plus those that were

not significant by p=0.05, but were clinically relevant or near statistically significant. The final

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multivariate model included age, gender, ISS and GCS from demographics (Table 1). From Tables

2 and 3 we included RCU site, as well mandible fracture plus an additional midface fracture

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because they were statistically associated with CSI in the univariate analysis. From associated
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injuries (Table 4), we did a multivariate comparison between all associated injuries. In that
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multivariate model, ICH and chest injuries were independent risk factors for CSI and were therefore

included in the final multivariate model. MVC was the only etiology statistically associated to CSI
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and was included in the final multivariate model.

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Data are presented as a mean (range) or number (%). For all analyses a P value less than

0.05 was considered statistically significant.

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Results
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During the study period, there were 23,394 patients listed in the MGH trauma registry by

discharge diagnosis (Figure 1): 3950 (17%) had craniomaxillofacial fractures (CMF) and 1822

(7.8%) had CSI. Mandibular fractures were present in 873 (22%), midface fractures in 2803 (71%),

mandible plus midface fractures, in 274. (6.9%) patients. The total number of subjects with

mandible fractures was therefore 1147, with a majority (n=652) managed as outpatients (after

clearing the cervical spine) and the other 495 admitted to the hospital. The overall incidence of CSI

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in patients with mandibular fractures was 4.4% (50/1147), outpatients 0% and inpatients 10%

(n=50/495). We concentrated our analysis on those patients admitted to the hospital.

Subjects with mandibular fractures with and without CSI showed no significant differences

in mean age or gender distribution (Table 1). The mean ISS for all admitted patients with

mandibular fractures was 14.5 (range 1-75), for those with CSI 25.9 (95% Confidence Interval (CI)

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22.6 – 29) and without CSI 13.2 (95% CI 12.3 – 14.3), p<0.0001). There were no differences in

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race, elevated blood alcohol level or positive drug test for CSI + vs CSI – patients. Of the 50

subjects who had a mandible fracture and CSI, 29 (58%) had CS fracture alone, 7 (14%) had

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ligamentous injury without fracture and 14 (28%) had both (Figure 2).

Table 2 demonstrates the frequency and effect of fracture site. Subjects with fractures of the

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ramus-condyle unit (n=258) were at significantly higher risk for CSI, OR 2.1 (p=0.0178) than other
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sites. Subjects with symphysis/parasymphysis or angle fractures were at significantly lower risk for
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CSI (OR 0.5, 95% CI 0.2 – 0.6, p=0.0218, OR 0.4, 95% CI 0.2 – 0.9, P=0.0224, respectively)

versus all other sites. A mandibular fracture combined with any midface fracture significantly
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increased the risk of CSI in univariate analysis when compared to isolated mandibular fractures
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(Table 3) (OR 1.8, 95% CI 1.1 - 3.4, p=0.0474). In addition, hospital admission was significantly

associated with CSI (p<0.0001).

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Subjects with intracranial hemorrhage (n=130, OR 4.7, 95% CI 2.6 – 8.6, p < 0.0001),

extremity (n=119, OR 3.1, 95% CI 1.7 – 5.6, p < 0.0001) and chest injuries (n=110, OR 6.8, 95%
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CI 3.7 – 12.7, p < 0.0001) were at the highest risk for concomitant CSI in the univariate analysis

when compared to subjects without these associated injuries. (Table 4). We then analyzed all the

statistically significant associated injuries in a multivariate model. Only intracranial hemorrhage

(29/50 subjects, OR 4.5, 95% CI 2.2 – 9.2, p<0.0001) and chest injuries (30/50 subjects, OR 7.4,

95% CI 3.3 – 16.7, p<0.0001) were found to be independent risk factors for CSI. We therefore

included only these injuries in the final regression analysis.

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Assault (n=154 subjects), fall (n=135) and MVC (n=77), were the most frequent

mechanisms of injury (Table 5). Subjects who were involved in MVC were at a significant risk for

CSI when compared to all other injury mechanisms (OR 2.6, 95% CI 1.4 – 5.1, p=0.003). Mortality

rate for inpatients with mandibular fractures was 5.7% (28/495); for patients with mandibular

fracture and CSI 16 % and without CSI 4.5%. (OR Mandible + CSI, 95% CI 1.7 – 9.7, p=0.0008).

