The characteristics of cervical spinal cord trauma at a North Tanzanian Referral Hospital: a retrospective hospital based study

Introduction Surviving a traumatic cervical Spinal Cord Injury (SCI) has an immense effect on an individual's physical function and independence. It also predisposes them to financial, social, psychological and several medical complications throughout their life. In high-income countries, improved multidisciplinary care has led to better long term outcomes, however in low-income countries, the burden of the condition and its associated mortality remain high. The aim of this study was to illustrate the sociodemographic and clinical characteristics of cervical level Traumatic Spinal Cord Injuries (TSCIs) at Kilimanjaro Christian Medical Centre (KCMC) in northern Tanzania. Methods This was a retrospective hospital-based study of 105 cervical TSCI cases admitted to KCMC from January 2012 to December 2016. Results We included 105 patients in the study cohort, with a male preponderance of 86.7%, giving a male-to-female ratio of 6.5:1. The mean age at injury was 44.1 years. Overall, 65.7% were farmers and 69 patients were from within the Kilimanjaro region. Road Traffic Crashes (RTCs) accounted for 47.6% of the injuries, 17.9% had associated injuries, 38.1% sustained complete TSCIs and 45.7% developed secondary complications during the ward stay. The mortality rate before discharge from hospital care was 35.2%. Conclusion The majority of patients were males from a low socioeconomic background and the most common cause of injury was RTCs. The secondary complication rates and mortality rates before discharge from hospital care are high.


Introduction
Distinguished by their etiology, Traumatic Spinal Cord Injuries (TSCIs) are a result of physical force directed towards the bony vertebral column. Trauma which results in a lesion of the cord is often blunt and accompanied by multiple injuries to the structures which surround it.
Vertebral injuries, ligament tears and disk prolapses often complicate the clinical picture [1]. Trauma to the vertebrae and its supporting structures may be severe enough to disrupt its protective function to the spinal cord. The resulting crush injury, dislocation, unstable or stable fracture can result in a spinal cord lesion of varying form including; a contusion, crush injury, laceration, well defined transection or nerve root avulsion [1]. Spinal cord lesions in the C1-C3 region are the most taxing SCIs often leaving patients ventilatordependent with limited communication and neck muscle control [2].
The description of functionality following high cervical cord lesions is in stark contrast to the near complete independence which may be recovered by individuals who sustain an injury in the L2-S5 regions [2]. Apart from the differing clinical experiences based on level of injury, subsequent to the analysis of costs incurred following admission, a drastic difference between tetraplegic patients and paraplegic patients is demonstrated [2]. A publication from the American National Spinal Cord Injury Statistical Center stated that for individuals injured at age 25, lifetime costs would amount to 4.6 million United States Dollars (USDs) for high tetraplegia while paraplegic patients would incur a much lower figure of USD 2.3 million [3]. Although the figures listed for the United States of America may not be comparable to expenditure in regions of the world with differing economic levels of development, they are a clear indication that tetraplegic patients face a tougher path to adapt and re-assimilate back into society. The cervical region of the vertebral column is the most vulnerable to trauma due to the relatively axial alignment of the facet joints between the bony vertebral bodies. Lesser force is required to dislocate cervical region facet joints compared to those in the thoracic and lumbar region. Additionally, the thoracic cage and abdomino-pelvic organs lend support to the thoracic and lumbar regions of the spine respectively [4].
The level of the lesion is a strong indicator of the mortality due to injury, risk of secondary complications, cost incurred during treatment and rehabilitation and the nature of rehabilitation which will be required [2]. Mortality following TSCIs has been analysed frequently by numerous studies and the impression of level of injury has been unmistakable; patients with tetraplegia are more likely to succumb to their injuries when matched with cohorts of patients with lesions below the cervical cord [2]. TSCIs at progressively higher cord levels are more likely to occur with concomitant head trauma resulting in a decreased level of consciousness during initial presentation to an acute care facility; thus likely contributing to a higher incidence of aspiration [5,6]. Traumatic injury to the cervical region of the spinal cord has been associated with the development of dysfunctional swallowing -dysphagia -with an increased risk of aspiration which would contribute significantly to the incidence of pulmonary complications in the TSCI cohort with higher level injuries [7].
Rehabilitation and assimilation into society are challenges which require the input of multiple disciplines to ensure a satisfactory outcome for a patient; it goes without saying that the financial input

Results
Study population: a total number of 105 patients were included in the study cohort, with a male preponderance of 86.7% (n=91). The age range of the study cohort was 13 to 88 years with a mean age of 44.1 years. The most commonly affected age group was 16 -30 years (n=29, 27.6%) ( Table 1). An overwhelming 65.7% (n=69) of the cohort were farmers and most patients resided within the Kilimanjaro Region (n=59, 56.2%). Road Traffic Crashes (RTCs) accounted for most of the injuries (n=50, 47.6%) followed closely by fall injuries (n=43, 41.0%) ( Table 2). A majority of the patients presented at KCMC within the first 24 hours of injury (n=61, 58.1%) and 38.1% (n=40) arrived more than 3 days later.

