Abbreviations
ASIA
American Spinal Injury Association
ATLS
advanced trauma life support
CT
computerized tomography
GSW
gunshot wound
HIC
high-income country
ICU
intensive care unit
LMIC
low- and middle-income country
MRI
magnetic resonance imaging
RTI
road traffic injury
TSCI
traumatic spinal cord injury
YLD
years lived with disability
Introduction
Traumatic spinal cord injuries (TSCIs) are devastating under any circumstance. However, patients in low-resource settings face unique challenges as they experience delays to care, a lack of prehospital care, and limited proper immobilization during transport, resulting in significantly higher in-hospital mortality than patients in high-income countries (HICs) ( ; ; ). While long-term mortality of TSCI in HICs is now primarily due to chronic diseases, TSCI patients in low-income countries continue to die of preventable secondary causes ( ). Those who survive struggle with access to proper assistive devices, rehabilitation services, follow up and health maintenance, and community reintegration ( ). Moreover, while TSCI incidence is stable or decreasing in HICs, rates in low- and middle-income countries (LMICs) continue to rise ( ). Though most of the available evidence regarding the epidemiology and outcomes of TSCIs comes from HICs, the limited data from LMICs provide essential insights into improving TSCI prevention and management. This chapter will discuss the epidemiology, etiology, treatments, and outcomes of TSCIs in different LMICs globally.
Epidemiology
The worldwide incidence of traumatic spinal cord injury (TSCI) is between a quarter and 1 million people annually ( ). The Global Burden of Disease Study reported a global age-standardized incidence rate of 13 per 100,000 and a prevalence of 368 per 100,000 in 2016. The regions with the highest reported incidence of TSCIs are central and eastern Europe and central Asia. Because of armed conflict, Syria, Yemen, Iraq, and Afghanistan have the highest incidence ( ) ( Fig. 1 ). The incidence of TSCI appears to be stable or decreasing in HICs, but increasing in LMICs ( ). In 2016, TSCIs were responsible for an estimated 9.5 million years lived with disability (YLDs) ( ). Available evidence on the epidemiology of TSCIs comes from HICs, but the limited data from LMICs provide essential insight into improving TSCI prevention and management strategies.
Sex and age
Males are disproportionately affected by TSCIs ( ), with some countries reporting a male preponderance of over 90% ( ; ). Males are more likely to be in situations that place them at risk for TSCI or participate in high-risk activities ( ) ( Fig. 2 ).
In HICs, TSCIs follow a bimodal age distribution, with one peak in the second to third decade and another peak after age 65 ( ). In LMICs, TSCIs predominantly affect younger patients. In the Eastern Mediterranean (specifically Iran, Pakistan, and Afghanistan), the mean age range is 26–38 years ( ; ). Similarly, in Southeast Asia, Sub-Saharan Africa, and Latin America, the mean age is 30–44 years ( ; ). Studies in China and India report a mean age range of 45–51 years ( ; ).
Etiology
The most common cause of TSCIs in most regions is falls, followed by road traffic injuries (RTIs) ( ).
Falls
Falls are the most common cause of TSCIs in Southeast Asia, parts of the Eastern Mediterranean, Sub-Saharan Africa, and the Western Pacific. In Southeast Asia, falls are responsible for 53%–84% of TSCIs ( ; ). Falls in these regions are primarily occupation-related ( ; ). In Iran and Pakistan, construction workers and well diggers are at high risk for falls due to unsafe work environments ( ; ). In Sub-Saharan Africa, falls are common from roofs, scaffolds, trees, or electric poles ( ; ). In Cambodia, approximately 50% of TSCIs are secondary to falls from trees or houses ( ; ). Malaysia’s high rates of falling TSCIs are attributed to migrant workers in high-risk conditions with limited safety regulations ( ). In China, falls are responsible for over 60% of TSCIs due to increased construction of buildings and subways ( ; ).
Falls from standing are also common. LMIC’s growing aging population has resulted in more individuals vulnerable to TSCIs from ground-level falls ( ). Also, ground-level falls while carrying heavy objects atop one’s head are common, particularly for females in Sub-Saharan Africa ( ).
Road traffic injuries
RTIs are the most common cause of TSCIs in Sub-Saharan Africa, Latin America, and parts of the Western Pacific. Studies from Ghana, Nigeria, and Botswana report up to 80% of TSCIs are due to RTIs ( ; ). While in Malawi, Tanzania, and Sierra Leone, RTIs and falls are evenly distributed ( ; ). In Latin America, 39%–44% of TSCIs are due to RTIs ( ). Within the Western Pacific, RTIs are the most common cause of TSCI in Malaysia, responsible for 66% of cases ( ). One-third of TSCIs in Cambodia are due to RTIs, most of which can be attributed to motorcycle collisions ( ; ).