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In the final multivariate model, ramus-condyle unit fractures (OR 2.4, 95% CI 1.1 – 5.6,

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p=0.0334) and chest injuries (OR 3.7, 95% CI 1.1 – 5.6, p=0.0013) were the only independent risk

factors for CSI (Figure 3); ISS had an OR of 14 but this was not statistically significant.

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Discussion

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The specific aims of this study were: 1) To estimate the incidence of CSI in patients
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diagnosed with mandibular fractures at MGH, 2) To measure the sites of mandibular fractures most
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frequently associated with CSI, 3) To estimate the incidence of CSI in patients with mandibular

plus any mid-face fracture 4) To document the most common associated injuries and mortality and
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5) To report causes of injury in patients with concomitant mandibular fractures and CSI. It was
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hypothesized that the frequency of CSI would be higher than previously reported due to better

overall survival in MVCs and improved imaging techniques i.e. CT and MRI scans. The results of
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this study indicated that the overall incidence of CSI was within the range previously reported [1, 3,
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and therefore, we could not confirm the hypothesis. However, the incidence of CSI in patients
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admitted to the hospital was indeed higher than previously reported. This may be due to the

increased severity of injury in admitted patients and improved imaging techniques for diagnosis of

CSI[12, 20, 21].

Second, it was hypothesized that the ramus-condyle unit and symphysis/parasymphysis

fracture sites would be significant risk factors for concomitant CSI. The ramus-condyle unit site

was confirmed to be an independent risk factor but the symphysis/parasymphysis site, to our

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surprise, was associated with a lower frequency of CSI. We hypothesized that the entire

ramus/condyle unit (RCU) is an area of weakness relative to the rest of the jaw and the skull base

and susceptible to fracture from compression forces or flexion/extension injuries. These fractures

sometimes occur in combinations or, depending on the mechanism and direction of the injuring

force, as isolated RCU fractures, isolated subcondylar fractures, isolated skull base fractures, or

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isolated CSI. In this series, isolated subcondylar fractures were not associated with concomitant CSI

and this is consistent with other studies in the literature [4, 13].

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The association of CSI and mandibular fractures, although uncommon, is well known.

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Because of the implications of unrecognized CSI, it is crucial to identify a CSI as soon as possible

to allow for early stabilization, safe transport and imaging for the definitive diagnosis. It is

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incumbent on the trauma team and the treating OMS to document or rule out CSI to plan and
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execute an appropriate plan for management of the patient’s facial fractures [22, 23]. Guidelines and
[22, 24, 25]
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protocols have been implemented for this purpose. . In previous reports, the incidence of

CSI ranged from 1 to 7%. [1, 8, 13]. The majority of these publications reported mandibular fractures
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without documenting specific fracture sites [8, 10, 26]. Fracture sites, however, are important because
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they reflect the etiology, age of patients and force of injury [27]. In the current study, ramus-condyle

unit fractures were confirmed as an independent risk factor for CSI in a multivariate model, but
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symphysis/parasymphysis and body fractures were not. Chu and co-workers (2016), reported that

only the mandibular body site was significantly associated with CSI [4]. In other reports, body
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fractures were not associated with CSI [13, 21]. The outcomes in these studies [4,13,21] were not
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confirmed in a multivariate model.

The MGH Trauma Service CSI protocol includes CT and MRI imaging. In the current

study, 7/50 subjects (14%) with mandibular fracture and CSI had MRI verified ligamentous injury

with a CT scan negative for cervical spine fracture. In 2016, Reich and co-workers, in a paper

entitled: “Underestimation of Cervical Spine Injury”, utilized CT scan as their standard imaging

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technique. They obtained additional MRI scans (n=5/50 patients) for other injuries/lesions and

found that 2 of the 5 patients had ligamentous injuries [3]. To our knowledge, the current study is

one of the first in the English language literature to routinely utilize MRI imaging to specifically

capture ligamentous injuries in association with facial trauma. The data in this study (14% of the

patients with CSI and mandibular fractures had a ligamentous injury on MRI with a negative CT

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scan) are consistent with the New England Multicenter study (16.6% of unevaluable patients or

those with persistent posterior cervical pain and a negative CT scan had ligamentous injuries) [18].

