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 Table of Contents  
ORIGINAL ARTICLE
Year : 2014  |  Volume : 17  |  Issue : 1  |  Page : 31-36

A review of traumatic spinal cord injuries at the Nnamdi Azikiwe University Teaching Hospital, Nnewi, Nigeria


1 Department of Orthopedic Surgery, Nnamdi Azikiwe University Teaching Hospital, Nnewi, Anambra State, Nigeria
2 Department of Physiotherapy, Nnamdi Azikiwe University Teaching Hospital, Nnewi, Anambra State, Nigeria

Date of Web Publication7-Apr-2014

Correspondence Address:
Chima C Ihegihu
Department of Orthopedic Surgery, Nnamdi Azikiwe University Teaching Hospital, Nnewi, Anambra State
Nigeria
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DOI: 10.4103/1119-0388.130180

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  Abstract 

Objective: To determine the pattern of traumatic spinal cord injuries in our center. Materials and Methods: A retrospective review of 46 case files of patients with traumatic spinal cord injuries, treated by the Orthopedic and Physiotherapy Units at the Nnamdi Azikiwe University Teaching Hospital, Nnewi, Anambra State, Nigeria from January 1 2001 to December 31 2005 (a five-year period). Results: A total of 46 patients were treated within this period. Thirty-four case files with complete data were reviewed. Thirty of the patients (88.2%) were males, while four (11.8%) were females. The male: female ratio was 7.5 to 1. The age range was from 15 years to 72 years. The mean age was 42 years and the median was 40 years. Most of the injuries, 64.7%, were as a result of a fall from a height. The most common level of injury was of the thoracic spine, 17 patients (50%); followed by the lumbar spine, 11 patients (32.4%); and cervical spine, six (17.6%) patients. Conclusion: Most of the injuries in this study were a result of a fall from a height, hence, could have been prevented. Use of better climbing tools and precautionary measures taken to ensure that scaffolds were built with good quality wood or steel, making them well secured, may have led to a reduction in the incidence of fall from a height.

Keywords: Falls, Frankel′s classification, injuries, spinal cord


How to cite this article:
Ihegihu CC, Ugezu AI, Ndukwu CU, Chukwuka NC, Ofiaeli RO, Ihegihu EY. A review of traumatic spinal cord injuries at the Nnamdi Azikiwe University Teaching Hospital, Nnewi, Nigeria . Trop J Med Res 2014;17:31-6

How to cite this URL:
Ihegihu CC, Ugezu AI, Ndukwu CU, Chukwuka NC, Ofiaeli RO, Ihegihu EY. A review of traumatic spinal cord injuries at the Nnamdi Azikiwe University Teaching Hospital, Nnewi, Nigeria . Trop J Med Res [serial online] 2014 [cited 2019 Sep 23];17:31-6. Available from: http://www.tjmrjournal.org/text.asp?2014/17/1/31/130180


  Introduction Top


Spinal cord injuries account for a significant proportion of musculoskeletal injuries worldwide. The reported annual incidence of traumatic spinal cord injuries varies from 2.3 per million to 83 per million. [1] When the spinal cord is injured, the results can be devastating and may result in death or long-term disability. These injuries can be life changing, because unlike many other tissues, the spinal cord has poor intrinsic regenerative capacity, [2],[3] and once damage is done, it is usually permanent.

Often, young healthy individuals are affected and the condition creates enormous physical, emotional, and financial stress to the individuals, their relatives, and sometimes to the society at large. On account of the significant force that is required to fracture the spine, many patients with spinal cord injuries suffer significant injury to other parts of the body as well. [4] Many of these associated injuries may be fatal. [5],[6]

There is no established national spinal cord injury registry in Nigeria, although several researches have been carried out in different parts of the country. [7],[8],[9],[10],[11] There is a need for this, as has been obtained in some other countries. [12],[13],[14],[15] This retrospective hospital-based review was carried out to determine the pattern of traumatic spinal cord injuries in our center. Data derived from this study will contribute to the National Database when a National Registry is established. Previous studies have shown that traumatic spinal cord injuries vary in etiology, level of injury, and age and sex distribution in different parts of Nigeria [7],[8],[9],[10],[11] and in different countries. [16],[17],[18],[19],[20]


  Materials and Methods Top


This is a retrospective hospital-based study on spinal cord injuries treated at the Nnamdi Azikiwe University Teaching Hospital (NAUTH) between January 1 2001 and December 31 2005, by the Orthopedic and Physiotherapy Units, before establishment of the Neurosurgery Unit. Nnamdi Azikiwe University Teaching Hospital is a Federal Government-funded tertiary health institution located in Nnewi a semi-urban town in Anambra State, South East Nigeria. Thirty-four case files with complete data were reviewed. Data of the patients including biodata, mechanism of injury, interval presentation time, level of injury, time of injury, intervention before presentation, associated injuries, Frankel classification [21] [Grade A: No function, Grade B: Sensory only, Grade C: Some sensory and motor preservation, Grade D: Useful motor function, Grade E: Normal function], and outcome and length of stay in hospital were entered in a preformed proforma. The data was then manually analyzed using descriptive analysis.