Discussion
The recurrence of a preponderance of male patients in TSCI populations across several studies cannot go unnoticed [9]. As the pattern frequently appears after the pediatric age group, it is a reflection of the manner in which gender roles affect the risk exposure Often, epidemiological data detailing the mechanism of injury reflects cultural norms and the social environment allowing identification of high risk situations for injury. A Turkish study identifying falls as a major cause of TSCIs linked the statistics to seasonal incidences of injury and concurred that individuals who sleep on rooftops during the summer months are at an increased risk of sustaining a TSCI [11].
Researches conducted in Afghanistan -a conflict ravaged countryidentified war-wounds as the primary cause of TSCIs [11]. Brazil (42%), Turkey (25%) and South Africa (21%) report amongst the highest proportions of TSCIs attributable to violence related incidents [11]. From KCMC, a publication dating back to 1985 detailed the clinical course of 47 patients with paraplegia admitted following traumatic incidents; 19 (40.4%) had been injured due to a fall from a tree and 11 (23.4%) had been involved in RTCs [12]. The higher incidence of injuries resulting from RTCs in the current study group is likely due to increased motor traffic levels since the 1980s. Although Often muscle strength would be recorded as a single value for each limb and progressive ward round notes would only document progress over time with vague references to improving or plateaued muscle power. References to specific myotomes was scarce upon admission.
In an effort to ensure that this vulnerable TSCI population receive the highest standard of care possible, since the initiation of the multidisciplinary ward rounds at KCMC, every patient's neurological examination is conducted in accordance to the International Standards for Neurological Classification of Spinal Cord Injury and duplicate records are maintained; in the patient's file as well as a secure hospital registry of TSCI patients [14]. This has allowed a better assessment of the patient's progress and the provision of more personalized rehabilitation services. It was possible to review imaging for every patient included in the study to allow assessment of the skeletal level of injury. For the purposes of this study, the C1-C4 vertebrae were Additionally, the challenge of a complete nervous and musculoskeletal system assessment in a semiconscious or unconscious head injury patient denotes the potential of missing a cervical TSCI. Secondary complications occurred in almost half the patients who were admitted following injuries. It is interesting to note that certain complications do not arise at the site of injury but rather they are due to dysfunctions of distant physiological systems with disrupted nervous system control. Vigilance on the part of the management team cannot be emphasized enough since evidence indicates that with appropriate care and precautions, a number of these secondary conditions are preventable [15]. An analysis of the data demonstrated that pressure sores were the most commonly encountered secondary complication (n=24, 22.9%). Systemic reviews of publications from developing countries analyzed pooled data and determined a pressure ulcers prevalence rate of 26.7 -46.2% in TSCI cohorts [16]. Of note is that the cited manuscript pointed out the likelihood that the figures are Page number not for citation purposes 5 probably an underrepresentation of reality as most studies were conducted in low-resource settings with a limited capacity of reaching all individuals with TSCIs and inclusion criteria varied across the publications [16]. Reported to occur in an average 30 -40% of patients following TSCIs, lesions result when skin or underlying tissue is injured following continuous pressure application or pressure combined with a shearing force [17]. Pressure ulcers can rapidly evolve from minor skin infections to potentially life threatening fullthickness wounds with tissue sloughing resulting in bone exposure.
TSCI patients are uniquely susceptible to the development of pressure sores as they are often initially bed ridden, with diminished or absent sensitivity, fecal and urinary incontinence contributing to incessant moisture exposure, atrophying muscles and usually poor nutrition -all risk factors for the development of lesions [17].
The mortality rate before discharge from hospital care was 35.2% in the cohort; a majority of the deaths (70%) occurred in patients with complete TSCIs. A complete TSCI entirely disrupts the physiological continuity of the spinal cord and leaves the region distal to the point of the lesion devoid of higher center control. Considerable differences in the counts of mortality have been noted when patients with complete TSCIs are compared to their counterparts with incomplete lesions [15]. Following the comparison of mortality rate data from developing and developed countries, the differences are starkly obvious and are likely due to the interplay of several factors which come into play from transport of the injured to the hospital, acute care and the occurrence and management of secondary complications [18,19]. Although KCMC's multidisciplinary spine team attends to all patients in the hospital with a SCI, acute management of SCI patients is often challenging due to delayed presentation to the hospital and the nonexistence of neurosurgical services at our center.
Limited expertise and lack of required equipment has translated into limited experience with spine surgery at KCMC. Cervical TSCIs are a significant threat to public health, even more so in an era with increasing road traffic levels [20]. They also represent a challenge to every aspect of health care due to the multi-disciplinary and laborintensive approach required to manage and rehabilitate patients.
Living with a disability in Africa, where even access to basic health care is a challenge for the majority, translates into a poor quality of life and isolation from society. Apart from investing in primary prevention of these injuries, there is a need for every individual involved in TSCI care in Africa to look beyond the 'confines' of low resources and to focus on maximizing efficiency with available assets.

Conclusion
The average cervical TSCI in-patient profile at KCMC is a young male from an economically fragile background. A strained health care budget in a low-income country also manifests in the high secondary complication rate. Cervical TSCI patients in a low resource setting have a grim prognosis, further compounded by the social and financial implications of the acquired disability.
What is known about this topic • Cervical TSCI's represent a burden to healthcare systems globally and especially so in low-income countries with limited medical resources; • Cervical TSCI's require a multidisciplinary approach to aid recovery and guide rehabilitation; • KCMC is home to the only spinal cord injury rehabilitation unit in the country.

What this study adds
• The average patient with a cervical TSCI in northern Tanzania is a middle aged male, from a low socioeconomic background; • A strained healthcare budget in a low-income country also manifests in the high secondary complication and mortality rates in individuals who have sustained a TSCI.