Returning to Work After Traumatic Spine Fractures: Current Status in a Military Hospital

ABSTRACT Introduction The consequences of traumatic spine fracture (TSF) are complex and have a major burden on patients’ social life and financial status. In this study, we aimed to investigate the return to work (RTW) after surgically treated TSFs, develop eventual predictors of delayed or failure to RTW, and assess narcotics use following such injuries. Methods This was a single-center retrospective cohort study that was performed in a tertiary care center. TSF patients who required surgical intervention from 2016 to 2021 were enrolled. Demographic, operative, and complication data, as well as narcotics use, were recorded. RTW was modeled using multivariate logistic regression analysis. Results Within the 173 patients with TSF, male patients accounted for 82.7%, and motor vehicle accidents were the most common mechanism of injury (80.2%). Neurologically intact patients represented 59%. Only 38.15% returned to work after their injury. Majority of the patients didn’t use narcotics more than 1 week after discharge (93.1%). High surgical blood loss, operation time, and hospital length of stay were significantly associated with not returning to work. In multivariant regression analysis, every increase of 100 ml of surgical blood loss was found to decrease the chance of RTW by 25% (P = 0.04). Furthermore, every increase of one hour in operation time decreases the chance of RTW by 31% (P = 0.03). Conclusion RTW is an important aspect that needs to be taken into consideration by health care providers. We found that age and high surgery time, blood loss, and hospital stay are significantly impacting patients’ RTW after operated TSF.


INTRODUCTION
Traumatic spine fracture (TSF) has devastating consequences including pain, deformity, high mortality, and other psychological, economic, and social impact on the patients and their families. 1,2The causes of TSF vary based on the age, but most of which are attributed to motor vehicle accidents (MVAs), falls, and violence. 1,3Owing to its biomechanical weakness against external stress, thoracolumbar junction is most vulnerable to injury. 4Thoracolumbar fractures are considered the commonest spinal injury with an estimated annual incidence of more than 160,000 injuries in North America.][4][5] The psychological impact after the injury includes depression, anxiety, and posttraumatic stress disorder.Subsequently, it increases pain and substance abuse, and predicts poorer outcomes. 6,7Socially, patient with traumatic spinal cord injury can be affected greatly since these patients are usually young adults in their prime.Patients' lives after the injury may be influenced by factors such as living independently, maintaining communication with friends and family, and returning to work. 8Moreover, SCI patients can be affected financially.][10] Employment rates were assessed and found to be 62% for patients with disabilities compared to 78% in general population. 11urgical fixation after unstable spinal fractures has been widely applied during the past decades as it proved to dramatically improve the patient's recovery.Presumably, spinal surgery allows early fracture stabilization and patient mobilization, thus enhancing employment potential.However, neurological injury, polytrauma, and medical complications decrease functional independence, reducing the probability of employment after surgically treated spinal fracture.
Pain management is an important factor that determines the quality of life in patients with TSF.Narcotics can be used in pain management for neuropathic pain, but on the other hand, narcotics are considered very addictive.There is limited evidence describing the return to work (RTW) rates in patients who sustained a surgically treated spinal fracture in Saudi Arabia.
The primary objective of this study was to estimate the "return to work" in a 2-year follow-up after rehabilitation of patients with TSF, and secondary objectives include identifying its influencing factors and describing the use of narcotics in such population.

Study Design and Aim
This was a single-center retrospective cohort study that was performed in a tertiary military care center in Riyadh, Saudi Arabia, to evaluate the employment status and narcotics use in TSF patients.

Inclusion Criteria
All patients with TSF aged from 18 to 65 years old who required surgical intervention from 2016 until 2020 were included.Indications for surgical treatment included: threecolumn fractures or fracture-dislocations, fracture with neurological injuries or local deformity, unstable fractures in polytrauma patients.

Data Collection
BestCare system, which is an electronic record system, was used to screen the electronic files and collect the data.Data related to patients' demographics, comorbidities, injuries, operative complications, medications, length of stay, work status before and after the injury, duration to RTW, and change in the work or study field due to the injury were recorded.Early RTW was defined as RTW within 3 months and remaining at work for more than 6 months of the following year, and late RTW was defined as returning to work within 2 years and remaining at work for more than 6 months of the following year.

Statistical Analysis
Statistical Package for the Social Sciences (SPSS version 22) was used for data analysis.Categorical variables were presented as frequencies and percentages whereas numerical variables were presented as mean ± standard deviation.Fisher's Exact Test was used instead of Chi-square to test the association between categorical variables due to the relatively small sample size.To assess the predictors of not returning to work, multivariate logistic regression analysis was performed by calculating the adjusted odds ratios, and odds ratios were reported with 95% confidence interval.A test was considered significant if two-sided P-value <0.05.

Ethical Considerations
Data collection commenced after obtaining the approval from the hospital research center (study number: NRC21R.124).Data were accessed by the research team only.Patient and subjects' confidentiality and privacy were assured, no names or medical record numbers were used, and all data were kept in a secure place within the hospital premises.

