In this study, out of 126 total spinal cord injury patients that we could evaluate, it was found that the number of traumatic SCI cases was higher than that of non-traumatic SCI, namely, 67.5%. This was in line with research conducted by Ones et al.  and Cosar et al. . However, this result was different from research conducted by Ge et al. where the total number of non-traumatic SCI cases from 2003 to 2014 was greater than SCI caused by trauma in Rochester, United States .
According to the results obtained, the mean age of patients with traumatic SCI was younger than the mean age of non-traumatic SCI patients, namely, 41.9 years and 48.4 years. This result was in line with a study conducted by Cosar et al. . Where the mean age of traumatic SCI patients was 37 years and was significantly younger than the average age of non-traumatic SCI patients. In a study conducted by van den Berg et al. in 2010, it showed a bimodal age distribution. The first peak was found in young adults between 15 and 29 years, mostly caused by traffic accidents. The second peak in older adults, aged more than 65 years, mostly caused by falls. Meanwhile, non-traumatic SCI was more common in elderly patients, because non-traumatic SCI was more often caused by age-related pathologies, such as tumors, degenerative diseases and vascular disorders .
In this study, men were more likely to experience cervical injuries than women with a ratio of 4: 1. In both traumatic SCI and non-traumatic SCI, men were found to be more at risk of developing SCI. The data found by Igho et al. shows the same thing, where men had a higher risk and number of fracture events due to their high participation in physical activities, such as construction work, motorbike riding, and others .
Traffic accidents were the main cause of traumatic SCI incidence in this study. There were 47.1% of traumatic SCI caused by traffic accidents while falling from a height was the next most common cause of fracture at 37.6%. These results were in line with a meta-analysis study conducted in the Middle East and North Africa, where in almost all countries the main cause of traumatic SCI events was traffic accidents . According to Nantulya, the causes of the high number of traffic accidents in developing countries were the increasing number of motor vehicles, poor enforcement of traffic safety regulations, and poor road infrastructure .
In this study, it was found that traumatic SCI were more common in the lower cervical, namely, C3–C7 as many as 71 patients (83.5%) while the upper cervical or C1 and C2 were 14 patients (16.5%). These results were in line with research conducted by Wang, in China. From 2001 to 2010, 656 patients (70.9%) had lower cervical fractures and 269 (29.1%) upper cervical fractures . The large number of fractures of the lower cervical spine was due to the biomechanical weakness of the cervical spine and a lot of movement in this region .
Non-traumatic SCI was caused by various conditions including degenerative diseases, neoplasms, infections, congenital diseases and vascular diseases. A research in the United States stated that the most common cause of non-traumatic SCI was degenerative disease . The results of this study also showed a similar result in which 62% of non-traumatic SCI patients were caused by a degenerative disease. However, in other studies it was also mentioned that neoplasms were the most common cause .
The total number of cervical injury patients at Dr Soetomo General Hospital from 2017 to 2019 was 126 patients. Of the total 126 patients, 83 patients survived either after conservative or operative treatment, and 43 patients who died, either those who had definitive therapy or those who had not. The most common causes of death in this study were respiratory failure and sepsis. The results of this study were in line with research conducted by Savic et al. where 29.3% of 2170 patients from 1943 to 2010 in England died from respiratory failure , while according to Thietie et al. The most common cause of death in SCI patients in their study was sepsis . Respiratory failure in SCI was caused by several mechanisms including weakness of the respiratory muscles, impaired cardiovascular function and autonomic nerves, pulmonary edema, prolonged bed rest, and impaired cough function . While sepsis in cervical injury patients could be caused by several pathologies, including urinary tract infection due to repeated insertion of Foley catheters or impairment of bladder emptying, skin and soft tissue infection, such as pressure ulcer, surgical osteomyelitis, and pneumonia due to sputum retention .
In this study there were 76 patients (60.4%) who underwent surgery, 25 patients (19.8%) underwent conservative therapy, and 25 patients (19.8%) died before surgery. Of the 76 patients who underwent surgery 55 patients (72.4%) via the posterior approach and 21 patients (27.6%) via the anterior approach. Either an anterior or a posterior approach can be chosen for stabilization of an unstable cervical injury based on the preference of the surgeon, indication and condition of the patient .
The mean length of stay (LOS) of traumatic SCI in this study was 28.8 ± 14.3 days. The mean length of stay (LOS) of non-traumatic SCI was 44.7 ± 28.7 days. There was a significant difference between the mean LOS of traumatic SCI and non-traumatic SCI patients (p = 0.004). This result was different from a study, conducted by Celani et al. where LOS in traumatic SCI was significantly longer than LOS in non-traumatic SCI. This might be because traumatic SCI was usually accompanied by other accompanying injuries, such as abdominal trauma, thoracic trauma, and multiple fractures . Different results were shown in this study, because the majority of non-traumatic SCI patients had other comorbidities, such as neurological or metabolic disease.
In this study also found a significant improvement in neurological scores at 6 months to 1-year follow-up after discharged. The restoration of normal motor function depended on the re-organization of the remaining spinal circuit ring. This ability to reorganize, commonly referred to as plasticity, was thought to have a profound effect on recovery of function after injury, as well as learning and memory in the undamaged central nervous system. In undamaged nerves, there were changes in synaptic function and the pattern of connections between synapses within the nerve circuit ring. In addition, there was growth or sprouting of undamaged axons as compensation for injured axons .