RTIs have surpassed falls as the leading cause of TSCIs in locations with rapid increases in motorization. In Brazil, RTIs are the leading etiology of TSCI in 2003, as the number of motorcycles in Brazil has increased by 491% ( ). In high population centers in China, such as Beijing, RTIs have surpassed falls as the most common cause of TSCIs, as the number of private vehicles has increased from 1.2 million in 2002 to 4.8 million in 2010 ( ; ; ). Factors contributing to high rates of RTIs in Sub-Saharan Africa and other LMICs include lack of road maintenance, unsafe driving, road unworthy vehicles, and poor enforcement of traffic laws ( ; ; ).
Violence and other causes
Violence has generally become a less common cause of TSCIs worldwide. However, in areas with active conflict and terrorism, such as in North Africa and the Middle East (specifically Syria, Yemen, Iraq, and Afghanistan), it is the most common cause of TSCIs ( ). A study in Afghanistan found 59% of TSCI cases were due to bullets or shrapnel (shelling, gunshots, and mine explosions) ( ). In Brazil, gun violence is responsible for nearly 30% of TSCIs ( ; ). In South Africa, violence is a significant contributor, as up to 60% of TSCIs are attributed to gun violence, stabbing, and blunt assault mechanisms ( ; ). Assault is a less commonly reported cause of TSCIs in the rest of Sub-Saharan Africa, accounting for 2%–10% ( ; ).
Finally, sports-related activities compose a small proportion of TSCIs globally, such as diving into shallow water (6%–12% of Brazil’s TSCIs), winter sports (≤ 5% of TSCIs in China) ( ; ; ). In Sub-Saharan Africa, specifically Nigeria and Botswana, sports-related activity is responsible for an estimated 2% of TSCIs ( ; ). A study from Iran reported a relationship between education level and TSCI etiology. Sports become a more common cause of TSCI with increasing years of education (primarily diving, gymnastics, wrestling), while violence and being struck by falling objects became less common ( ).
Spinal cord level and severity
Overall complete cervical injuries are the most common, however significant TSCI level and severity variations exist globally ( ). For example, the thoracic spine is the most commonly injured spinal level in Pakistan, Iran, and Afghanistan, with cervical injuries composing 30% of TSCIs ( ; ; ). However, most Afghani patients have complete thoracic or lumbar injuries, and only 7% have cervical injuries, which is reflected in improved survival ( ).
In Sub-Saharan Africa, the cervical spine is the most common injured site (30%–68% of cases), followed by the thoracic (10%–39%) and lumbar spine (4%–59%) ( ; ). Injury severity, however, varies significantly. In South Africa, Malawi, Tanzania, and Ghana, complete injuries range from 23% to 48% of patients, whereas up to 92% of TSCIs are complete in Nigeria and Sierra Leone ( ; ; ; ).
In Brazil, the most common location of TSCI is the thoracic spine (46%–61%), with approximately 60% being complete ( ; ). Cervical injuries in Brazil were more common in automobile collisions, whereas thoracic injuries were more associated with motorcycle collisions and GSWs ( ).
In China, 47%–76% of TSCIs are reported to be cervical, and 14%–55% of injuries are complete ( ). Beijing has higher tetraplegia rates and complete injuries than other regions in China ( ). The cervical spine is generally the most common location of injury in Southeast Asia and the Western Pacific. In both regions, falls are associated with lumbar injuries and motorcycle and automobile collisions with cervical injuries ( ; ). In Cambodia, lumbar injuries are more common than cervical injuries ( Fig. 3 ) ( ; ).
Diagnosis
Diagnosis of TSCI relies on a combination of history and clinical findings with the use of radiographic adjuncts. Clinical findings include flaccid paralysis and lack of response to painful stimuli below the level of injury, as well as bradycardia, priapism, and paradoxical breathing ( ).
A complete TSCI produces total loss of all motor and sensory function below the level of injury. Nearly 50% of all TSCIs are complete. Even with a complete TSCI, the spinal cord is rarely completely transected. More commonly, loss of function is caused by a contusion to the spinal cord or ischemia of the spinal cord. In an incomplete TSCI, some function remains below the primary level of the injury.
Clinicians commonly utilize the American Spinal Injury Association (ASIA) grading scale to describe the injury severity ( ).
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ASIA A: a complete spinal cord injury with no sensory or motor function preserved
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ASIA B: an incomplete sensory injury with complete motor function loss
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ASIA C: an incomplete motor injury, where there is some movement, but less than half the muscle groups are anti-gravity (can lift against the force of gravity with a full range of motion)
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ASIA D: an incomplete motor injury with more than half of the muscle groups are anti-gravity
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ASIA E: normal
The more severe the injury, the less likely recovery will occur. Historically, the radiological diagnosis of TSCI started with plain spine radiography. However, with the technological advancements and availability, the entire spine may be imaged with computerized tomography (CT) as an initial screen to identify fractures and other bony abnormalities. For patients with known or suspected injuries, magnetic resonance imaging (MRI) helps delineate spinal cord anatomy and detect any blood clots, herniated disks, or masses that may be compressing the spinal cord. MRI is recommended if feasible and is especially useful if CT findings are discordant with symptoms and for surgical planning ( ).