RESULTS
There were a total of 173 patients with TSF.The majority of the patients were males (82.7%) with a mean age of 33.8 ± 13.2 and an average Body mass index (BMI) of 25.44 ± 6.1.Only 26.3% of the patients were smokers (Table I).The mechanism of injury was MVA in 80.2% of the cases (Table I).Thoracolumbar injuries were found to be the most frequent injuries (70.5%).Three-column fractures were the most common fractures (32.2%) followed by fracturedislocations (29.80%) (Table I).The most common associated injury was chest injury (41%) such as pneumothorax and rib fractures.Post-operative complications were infrequent with urinary tract infection being the commonest followed by venous thromboembolism, accounting for 9.2% and 5.2%, respectively.Intraoperatively, 20.2% of the patients required blood transfusion, and only 8% required postoperatively.The mean intraoperative blood loss was 338.47 mL ± 274, and the mean operation time was 226.4 minutes (3.7 hours).The mean length of stay in days was 44.89 days ± 76.3.Around half of the patients were admitted to the intensive care unit (44.51%) with a mean length of stay of 16.09 days ± 29.2 (Table II).After discharge, only 6.9% of the patients required continued narcotics in their follow-up appointments.Regarding the RTW, 38.15% of the patients have returned to their jobs after their injury with an average time to RTW of 8.9 months, and 24.24% of them had to change their work style, for example, desk job instead of field job, or had to change their university specialty due to the injury.Patients who returned to work early accounted for 9.25% (16).In regard to the American Spinal Injury Association (ASIA) score pre-operatively, majority of the patients (59.0%) were E (Table I).There was only 1.7% mortality.
Age was found to be significantly associated with returning to work, where younger patients tend to RTW more than older patients (P-value = 0.005).Type of fracture was also significantly associated with returning to work (P-value = 0.016).More than half (60%) of patients with burst fracture didn't return to work.RTW was significantly associated with blood loss (P-value = 0.001), operation time (P-value = 0.003), length of stay (P-value = 0.012), and American Society of Anesthesiologists (ASA) score (P-value = 0.001).Patients  with complete SCI (ASIA A) were associated significantly with RTW (P-value = 0.001).Gender, BMI, and mechanism of injury were not found to be significant predictors of RTW (P-value = 0.758, 0.098, and 0.084, respectively) (Table III).
Regarding the narcotics use, there was no statistically significant association of age and narcotic use (P-value = 0.061).Patients with SCI or chest-associated injuries tend to use more narcotics (P-value = 0.029).Smoking was significantly associated with narcotics use (P-value = 0.015), and we noted that smokers tended to use more narcotics.
Multivariant regression analysis showed an association between a 100 mL increase in blood loss during the operation and a 25% decrease in the likelihood of returning to work (odds ratio (OR) = 0.75, 95% confidence interval (CI) = 0.57-1, P = 0.04).Furthermore, each additional hour in operation time was associated with a 31% decrease in the chance of returning to work (OR = 0.69, 95% CI = 0.49-0.98,P = 0.03).Lastly, individuals under the age of 20 show a 20fold higher likelihood of returning to work compared to those in the 50 to 60 age group (OR = 20.9,95% CI = 3.2-133.9,P = 0.001), and a 10-fold higher likelihood compared to individuals aged 40 to 50 (OR = 21.1, 95% CI = 2.9-151.6,P = 0.002), indicating a notable association between younger age and increased probability of returning to work (Table IV).

