Demography, Diagnosis and Complications of Spinal Cord Injury Patients in a Rehabilitation Center of Bangladesh

Spinal cord injury, is certainly a debilitating and devastating condition in terms of its effect on a person`s physical, mental, familial as well as social life [1]. Due to its profound impact on a person`s overall quality of life and increasingly high incidence, injury to spinal cord due to any pathology is now considered as a morbid condition as well as a threat to both personal and national economy [2,3]. Spinal cord injury itself is a crippling condition, at the same time may lead to a variety of complications which can affect the life of the patient as it increases the treatment cost significantly and accelerate the disease process which link to early mortality [1,3,4]. The incidence of Spinal cord injury is increasing throughout the world with an annual incidence rate of 15 to 40 per million with a male predominance, more prevalence in low socio-economic society and the causes ranges from traumatic in most of the case like motor vehicle accident to gunshot injury and physical violence, however non traumatic causes like Tuberculosis (TB) of the spine is also responsible for this [3-6]. A great variety of complications usually follow injury to spinal cord such as pressure sore, urinary complications, most of which are preventable nonetheless these associated complications are the most common cause of re-hospitalization following spinal cord injury and eventually lead to a great deal of disability, morbidity, degree of dependence and mortality [1-4].


Introduction
Spinal cord injury, is certainly a debilitating and devastating condition in terms of its effect on a person`s physical, mental, familial as well as social life [1]. Due to its profound impact on a person`s overall quality of life and increasingly high incidence, injury to spinal cord due to any pathology is now considered as a morbid condition as well as a threat to both personal and national economy [2,3]. Spinal cord injury itself is a crippling condition, at the same time may lead to a variety of complications which can affect the life of the patient as it increases the treatment cost significantly and accelerate the disease process which link to early mortality [1,3,4]. The incidence of Spinal cord injury is increasing throughout the world with an annual incidence rate of 15 to 40 per million with a male predominance, more prevalence in low socio-economic society and the causes ranges from traumatic in most of the case like motor vehicle accident to gunshot injury and physical violence, however non traumatic causes like Tuberculosis (TB) of the spine is also responsible for this [3][4][5][6]. A great variety of complications usually follow injury to spinal cord such as pressure sore, urinary complications, most of which are preventable nonetheless these associated complications are the most common cause of re-hospitalization following spinal cord injury and eventually lead to a great deal of disability, morbidity, degree of dependence and mortality [1][2][3][4].
Spinal cord injury is a severe condition of the musculoskeletal system, more often leading to permanent disability and on the top of that brings about drastic changes the functioning ability of the patient and eventually encompassing each and every aspect of life [5][6][7][8]. Complications may associate virtually all systems of the body namely cardio-respiratory system, genitourinary system, local disorders like pressure sore or full blown biochemical disorders. Such domino effect following the injury to spinal cord significantly decreases the quality of life of the individual and happens on the early or acute stage when initial rehabilitation process are being initiated [6]. Spinal cord injury whether traumatic or form other cause and Bangladesh a poor developing country with a literacy rate of about 61.0% among the age of 15 years and above [12,13] spinal cord injury and its health related complications are a major issue as it causes a great deal of morbidity and mortality as well as economic problems [14]. The researcher aimed to looking into the trend in demographic distribution of spinal cord injury, diagnosis, as well as complications in patients with spinal cord injury which will help to identify the specific population group at risk and take preventive measure to prevent the associated complications [15][16][17].

Study place
Centre for the Rehabilitation of the Paralysed (CRP) one of the largest rehabilitation centre for different injury in Bangladesh. It receives referrals from other hospitals and all over the Bangladesh. Here patients admitted with or without pressure ulcer. Some pressure ulcers are cure by conservative treatment and some are needs surgery when it became uncontrolled. In CRP given extensive education and counseling about pressure ulcer care not only pressure care but also all aspects about how they can pass their life with Spinal Cord Injury (SCI). The rehabilitation procedure going through 3 months long or sometimes more according to patient's physical condition and recovery time. After patients discharge from CRP, health care professionals will follow-up the patients in Community by doing patients home visit.

