The cost of spinal cord injury in low- and middle-income countries

Roger Härtl

Roger Härtl (New York, USA) discusses his research into traumatic spinal and spinal cord injuries in East African countries, looking specifically at which treatments are more economically beneficial.

Injuries to the spine and spinal cord from trauma occur worldwide and affect all populations. These traumatic events often cause symptomologies that are indications for surgical intervention, but due to limited access to resources, not everyone who would be a candidate for surgical intervention receives the care they need. This effect is exacerbated in the settings of low- to middle-income countries (LMICs), where the costs of surgery, and more specifically instrumentation, falls on to the patient. Owing to the high personal cost and inability to work due to the traumatic injury, many patients in LMICs receive non-operative care, which is associated with poor outcomes. These high costs of surgery may be offset by a greater quality of life after the injury and a sooner return to work.

To investigate the economic impact of traumatic spinal and spinal cord injuries, our group designed a pilot study in collaboration with a partner hospital, Muhimbili Orthopaedic Institute (MOI), a major referral hospital in Dar es Salaam, Tanzania. MOI is the only centre in Tanzania and neighbouring countries that offers surgical intervention to traumatic spinal injuries. Other centres in the area offer decompressive spinal surgery, but this does not include the instrumentation procedures necessary to treat traumatic spinal injuries. To our knowledge this study is the first of its kind.

Starting in the fall of 2016 and onward, a prospective traumatic spinal injury database was established with de-identified data to record patients’ outcomes. Over 250 patients were included in our study, and about half underwent surgery, while the other half had non-operative treatment (three-months bedrest). Our group analysed the data in terms of cost of treatment per Disability-Adjusted Life-Year (DALY) averted. This statistic gives a quantitative value for the money spent now to avoid loss of lifespan later in life from the disease, and it is commonly used to measure health effects in LMICs.

The statistical analysis revealed that operative treatment was more cost effective across all types of spinal trauma procedures for patients that are neurologically intact, neurologically improved, and paraplegic than non-operative treatments.

This can be interpreted as each dollar instrumentation surgery after traumatic spinal injury is more effective than each dollar spent on non-operative treatment for the same patient for improving their quality of life after the injury. Our study provides empirical support that spinal trauma surgery should be a prioritised intervention in LMICs settings. This conclusion requires sufficient perioperative and post-operative care. Surgical treatment does not exist in a vacuum. Several members across multiple specialties are required to make these procedures possible. Proper anaesthesia, nursing, intensive care, and rehabilitation are also part of the healing process, and spinal surgery would not be possible anywhere without the expertise these groups as well as countless others that allow a hospital to function.

We continue our active collaboration with the Tanzanian neurosurgery and orthopaedic team. We hosted our 7th annual neurosurgery, neuro-trauma, and critical course online this year, which had a global panel of presenters. We also recently concluded the online portion of the first scoliosis course in East Africa. We were able to implement a protocol for the treatment of spinal trauma for the neurosurgical and orthopaedic teams in the Tanzanian hospital decreasing the time from admission to surgery from >25 days to less than five days after admission. Currently, our partners rely heavily on donated instrumentation and grants to be able to provide the necessary care to these spinal trauma patients.

Roger Härtl (New York, USA) is a professor Neurological Surgery, Director of Spinal Surgery and Neurotrauma at the Weill Cornell Brain and Spine Center, and the director of the Weill Cornell Medicine Center for Comprehensive Spine Care.


Consulting Fees: DePuy Synthes, Brainlab, Ulrich

Royalties: Zimmer Biomet

Other: RealSpine (Investor)


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