DISCUSSION
TSF patients tend to have the same profile, which is male in their third to sixth decade of life with the etiology being either MVA or falls from height.3][14] Compared to nearby countries like Kuwait, patients' mean age, which is 37.1, and prominence of thoracolumbar injuries are similar features when compared to our study. 15Compared to worldwide data, thoracolumbar injury being the most prominent site of TSF is similar in Netherlands and China; however, the mechanism of injury is not, as it was found to be rather falls from height (44.7% and 58.9%, respectively, for both aforementioned countries). 16,17raumatic spinal cord injury is tremendously devastating for the patients and their families due to the permanent or temporary limitations the injury carries.It can alter and disrupt patient's quality of life in many ways, including dependency, chronic pain with use of narcotics, psychological damage, and economical damage in a form of losing/changing job or treatment costs in the short and long term. 1,2,6Independence is an important or arguably the most important aspect following traumatic SCI.It can influence the rehospitalization rate, psychological health, and employment.This burden is not limited to the patients but also to their families and care providers as those patients need special attention and care especially when neurologically affected or paraplegic. 18ne of the main areas that can influence patients' economical and psychological status is returning to work.While investigating whether patients are getting back to work or not after TSF, we found that only around one-third have returned to their work/education and one-fourth of them had to change their work or study field due to the injury.A review of the literature demonstrated employment can vary, and ranges from 13% up to 69%; similarly, in another review it ranged from 21% to 67%. 19In another study, they found among patients who were working before the injury, a few (9.1%) were selfemployed.After the injury, 78.7% were still employed, and among those, 64.6% were self-employed.Moreover, only 11.48% have returned to the same jobs pre-injury.This raised an important issue that even if patients are returning to their jobs after the injury, they are not capable of doing the same previous job routine/performance. 20 In a separate study conducted in Malaysia, the employment rate after injury stood at 76.2%. 21Contrasting this finding with existing literature, the notable disparity in return-to-work rates observed in our current study can be attributed to its focus on a trauma center, where patients presented with a range of injuries, including abdominal, brain, and lower limb injuries.Additionally, a considerable portion of our patient population comprised military personnel, whose occupational demands entail specific physical requirements.Notably, only 4 (2.3%) out of 173 patients underwent medical retirement.
Many patients, especially those aged over 40, who did not return to work chose to retire after their injury.Furthermore, in Saudi Arabia, individuals with disabilities can opt for retirement, regardless of their years of service, receiving a full salary.This retirement option was used by some patients also.For the factors that influence returning to work, the current study found that age is significantly associated with returning to work; likewise, many reviews and studies concluded the same association, younger patients tend to RTW more than older patients.
Burst fractures were found to be significantly negatively associated with returning to work, but there are no studies that investigated this association.This association could be explained by the severe nature of burst fractures that are often surgically managed when compared to other types such as simple compression fractures.Blood loss, operation time, and length of stay were found to be significantly associated factors with returning to work.In fact, longer OR time, blood loss, and length of stay may indicate more severe injuries, and therefore patients that would more likely have complications post-operatively.Furthermore, ASA score was significantly associated with returning to work.With higher ASA score, patients have more severe comorbidities that subsequently lead to poor prognosis and lesser chances of returning to work.
In a study by Burnham, it was found that 53.8% of the subjects returned to work after TSF and the most important predictor was whether the individual had worked within the year previous to injury (9.7 times more likely to be classified as employed at 1 year follow-up). 22In the current study, the majority of the patients were military personnel, and even if they were working before the injury, getting benefits from their status as military probably has led to the fact that more than 50% did not get back to their work.
After correcting for a number of important covariates, our logistic regression model found surgical blood loss, operation time, and hospital length of stay to be independent negative predictors of RTW.In a study by McLain, work status correlated directly with neurological impairment and was not related to level of injury, hardware failure, extent of surgical dissection, or construct pattern.However, only univariate analysis was used to determine those factors presented as independent predictors of outcome; a multivariate analysis would have been more appropriate to accurately establish the relation between the different variables. 23pioid use for non-cancer pain has been steadily increasing over the past decades and became a serious public health concern. 24This is why it seemed important to assess narcotics use in the current study and try to understand the factors that lead to an increased consumption among the patients.There was no statistical significance between age and narcotic use, but it was noted that younger patients tend to use less narcotics compared to older patients.Moreover, smoking was found to be significantly associated with narcotics use.Many studies have found that patients who smoke cigarettes have higher frequency and doses of narcotics compared to non-smokers.
Surgeons should consider assessing and reassessing the socio-economic well-being of the patients throughout their recovery period.In a study investigating the priorities for physical and socioeconomic recovery after fractures of the extremities or the pelvis, 25 it was shown that work-related recovery and disability benefits were a secondary concern compared with physical recovery in the first 12 months after the injury; however, the importance of work-related recovery was higher after the subacute phase.
In this study, we assessed the RTW in a Saudi population with TSFs and whether patients were able to continue the same work they had previously.To our knowledge, this is the first study to conduct such assessment in the Middle Eastern region.Furthermore, narcotics use in patients with spine injuries was evaluated which was not previously performed.
The limitations of this study include the fact that data were collected from a single military center.Next, its observational and retrospective design.The patients were not randomized for treatment and there were no controls; however, it is not possible to establish a randomized study in this type of patient cohort.There was a mixture of both neurologically intact and injured patients, but this should not revoke the value of the observed results.And finally the lack of a functional evaluation of the patients; however, this was not the objective of the current study.Multicentric studies will be required in the future to further investigate the factors related to RTW and narcotics use after TSFs in order to define specific preventive measures.

CONCLUSION
Spinal fractures are not uncommon and the current study has highlighted the burden of unemployment or altered employment that often results.It was found that age, type of spinal fracture, surgical blood loss, operation time, and length of stay are significantly associated with patients RTW.The information may be useful for those responsible for vocational counseling in identifying patients at risk of unemployment so that proactive treatment strategies may be instituted.

TABLE I .
Demographics

TABLE II .
Other Numerical Variables

TABLE III .
Association between RTW with surgical blood loss, operation time, and ASA score.

TABLE IV .
Multivariate Regression Analysis: Association between RTW with surgical blood loss, operation time, and age.