Data collection, management and analysis
Data were collected between 2012 and 2013 from the community during the home visit of previously admitted patients at CRP with spinal cord injury. A structured preformed pretested questionnaire was used to collect the data from 201 patients by face to face interview. After collection data were managed properly and was analyzed in SPSS 16 version and Microsoft Excel Software 2007 version.

Ethical consideration
The researchers were properly concerned about the ethical issues relate to the study. Formal ethical clearance was taken from the ethical review committee of the CRP for conducting this study. As the patients were discharge from CRP they all are willing to give all information to the CRP health care professionals. Confidentiality of the persons and the information was maintained and observed and unauthorized persons did not have any access to the collected data.
Out of 201 respondents, 168 diagnoses was available and among them 56.5% (95) had the diagnosis of traumatic paraplegia and 29.2% had traumatic tetraplegia whereas Non-traumatic paraplegia, Guillain-Barre Syndrome and TB spine were the other diagnosis having the distribution of 9.5%, 4.2% and 0.6%, respectively ( Figure 1). 22.7% (45) of the respondents had pressure sore present and most of these sore were located over buttock which had 67.5% followed by Ischial Tuberosity having 7.5% of the sore (    received medical and same amount had the hospital management however 22.8% did not receive any treatment (Table 3).

Discussion
The study population was a selected group of people suffering from spinal cord injury that made it necessary to get admission in hospital. The Demographic variables author took into consideration were sex, age, employment status and income of the patient. Out of 201 study population 176 were male and 25 were female and this male predominance was also reported in the previous studies carried out both locally [14,[18][19][20] and globally [4][5][6][7][8][9][10][11]21] (Table 1). In this study most of the patients were in their 3 rd decade which consisted 28.6% , followed by 27.4% in between 21-30 years and 26.8% in between 41-50, which was also a common finding as reported by Hossain et al. [22] where mean age was 47.44 ± 13.30 [17]; Ulrich et al found it 36.1 and according to Lali et al. [21] mean age was 35.3, but in some studies the age of the study population was little bit different [4,14,16,18] (Table  1). It was found that 93 of the respondent (47%) were employed and 103 were unemployed (57%) which somewhat correlate with Zahangir et al, who reported 36% of the patient to be day laborer [18] and also Ulrich et al., according to whom only 22% of the patients were full time employed but does not go in line with Lali et al. and other articles [4,14,17,22] (Table 1). A general trend of development of pressure sore among people with low income was found in this study which was also common in the other reports [4,11,18,19]. Most of the respondents of this study had paraplegia (56.5%) and the principle cause was trauma which was similar to the report Rahman et al. but Guihan et al. reported most of their patients (73.3%) had complete spinal cord injury [10, 14,20] but in all the reports the major cause of injury was reported to be trauma whether road traffic accident or fall from height or any other mechanism of traumatic injury [4,10,11,14,20,21] ( Figure 1). Regarding the location, the authors found Buttock to be the predominant site for developing site pressure sore as evident form 67.5% patient had sore over their buttock followed by Ischial tuberosity (7.5%) and this finding was similar to Hossain et al. and Ulrich et al. reported the lower back to the commonest site for pressure sore [17,22] (Table 3). In this article 44.6% of the respondents had urinary complication and 16.9% had dysuria and 10.8% had urinary incontinence which is almost similar to the report of Thiyagarajan et al. and Guihan et al. [16,20] (Table 3). 30 patients with pressure sore had other skin disease which may be supported by the report of Guihan and Bombardier, where 96.2% patient had associated skin disease, but Endocrine conditions like Diabetes had a significant association whit development of pressure sore along with vascular conditions which were not evident in the current study [20]. Moreover, other risk factors for developing pressure sore in patients with spinal cord injury like inability to turn the body independently or systemic conditions like anemia, jaundice, malnutrition as reported by many authors [4,9,10,16,22] where not evident in this particular study.

Conclusion
Spinal cord, injury regardless of the cause has grave consequences as it creates a great deal of physical, psychological as well as economic restraints. Adult male seems to be at more risk of spinal cord injury and paraplegia is the commonest diagnosis, usually associated with multidimensional complications such as pressure sore. Further large scale study would help to generalize the findings and to encourage the further involvement of the stake holders to prevent the onset of the devastating course.