  Results Top


Sex distribution

A total of 46 patients who had spinal cord injuries were treated in the five-year study period from January 1 2001 to December 31 2005. Thirty-four case files (73.9%), with complete data, were included in the study. Thirty (88.2%) were males and four (11.8%) were females; the male: female ratio was 7.5 to 1 [Table 1].
Table 1: Sex distribution


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Age distribution

The age range was from 15 years to 72 years; the mean age was 42 years and the median age was 40 years. The age range with the highest incidence was the third decade (21-30 years), which made up 26.5% (nine patients) of the total, followed by the fourth and fifth decades 20.6% (seven patients) each [Figure 1], [Table 2].
Table 2: Age distribution in years


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Figure 1: Age distribution (in years)

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Time of injury, presentation time, and intervention before presentation

Most of the injuries 64.7% (22 patients) occurred in the morning, while 20.6% (7 patients) occurred in the afternoon. Only 14.7% (5 patients) occurred at night. Sixteen patients (47.1%) presented within the first 24 hours of injury, nine (26.5%) within one week of injury, six (17.6%) within the second week of injury, and three (8.8%) six weeks after. Twenty-nine patients (85.3%) had initial treatment either at a private hospital, native bone setter or spiritual home, before presentation to the hospital. Only five patients (14.7%) were brought straight from the scene of injury [Table 3], [Table 4], [Table 5].
Table 3: Time of injury


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Table 4: Interval of presentation time


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Table 5: Intervention before presentation


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Occupation of the patients

The victims were mainly from the low socioeconomic class. Thirteen (38.2%) were farmers, eight (23.5%) were petty traders, three (8.8%) were carpenters, two (5.9%) commercial motorcyclists, one mechanic, one driver, and one mason. Two patients (5.9%) were civil servants, while three (8.8%) were students [Table 6].
Table 6: Type of occupation


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Etiology of injuries

Twenty-two (64.7%) injuries were as a result of a fall from a height, mainly palm trees and uncompleted buildings, while eight (23.5%) were from road traffic accidents (four each from motor vehicular and motorcycle accidents). The remaining injuries were as a result of two assaults (street violence), one sports injury (football), and one industrial accident. Twenty-seven patients (79.4%) were fully conscious on presentation, while seven (20.6%), who had associated head injury, were brought in unconscious [Table 7].
Table 7: Etiology of spinal cord injuries


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The Frankel classification of injuries, associated injuries, and level of injury at presentation

At presentation and initial assessment 22 patients (64.7%) had complete spinal cord injury (Frankel Grade A), while 12 patients (35.3%) had incomplete cord injury (Frankel Grade B: 5, Grade C: 3, and Grade D: 4). Only 13 (38.2%) had associated injuries to other parts of the body; seven patients (20.6%) had associated head injury, four (11.8%) chest injuries, and two (5.9%) had abdominal injuries. Twenty-one patients (61.8%) did not have any associated injuries. The most common level of injury was the thoracic spine, 17 patients (50%); followed by the lumbar spine, 11 patients; (32.4%) and cervical spine, six patients (17.6%), as presented in [Figure 2] [Table 8], [Table 9], [Table 10].
Figure 2: Neurological level of injury

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Table 8: Frankel classification of injuries at presentation


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Table 9: Associated injuries


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Table 10: Level of injury


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Treatment, outcome, and length of stay in hospital

All the patients were treated non-operatively by the Orthopedic Units in collaboration with the Physiotherapy Department. Six patients (17.6%) whose injuries were at the level of the cervical spine had initial skull traction with tongs and callipers, and subsequently a hard cervical collar or Minerva jacket. Twenty-eight patients (82.4%), whose injuries were at the thoracic and lumbar spines, had thoracolumbar jackets fashioned from plaster of Paris, for stabilization. All the patients had drugs that were mainly non-steroidal anti-inflammatory drugs, analgesics, multivitamins, and antibiotics. All the patients also had physiotherapy, which comprised of breathing exercises, continued chest mobility, postural drainage, two-hourly positioning, padding of pressure points, joint range of motion exercises, pain management using transcutaneous electrical nerve stimulation (TENS), and strengthening of innervated muscles. On discharge, four patients (11.8%) had full recovery and eight patients (23.5%, five patients Frankel B and three patients Frankel C) had partial recovery. Twenty-one patients (61.8%) had complete spinal cord injury: Sixteen (47.1%) in the thoracic and lumbar spine; and five (14.7%) in the cervical spine. One patient who had complete cord injury at the level of cervical spine died. Twenty patients were admitted for one month or less. Many of the patients were discharged against medical advice. Four patients were admitted for about two months, six for about three months, and four for about four months [Table 11], [Table 12], [Table 13].
Table 11: Non-operative treatment


