Operative Treatment of Traumatic Spinal Injuries in Tanzania: Surgical Management, Neurologic Outcomes, and Time to Surgery

Abstract

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.

Variation in global treatment for subaxial cervical spine isolated unilateral facet fractures

“…Some regional exceptions exist, however, with surgeons from Africa/Asia/Middle East significantly less likely to recommend surgical treatment for F3N0 fractures than surgeons from the remainder of global regions. This may be secondary to limited resources and infrastructure-reserving surgery for more severe cases, patient socioeconomic factors, as well as cultural differences in patient expectations and outcomes in that particular region [28][29][30][31]. Interestingly, while the treatment for F2N0 fractures is highly controversial in the scientific literature, 73.4% of surgeons recommended nonoperative care, with no significant region or experiential variation [14,20,32].…”

Cervical Spine Trauma in East Africa: Presentation, Treatment, and Mortality

“…This case series represents an extension of a previously published cohort. 17,21 Clinical and Operative Data Several demographic and injury-specific data points were collected, including age, sex, and mechanism of injury. Injury levels were categorized according to prior studies and described per cervical level.…”

“…[26][27][28][29] Unilateral facet dislocations were defined as listhesis of 25% or less, bilateral facet dislocations had listhesis of 25%-75%, and spondyloptosis had listhesis of 100%. 21 Central cord syndrome was defined according to prior studies and by radiographic and/or clinical presence of a cervical SCI without ongoing compression, which most often occurred in the setting of preexisting spondylosis and canal narrowing. 30,31 We acknowledge that the definition of central cord syndrome is controversial, and any spondylosis with active compression due to a fracture, disc prolapse, ligamentum flavum buckling, or facet arthropathy, was not defined as central cord syndrome.…”

“…Previous reports of LMIC spine trauma patients have noted a median time from injury to hospital admission of 48 hours. 21 Thus, it is possible that in the critical 24-48 hours after CST, the more severely injured patients not yet at the hospital may quickly lose vital respiratory or autonomic function and die. Thus, those that survive the early time period may represent a self-selecting, stable group of patients that have passed the critical window of vulnerability.…”

“…19,20 Neurosurgery is tertiary and expensive, leaving operative resources scarce throughout less-resourced countries. 19,21,22 Many LMIC regions report low rates of operative treatment for CST due to lack of equipment and implants. 4,23,24 Given the devastating effects of CST in lessresourced environments, an epidemiologic investigation is needed to better understand this patient population.…”