Air Crash Investigation: Pattern of Spinal Injuries, Management During the COVID-19 Pandemic, and Outcomes

DISCUSSION

Fortunately, aircraft accidents are rare worldwide when compared with high-velocity road traffic accidents and trauma caused by falling. Baker et al5 showed that aviation-related injuries result in approximately 1000 hospitalizations each year in the United States, with an in-hospital mortality rate of 2%. Spinal injury incidence, mechanisms, and management are well described in the literature regarding the common modes of injury,6 but the evidence is limited with respect to spinal injuries secondary to aircraft accidents. The literature suggests predominant lower limb injuries in these patients.5,7 Older literature8–10 regarding aircraft accident management may suggest a higher rate of incidence of missed fractures due to the lack of availability of modern imaging, like CT images and MRI. There also is a discrepancy in the incidence of spinal injuries, as diagnosing spinal injuries in fatal accidents11–14 is often excluded. There have been many scenarios where air crashes have led to high mortality rates, and the incidence of spinal injuries therefore cannot be analyzed.

Although MRI was available at the center, a CT image was considered the investigation of choice to save time, establish a diagnosis, and prioritize the patients who needed surgery first. Also, following COVID-19 guidelines for sanitation was more difficult to manage with MRI than with the CT image. When there was sufficient time available during the waiting period for surgery, an MRI was also performed. Lack of utilization of MRI due to timing, resources, and sanitization protocol may be responsible for the underestimation of posterior osteoligamentous tension band injuries and the discrepancy in classification for some patients.

Analysis of the 2011 Iran Air Boeing 727 crash by Mirzatolooei et al15 showed 78 people were killed and 27 people survived out of 105 passengers. A total of 15 out of the 27 patients had fractures to their spine, predominantly at the thoracolumbar junction (7 burst fractures, 5 compression fractures, and 3 fracture dislocations). A relatively lower number of deaths in our case series is probably for 2 reasons. First, the brunt of the injuries were suffered by the pilots, as the nose of the flight hit the ground from the tabletop runway, which helped reduce the speed during deceleration. Also, there was no fire accident following the crash in this case, which saved lives of most of the passengers. This was unlike many other air crash incidents, including a strikingly similar air crash on a tabletop runway in Mangalore (India) in 2010, which had only 8 survivors and 158 deaths; most of the bodies were charred beyond recognition).16 Lee et al17 reported only 3 cases of spine fracture caused by a commercial airplane accident in 2013, with 307 passengers aboard. Each of the 3 patients suffered a compression fracture at the midthoracic and thoracolumbar junction.

As observed in our patients, the majority of the severe spinal injuries presented with varying degrees of neurological deficits. Whether the injuries were primary in nature at the time of incident or secondary as the patients were pulled out of the jammed seats and shifted to hospital in available vehicles other than ambulances without spine board is something to ponder upon. Analyzing the severity of injury with the seating position, it was found that majority of patients with severe injuries were seated in the front third of the plane. Though conclusions cannot be made with this evidence, suggestions to improve the energy absorbing capacity of the seats in the front half of the plane could help in preventing severe injuries in future air crash events. Attempts by flight engineers to design better seat belts, similar to the crew seat supports with 4-point contact rather than the present 2-point contact seat belts would be helpful in prevention of flexion distraction injuries. Trials to lower the gravitational force in vertical deceleration phase of accident could be game changing in the future.

As described earlier, this study distinguishes itself due to the timing of the air crash, which was during the peak of the COVID-19 pandemic in India. COVID-19, just by itself, warrants consideration as a “mass casualty” incident.18 Disaster management during a pandemic is not a simple task, and following the principles of the “disaster cycle” is important. Mitigation of an air crash is not possible, but adequate preparedness in terms of preventing a shortage of manpower and equipment (eg, PPE) and infrastructure organization take precedence. Disaster planning takes exercise, practice, and revision.19 Like in most institutions across the world, the pandemic was not anticipated to this extent, and proper planning to escalate the demand of manpower and PPE was necessary at the time of the air crash, which was excellently done.

As far as an air crash disaster management plan is concerned, a mock disaster drill was performed at the same site (Calicut International Airport) in 2012. Medical personnel from our institution, with the specified role of disaster management team, were involved in performing the mock exercise. The mock drill definitely helped those who were present in the emergency department on the day of the air crash to triage and manage effectively. None of the staff members involved in managing air crash patients from the emergency ward, and none of the surgeons and staff members involved in their surgeries, became positive for COVID-19. These outcomes speak for themselves about how following standard guidelines is in everyone’s best interest.