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The overall incidence of CSI in association with mandibular fractures, using the protocol

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noted above, was 4.4%. This is consistent with previously reported studies and did not support our

hypothesis of a rise in the incidence of CSI [4, 10]. However, when we analyzed admitted patients

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with mandibular fractures, the frequency of concomitant CSI was 10%. This outcome supported the
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hypothesis. We analyzed the data for admitted patients with mandibular fractures to assess the
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higher risk. MVC and various non-craniofacial injuries were associated CSI in the univariate

analysis. (Table 5). Chu and co-workers reported risk factors for mandible fracture and CSI also
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using a univariate model and they similarly demonstrated that thoracic injury, low GCS, and
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MVC’s were significantly associated with CSI [4]. We additionally constructed a multivariate model

which demonstrated that ramus-condyle unit fractures and chest injuries were independent risk
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factors for CSI. In this model, we included age, gender, ISS and GCS from demographics. We also

included RCU, mandibular plus any midface fracture, ICH, chest injury and MVC as described in
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the methods section.

Limitations of this study should be considered and might affect the applicability of the

results to the general trauma population. This was a retrospective study; therefore, patients with

incomplete data were excluded which could skew the results. However, the large sample size over a

10-year period likely compensates for this limitation. Long-term outcomes of the patients were not

the subject of this study but it would be interesting to look at these in a future prospective study.

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For example, it was not the purpose of this study, and it was not possible, to determine the long

term clinical significance of the additional injuries identified by MRI scan. Our purpose was to

document CSI because these injuries could impact the acute management and timing of the

definitive treatment of the patient’s facial fractures. Clearly, identification of ligamentous injuries

as well as fractures is important because of the potential instability of the spine and its effect on

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management of facial fractures. We did not include data from patients with midface and no

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mandible fractures in this study. Risk factors for CSI in patients with midface fractures is the

subject of an ongoing study by our group and will be reported later.

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The strength of the study is that this is a single institution analysis from an American

College of Surgeons verified level 1 trauma center. As such, MGH Registry accurately records data

for the acute phases of injury and management.

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Results of this study indicate that the incidence of CSI associated with mandibular fractures
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is related to specific sites of fracture, associated midface injury, necessity for hospitalization and

etiology. The mortality rate of trauma patients with mandibular fracture plus CSI was fourfold that
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of subjects without CSI. Chest injury and ramus-condyle unit fracture site were independent risk
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factors for concomitant CSI.

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Acknowledgements

This project was funded in part by the MGH Department of Oral & Maxillofacial Surgery
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Education and Research Fund, Finnish Dental Society Apollonia and Helsinki University Hospital

Funds

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20. Alvi A, Doherty T, Lewen G: Facial fractures and concomitant injuries in trauma patients.
Laryngoscope 113:102, 2003
21. Roccia F, Cassarino E, Boccaletti R, Stura G: Cervical spine fractures associated with
maxillofacial trauma: an 11-year review. J Craniofac Surg 18:1259, 2007
22. Patel MB, Humble SS, Cullinane DC, Day MA, Jawa RS, Devin CJ, Delozier MS, Smith LM,
Smith MA, Capella JM, Long AM, Cheng JS, Leath TC, Falck-Ytter Y, Haut ER, Como JJ: Cervical spine
collar clearance in the obtunded adult blunt trauma patient: a systematic review and practice
management guideline from the Eastern Association for the Surgery of Trauma. J Trauma Acute
Care Surg 78:430, 2015

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23. Como JJ, Diaz JJ, Dunham CM, Chiu WC, Duane TM, Capella JM, Holevar MR, Khwaja KA,
Mayglothling JA, Shapiro MB, Winston ES: Practice management guidelines for identification of
cervical spine injuries following trauma: update from the eastern association for the surgery of

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trauma practice management guidelines committee. J Trauma 67:651, 2009
24. Hoffman JR, Mower WR, Wolfson AB, Todd KH, Zucker MI: Validity of a set of clinical
criteria to rule out injury to the cervical spine in patients with blunt trauma. National Emergency

