The first study to describe spinal trauma management and its outcomes in East Africa was recently published in the Journal of Neurosurgery: Spine. First authors Andreas Leidinger and Eliana E Kim, senior author Roger Härtl (Weill Cornell Brain and Spine Centre, New York, USA) and colleagues conclude that their results “provide strong support to implement evidence-based protocols for the management of spinal trauma”.
Spinal trauma is a major cause of disability worldwide, and the burden is especially severe in low-income countries, where hospital infrastructure is poor, resources are limited, and the volume of cases is high. Currently, the authors note, there are no reliable data on incidence, management, and outcome of spinal trauma in East Africa.
The main objective of this study, therefore, was to describe, for the first time, the demographics, management, costs of surgery and implants, treatment decision factors, and outcomes of patients with spine trauma in Tanzania.
Leidinger, Kim and colleagues report that due to the lack of referral hospitals, patients are admitted late after trauma, often with severe neurological deficit. In addition, they found that surgery is performed but generally late in the course of the hospital stay and the decision to perform surgery and timing are heavily influenced by the availability of implants and economic factors such as insurance status.
Finally, they note that patients with incomplete deficits who may benefit most from surgery are not prioritised, even though their findings indicate that surgery may have a positive impact on patient outcome. They suggest: “Further studies with a larger sample size are needed to confirm our results.”
Leidinger, Kim and colleagues included and analysed 180 patients in this study. They found that the mean distance from site of trauma to the surgical referral centre in Tanzania—Muhimbili Orthopaedic Institute (MOI)—was 278km, and the time to admission was on average 5.9 days after trauma. They note that young males were primarily affected, making up 82.8% of the total cohort.
On admission, 47.2% of patients presented with Abbreviate Injury Scale (AIS) grade A and the most common mechanisms of injury were motor vehicle accidents (28.9%) and falls from height (32.8%). Forty per cent of admitted patients underwent surgery, with the mean time to surgery being 33.2 days. Out of the patients who underwent surgery, 21.4% improved in AIS grade at discharge (p=0.03). Overall, the authors found that the only factor associated with improvement in neurological status was undergoing surgery (p=0.03) and shorter time to surgery (p=0.02).
The investigators describe the study as a retrospective review of prospectively collected data on spinal trauma patients in a single surgical referral centre (MOI) from October 2016 to December 2017. They collected general demographics and information on distance from site of trauma to the centre, AIS, time to surgery, steroid use, and mechanism of trauma and AOSpine classification and costs.
Surgical details and complications were recorded and the primary outcome was defined as neurological status on discharge. The authors analysed surgical outcome and determining predicting factors for a positive outcome.
The authors note some limitations of this study. They mention, for example, that its scope is limited to the pool of patients who survived long enough to eventually be referred to MOI and thus does not enable them to calculate the total number of spinal trauma patients in Tanzania or its absolute mortality and morbidity.
Furthermore, they did not collect information concerning the type of transportation to MOI, “which limits out understanding of the characteristics and areas of coverage of medicalised transportation in Tanzania”.
On the wider significance of the study, the authors comment: “These results provide strong support to work with the local surgeons and the hospitals in order to implement treatment protocols that prioritise ICU admission, haemodynamic monitoring, and early surgical management, especially of patients with incomplete deficits.”
They continue: “Education and more collaboration with surgical societies and academic groups dedicated to global surgery are also necessary. These efforts are currently underway but will also require healthcare-related changes that are beyond our direct influence, such as insurance coverage and availability and pricing of surgical implants.”