Traumatic spinal cord injury and outcomes in low-resource settings

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.

Fig. 1, Global prevalence of traumatic spinal cord injury. The figure illustrates the age-standardized prevalence of TSCI per 100,000 people by country in 2016 ( James et al., 2019 ). The countries with prevalence over 1300 per 100,000, shown in dark red , are Lebanon, Iraq, and Afghanistan.

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 ).

Fig. 2, Gender distribution of traumatic spinal cord injury by region. The range of proportions of spinal cord injured patients by sex is shown by region. EMR , Eastern Mediterranean; SEAR , Southeast Asia; AFR , Africa; AMR-L , Latin America; WPR , Western Pacific.

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) ( ).

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