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X-Radiography Utilization Study Group. N Engl J Med 343:94, 2000
25. Stiell IG, Wells GA, Vandemheen KL, Clement CM, Lesiuk H, De Maio VJ, Laupacis A, Schull
M, McKnight RD, Verbeek R, Brison R, Cass D, Dreyer J, Eisenhauer MA, Greenberg GH, MacPhail I,

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Morrison L, Reardon M, Worthington J: The Canadian C-spine rule for radiography in alert and
stable trauma patients. Jama 286:1841, 2001
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26. Mithani SK, St-Hilaire H, Brooke BS, Smith IM, Bluebond-Langner R, Rodriguez ED:
Predictable patterns of intracranial and cervical spine injury in craniomaxillofacial trauma: analysis
of 4786 patients. Plast Reconstr Surg 123:1293, 2009
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27. Oruc M, Isik VM, Kankaya Y, Gursoy K, Sungur N, Aslan G, Kocer U: Analysis of Fractured
Mandible Over Two Decades. J Craniofac Surg 27:1457, 2016
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Table 1. Demographics in patients with mandibular fractures and CSI status.

CSI + CSI - OR (CSI +) p-value*

Age, Mean (range) 40 (19 - 93) 38 (18 - 91) 0.5

Gender, Male, n=400 42 (84) 358 (80) 1.3 (95% CI 0.6 – 2.8) 0.5

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ISS, Mean, (95% CI) 26 (22.6 – 29.1) 13.3 (12.2 – 14.4) < 0.0001

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GCS, Mean (95% CI) 11.3 (10 – 12.7) 13.0 (12.5 – 13.4) 0.0230

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Isolated mandibular 18 (7.4) 226 (93) 0.5 (95% CI 0.3 – 0.9) 0.0474
fractures

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CI, confidence interval
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Table 2 Mandible fracture sites
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CSI +, CSI -
n=50 pts(%) n=445 pts(%)
Site OR p-value
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Sym/Para* 14 (28) 200 (45) 0.5 (95% CI 0.2- 0.9 0.0218

Body 18 (36) 212 (48) 0.6 (95% CI 0.3-1.1 0.12

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RCU** 34 (68) 224 (50) 2.1 (95% CI 1.1-3.9) 0.0178

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Angle 7 (14) 129 (29) 0.4 (95% CI 0.2-0.9) 0.0224

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*Symphysis/parasymphysis
**Ramus/condyle unit
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Table 3 Mandible + mid-face fractures

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Site CSI + CSI – OR (CSI +) p-value
n=50 n=445
pts (%) pts (%)

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Man + any Mid, 32 (64) 219 (49) 1.8 (1.0 – 3.4) 0.0474

Man + Max + Sw 16 (32) 128 (29) 1.2 (95% CI 0.6 – 2.2) 0.6

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Man + Zy, 17 (34) 110 (25) 1.6 (95% 0.8 – 3.0) 0.15

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Man + No 13 (26) 93 (12) 1.3 (95% CI 0.7 – 2.6) 0.4
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Man + Or 21 (42) 137 (31) 1.6 (95% CI 0.9 – 3.0) 0.1

Man + LF 9 (18) 46 (10) 1.9 (95% CI 0.9 – 4.2) 0.1

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Table 4 Associated injuries

Associated injuries CSI +, CSI -, OR (CSI +) p-value

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(%) (%)
ICH* 29 (58) 101 (23) 4.7 (95% CI 2.6 – 8.6) < 0.0001

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Extremity 23 (46) 96 (22) 3.1 (95% 1.7 – 5.6) < 0.0001
Chest 30 (60) 80 (18) 6.8 (95% CI 3.7 – 12.7) < 0.0001

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Pelvis 12 (24) 24 (5.4) 5.5 (95% CI 2.6 – 11.9) < 0.0001
Abdomen + GI** 9 18) 25 (5.6) 3.7 (95% CI 1.6 – 8.4) 0.001
Eye 3 (6) 12 (2.7) 2.3 (95% CI 0.6 – 8.4) 0.2

*ICH=intracranial hemorrhage
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Table 5 Etiologies

