Inadequate initial treatment main cause of neglect of thoracolumbar injuries in the developing world



A study published in the Asian Spine Journal has found that, unlike that reported in Western literature, the majority of neglected thoracolumbar injuries persisting in the underdeveloped and developing world are due to “inadequate treatment at the initial contact”. Patients presenting with thoracolumbar injuries were affected by a “lack of adequate infrastructure and trained manpower,” among other causes.

According to recent literature, Kavin Khatri and others observed, thoracolumbar injuries are neglected in as many as 26.6% of cases at high-volume centres in the developing world. Given a “paucity of literature” on the best methods of treatment for such neglected injuries—characterised in this paper by three weeks’ or more delay in definitive treatment—the authors set out to investigate the differing reasons for neglect in the developing world in order to establish targeted strategies for treatment. Whilst English-language literature has reported overlooked diagnosis to be the most common cause of neglected  injury, the authors suspected that “the same may not be true in [the] case of developing countries like India.”

The research team, based in New Delhi and Faridkot (both India) performed a retrospective review of hospital records and radiographs of patients presenting with traumatic thoracolumbar injuries of more than three weeks at the All India Institute of Medical Sciences (New Delhi, India) between January 2008 and March 2014. These records included clinical history and operative notes, as well as pre- and postoperative radiographs, which were assessed for the aetiology, manifestation and treatment of injuries. Consent for study was received from forty patients, who also met inclusion criteria, with no cervical injury, and no surgical management prior to presentation at the centre.

Thirty-three patients were male, with an age range of 9 to 58 years (mean=25.95). The cause of initial injury was predominantly due to falling from a height (n=37), with nine injuries caused by traffic accidents, and one by diving. The authors investigated the hospital records to “determine the demographic data, mode of injury, treatment given, complications associated with injury and treatment, preoperative and postoperative neurological status using American Spinal Injury Association (ASIA) grading along with spinal cord independence measure (SCIM) score.”

When the authors analysed these data, they found that 45% of neglected injuries were caused by “inadequate primary treatment at the first contact hospital”. Among this group, 32% were caused specifically by a “lack of adequate infrastructure and trained manpower”, with 8% due to “poor rehabilitation subsequent to initial treatment”, and 5% to “ignorance among patients and physicians about the seriousness of the spinal injuries.”

Late presentation at hospital, the next major cause of neglect, affected 38% of injuries. Of this subgroup, 20% of cases were caused by “non-availability or complete absence of healthcare facilities”. “This problem is faced in many developing nations globally,” the authors commented, “Few hospitals in our country cater to large population[s], leading to long waiting period[s] and poor rehabilitation.” Ten per cent of late presenting cases were caused by patients “opting for other forms of treatment than modern allopathic medicine,” such as Ayurvedic medicine or homeopathy—with 8% of late presenting cases caused by a “lack of financial resources”.

Seventeen per cent of these cases involved spinal injuries missed due to treatment for associated head injury or polytrauma.

The delay before definitive treatment varied from three to six weeks in 22 patients, between six and twelve weeks for 10 patients and over twelve weeks for eight. The authors chose three weeks as a starting point for measuring neglect “because in the majority of the cases, that is when fibrosis sets in around the injured segment and makes operative intervention difficult.”

Cataloguing the details of treatment itself, the authors noted that the majority of cases (n=26) required a posterior approach, with an approach performed in nine patients, and a combined anterior and posterior approach required for five patients.

Complications were common after surgery. Fifty-eight per cent of patients developed bed sores—the most-reported complication—with urinary tract infection, respiratory tract infection and gastrointestinal complications frequently reported.

Using delay before treatment as a subgroup, researchers found no statistically significant (p<0.05) correlation between delay in surgery and SCIM score. However, improvements in SCIM score were reported by patients at a significant level by last follow-up, and this was “irrespective” of the level of vertebral injury. Authors noted that the improvement in ASIA grade after surgical intervention was significant “in cases with higher grades of ASIA at initial contact.”

According to the authors, the study was limited by “its retrospective design, lack of control group” as well as a high drop-out rate. Larger prospective studies would be required to compensate for “parameters like site and extent of injury” which can have an impact on functional outcome.

“The surgical management of old neglected spinal injuries is difficult, lengthy and fraught with potential neurological complications,” the authors wrote, emphasising the increased likelihood of requiring treatment by extensive anterior procedures. Delays in rehabilitation due to such procedures can lead to “suboptimal” results, sometimes requiring secondary surgical procedures. Lack of compliance with rehabilitation programmes was also suggested as a cause of the high rate of bed sores experienced by patients in the study.

“This study emphasises the point at which surgical intervention should be carried out, even in delayed or missed cases,” the authors concluded, given the significant improvements in ASIA grade scores in spite of the increased complexity of surgeries in these neglected cases. “This study shows the importance of providing adequate infrastructure, trained manpower and awareness about the seriousness of the spinal injury at [the] primary healthcare level,” they stated. This review contains the material, they suggest, to help with “the development of strategies and interventions required in the management of neglected traumatic spinal injuries”. Too, this data could be used by healthcare providers, the researchers said, to “pursue their cases for neglected spine rehabilitation services in this part of the world.”