RESUMEN
STUDY DESIGN: Retrospective case series. OBJECTIVE: Little is known about operative management of traumatic spinal injuries (TSI) in low- and middle-income countries (LMIC). In patients undergoing surgery for TSI in Tanzania, we sought to (1) determine factors involved in the operative decision-making process, specifically implant availability and surgical judgment; (2) report neurologic outcomes; and (3) evaluate time to surgery. METHODS: All patients from October 2016 to June 2019 who presented with TSI and underwent surgical stabilization. Fracture type, operation, neurologic status, and time-to-care was collected. RESULTS: Ninety-seven patients underwent operative stabilization, 23 (24%) cervical and 74 (77%) thoracic/lumbar. Cervical operations included 4 (17%) anterior cervical discectomy and fusion with plate, 7 (30%) anterior cervical corpectomy with tricortical iliac crest graft and plate, and 12 (52%) posterior cervical laminectomy and fusion with lateral mass screws. All 74 (100%) of thoracic/lumbar fractures were treated with posterolateral pedicle screws. Short-segment fixation was used in 86%, and constructs often ended at an injured (61%) or junctional (62%) level. Sixteen (17%) patients improved at least 1 ASIA grade. The sole predictor of neurologic improvement was faster time from admission to surgery (odds ratio = 1.04, P = .011, 95%CI = 1.01-1.07). Median (range) time in days included: injury to admission 2 (0-29), admission to operating room 23 (0-81), and operating room to discharge 8 (2-31). CONCLUSIONS: In a cohort of LMIC patients with TSI undergoing stabilization, the principle driver of operative decision making was cost of implants. Faster time from admission to surgery was associated with neurologic improvement, yet significant delays to surgery were seen due to patients' inability to pay for implants. Several themes for improvement emerged: early surgery, implant availability, prehospital transfer, and long-term follow-up.
RESUMEN
OBJECTIVE: Spinal trauma is a major cause of disability worldwide. 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, there are no reliable data available on incidence, management, and outcomes of spinal trauma in East Africa. The main objective of this study 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. METHODS: The authors retrospectively reviewed prospectively collected data on spinal trauma patients in the single surgical referral center in Tanzania (Muhimbili Orthopaedic Institute [MOI]) from October 2016 to December 2017. They collected general demographics and the following information: distance from site of trauma to the center, American Spinal Injury Association Impairment Scale (AIS), time to surgery, steroid use, and mechanism of trauma and AOSpine classification and costs. Surgical details and complications were recorded. Primary outcome was neurological status on discharge. The authors analyzed surgical outcome and determined predicting factors for positive outcome. RESULTS: A total of 180 patients were included and analyzed in this study. The mean distance from site of trauma to MOI was 278.0 km, and the time to admission was on average 5.9 days after trauma. Young males were primarily affected (82.8% males, average age 35.7 years). On admission, 47.2% of patients presented with AIS grade A. Most common mechanisms of injury were motor vehicle accidents (28.9%) and falls from height (32.8%). Forty percent of admitted patients underwent surgery. The mean time to surgery was 33.2 days; 21.4% of patients who underwent surgery improved in AIS grade at discharge (p = 0.030). Overall, the only factor associated with improvement in neurological status was undergoing surgery (p = 0.03) and shorter time to surgery (p = 0.02). CONCLUSIONS: This is the first study to describe the management and outcomes of spinal trauma in East Africa. Due to the lack of referral hospitals, patients are admitted late after trauma, often with severe neurological deficit. Surgery is performed but generally late in the course of hospital stay. The decision to perform surgery and timing are heavily influenced by the availability of implants and economic factors such as insurance status. Patients with incomplete deficits who may benefit most from surgery are not prioritized. The authors' results suggest that surgery may have a positive impact on patient outcome. Further studies with a larger sample size are needed to confirm our results. These results provide strong support to implement evidence-based protocols for the management of spinal trauma.