Etiologies, Number CSI + CSI - OR P –value

n=50pts n=445pts
(%) (%)

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Fall 16 (33) 119 (27) 1.3 (95% CI 0.7 – 2.4) 0.4

MVC* 15 (30) 62 (14) 2.6 (95% CI 1.4 – 5.1) 0.0030

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Motorcycle crash 5 (10) 25 (5.6) 1.9 (95% CI 0.7 – 5.1) 0.2

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Bicycle accident 2 (4) 16 (3.6) 1.1 (95% CI 0.2 – 5.0) 0.9

Assault 1 (2) 153 (34) 0.04 (95% CI 0.005 – 0.3) < 0.0001

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Gunshot 5 (10) 35 (8) 1.3 (95% CI 0.5 – 3.5) 0.6
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Pedestrians 4 (8) 13 (3) 2.9 (95% CI 0.9 – 9.2) 0.06

Sports 0 (0) 9 (2) - 0.3

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Other 1 (2) 10 (2) 0.9 (95% CI 0.1 – 7.1 0.9

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Figure legends:

Figure 1. Flow chart of all patients with mandibular fractures and concomitant cervical spine

injuries (CSI).

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Figure 2. CT and MRI imaging

2A. Three-dimensional reconstruction of fine cut CT scan of patient with a left ramus/condyle unit

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fracture.

2B. Sagittal CT view of cervical spine demonstrating dens fracture of C-2 in this patient.

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2C. Sagittal MRI, STIR sequence, demonstrating anterior and posterior longitudinal ligament
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disruption. (arrows)
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Figure 3. Risk factors for cervical spine injury (CSI) in patients with mandibular fractures. Ramus-
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condyle unit fracture (OR 2.4) and chest injury (OR 3.7) were independent risk factors for (CSI).
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AMERICAN ASSOCIATION OF ORAL AND MAXILLOFACIAL SURGEONS
Financial Relationships Disclosure Form
For Faculty, Authors, Committee/Board Members, Reviewers and Staff
Organizations accredited by the American Dental Association Continuing Education Recognition Program (ADA CERP) and
Accreditation Council for Continuing Medical Education (ACCME) are required to identify and resolve all potential conflicts of
interest with any individual in a position to influence and/or control the content of CDE/CME activities. A conflict of interest will be
considered to exist if: (1) the individual has a ‘relevant financial relationship;’ that is, he/she has received financial benefits of
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health care goods or services consumed by, or used on, patients), and (2) the individual is in a position to affect the content of
CDE/CME regarding the products or services of the commercial interest.

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All individuals in a position to influence and/or control the content of AAOMS CDE/CME activities are required to disclose
to the AAOMS, and subsequently to learners: (1) any relevant financial relationship(s) they have with a commercial
interest, or (2) if they do not have a relevant financial relationship with a commercial interest.

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Failure to provide disclosure information in a timely manner prior to the individual’s involvement will result in the
disqualification of the potential Faculty, Author, Committee/Board Member, or Staff, from participating in the CDE/CME
activity.

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Type of CME activity: JOMS Manuscript Submission_______________________________________________________
Title of Submission: _Risk Factors for Cervical Spine Injury in Patients with Mandibular Fractures
________________________________________________________________________________
Name: Leonard B. Kaban, DMD, MD_____________________________________________________ Date: June 13,

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2018________________________________

Please check one to indicate your role:

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months) with any entity producing, marketing, re-selling, or distributing health care goods or services consumed by, or used on,
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____ YES-I have or ___an immediate family member has a financial relationship or interest (currently or within the past 12 months)
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Electronic Signature*: __
__________________________________________________ Date: _June 13, 2018___________________
Corresponding author
*Electronic signature required from corresponding author only. It is the responsibility of the corresponding author to

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collect and submit all relevant conflicts of interest (or lack thereof) of all contributing authors at the time of the
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Name: _George C. Velmahos
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Revision Notes: Responses to Reviewers – JOMS-D-18-00766

Before we can finalize the acceptance of your manuscript, please cite all figures in numerical
order in the text of the manuscript (Figure 3 does not appear to be cited).

Response: Manuscript revised accordingly. Results, 6th paragraph, line 3, figure 2 corrected to
figure 3.

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