The majority of data regarding the imaging modalities used in diagnosing TSCI in LMICs come from Sub-Saharan Africa. Most patients received plain radiographs in those studies that reported diagnostic methods (71%–100%) ( ; ). CT scans and MRIs are less commonly utilized. Reasons included lack of availability in the treatment facility or patient inability to pay for the diagnostic test. Between 7% and 59% of patients had a CT scan, and 41%–72% had an MRI ( ; ). For reference, a 2019 survey of emergency medicine providers found that 99% and 97% of respondents in HICs reported access to in-hospital plain radiography and CT, respectively. Of respondents in LMICs, 91% reported access to in-hospital plain radiography, and 65% reported access to in-hospital CT ( ).
Prehospital and acute management
Care provided during the first 24–48 h following a traumatic TSCI is critical and can significantly influence TSCI outcomes ( ). Prehospital management requires rapid evaluation, including measurement of vital signs and level of consciousness; initiation of injury management, spinal immobilization to preserve neurological function until long-term spinal stability is established, and control of bleeding, body temperature, and pain; and prompt and safe access to the healthcare system.
Prehospital care is underdeveloped in low-income countries. Emergency medical services are frequently inadequate or nonexistent. For example, in Tehran, Iran, only one-third of patients with spinal injuries are transported by emergency medical services ( ). Similarly, in Botswana, only 20% of patients are transported by ambulance ( ). Difficult terrain and transportation costs delay care, and patients may not arrive at a hospital for several days after their injury. Studies from Tanzania and Nepal reported approximately one-third of patients took greater than 2 days from injury to reach a hospital ( ; ; ). In Afghanistan, the average time to a hospital after sustaining TSCI was 3.4 days ( ).
Due to cost and resource limitations in LMICs, spinal precautions are infrequently practiced in the prehospital setting. Among patients with cervical spine injuries in Nepal, only 36% arrived at the hospital with a cervical collar ( ). In India, up to 98% of TSCI patients are not adequately immobilized ( ; ). A study from Malawi reported that 37% of patients with TSCI had cervical collars placed at some point during their hospitalization and that no other spinal braces were utilized ( ).
Treatment strategies
Management of spinal cord injuries is divided into phases. Acute phase management is based on Advanced Trauma Life Support (ATLS) principles, including prioritizing and treating life-threatening injuries to maximize survival, treating disabling injuries to minimize impairment, and limiting pain and suffering. Assessment should begin immediately upon arrival at the hospital and include: a medical history, signs and symptoms, neurological examination, radiological imaging, and laboratory testing ( ). Signs and symptoms of spinal cord injury include weakness, sensory and motor deficits, bowel and bladder dysfunction, anatomical deformity, and localized tenderness.
Decisions about the best management strategy depend on the environment, available infrastructure, and surgical expertise. For TSCIs, there are risks and benefits to both nonoperative and surgical management. Many factors must be considered to determine the most appropriate management approach, including the level of injury, type of fracture, degree of instability, presence of neural compression, and impact of other concurrent injuries. Nonoperative management involves measures to immobilize the spine and to reduce dislocation with bed rest, traction of the spine, or the wearing of orthoses for 2–3 months. Indications for surgical management include spinal column stabilization and spinal cord decompression by reducing a dislocation or removing fracture fragments that cause neural compression.
Operative management of TSCI, within the first 48 h, has been associated with improved neurologic outcomes ( ). Nonoperative management of these injuries is associated with a fourfold increase in mortality than those with similar injuries managed operatively ( ). Also, operative intervention is associated with early mobilization, better neurologic improvement, and higher return to wage-earning jobs ( ).
In LMICs, a high proportion of patients presenting with spinal cord injury do not undergo operative intervention. Studies have shown 0%, 30%, and 60% of TSCI patients undergo surgical intervention in Malawi, Nigeria, and Ghana, respectively ( ; ). The primary reasons expressed in studies for nonoperative management or delays in surgical intervention are a paucity of neurosurgical workforce, lack of patient finances, delays in imaging access, and unavailability of operating room access ( ).
Globally, approximately 22.6 million new cases need neurosurgery consults annually, with 13.8 million persons requiring surgical intervention ( ; ). However, approximately 5.2 million neurosurgical cases go untreated, primarily due to lack of neurosurgical services and inadequate surgical workforce, with Africa bearing the lowest surgeon densities ( ). In 2018, the median workforce densities (neurosurgeons per 100,000 population) by WHO region were Americas (0.54), Africa (0.05), Eastern Mediterranean (0.34), Europe (0.99), South-East Asia (0.13), and Western Pacific (0.11) ( Fig. 4 ) ( ). Approximately one neurosurgeon per 212,000 people is required to meet the healthcare demands from neurotrauma adequately, and an estimated 23,300 additional neurosurgeons globally are needed to address this significant deficit ( ).
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