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Table 12: Outcome


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Table 13: Length of stay in hospital, in weeks


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  Discussion Top


The incidence of traumatic spinal cord injury is relatively low compared to other musculoskeletal injuries. [22],[23],[24] In a study carried out in a level 1 trauma center, over a 13-year period (1996 to 2008), 5.8% of all trauma patients suffered spinal fractures, with 21.7% of the patients with spinal injuries, having spinal cord injuries. [25] Forty-six cases were seen over a five-year period in our teaching hospital. Thirty-four case files (73.9%) had complete records, due to poor record keeping and documentation: A common problem in our government institutions. In all the previous studies by other researchers, there was a male preponderance for spinal cord injuries. The ratio of males to females depended on the location of the center where the study was carried out: Rural, semi-urban or urban environment and ranged from 0.99 [26] to 12. [10] The male preponderance is not surprising, as males are the bread winners in most societies. Men in the most active and productive period of their life, mostly in their third decade, followed by the fourth and fifth decades were affected more. Only two spinal cord injuries were seen in the second decade. The incidence of traumatic spinal cord injury is relatively low in the children and adolescent population; 2.4 per million children and 25.1 per million adolescents. [27] Most of the injuries, 29 (85.3%), occurred during the day (morning and afternoon), as this was the period of the day when most people in this environment were engaged in their various occupations. The population in this town, where the teaching hospital is located, is a rural population, predominantly made up of farmers, traders, and artisans, who are generally indoors at nights unlike in most urban towns where there is a lot of traffic activity in the night. Hence, productive occupational activities were carried out during the day. Most of the patients were in the low socioeconomic class, as indicated by their occupation and mode of injury. The injuries were mostly from a fall from a height: Farmers falling mainly from top of palm trees or carpenters and masons falling from top of uncompleted buildings and scaffolds. This contrasts with studies carried out in urban centers where road traffic accident was the most common cause of injury. [8],[9],[10],[11],[20],[25] In urban towns, there is an increased network of roads, hence, an increased use of motor vehicles and motorcycles. In this study, our population was rural and we found that 'fall from a height' was the most common cause of injury, as in earlier studies done in Nigeria, [7],[28],[29] a recent study carried out in a predominantly rural population in eastern Nepal, [30] and a study in Tianjin, China, [31] a semi-urban town.

Palm wine is still a popular drink enjoyed in this part of the country. It is in high demand for social events like traditional marriages and traditional title taking. The palm fruit is also a source of palm oil and other medicinal lotions for the skin, while the palm fronds are used for making brooms and thatched roofs. Hence, the palm tree is a highly commercial tree that is economically beneficial, and falls from it are common.

Most of the patients 27 (79.4%) were brought into the hospital fully conscious, as the mechanism of injury was of a low-velocity type, wherein the patients had some measure of control and could at least avoid landing on the head to avoid head injury, thus minimizing injuries to other parts of the body. All the seven patients (20.6%) who were brought in unconscious were involved in high velocity road traffic accidents. At presentation, most of the patients 22 (64.7%) had complete spinal cord injury (Frankel Grade A). One is not exactly sure of the reason; but it may be related to the prolonged interval of presentation time, mode of transportation, and intervention at private hospitals, traditional bone-setters, and spiritual homes, by personnel not skilled in the management of spinal cord injuries. Further study is needed on this aspect. The finding of thoracic spine (50%) as the most common site of injury followed by lumbar spine (32.4%) is similar to the findings in other studies, where fall from a height was the most common cause of injury. [7],[28],[29],[32] Only six patients (17.6%) had cervical spine injury, in this study. This is understandable, as road traffic accidents accounted for only eight (23.3%) of the injuries. In studies done in urban centers, where road traffic accidents were the most common cause of injury, the most common area of the spine involved was the cervical spine. [9],[10],[20]

All the patients were treated non- operatively and the goals of treatment were to prevent progression of loss of neurological function, achieve stabilization of the spine to allow fusion, and optimal rehabilitation. The outcome of treatment was unsatisfactory. At the time of discharge, only four patients (11.7%) had full recovery. Sixteen patients (47.1%) were discharged paraplegic, while five patients (14.7%) were discharged quadriplegic. Eight patients (23.5%) were discharged with some neurological deficit and impaired function. The low mortality of 2.9% (one patient) may be due to the low incidence of cervical cord injury and the early demand for discharge against medical advice by relatives of some who had complete cord injury. Those who stayed beyond three months in hospital were financially handicapped and could not go home immediately after discharge.


  Conclusion Top


Many of the spinal cord injuries in this study could have been prevented, as most were as a result of a fall from a height. Use of better climbing tools may have reduced the incidence of snapping of the rope used for climbing, the common reason for the falls. Precautionary measures taken to ensure that scaffolds were built well, with good quality wood or metal, and were well-secured, may also have reduced the incidence of falls from the top of uncompleted buildings and scaffolds. Improved traffic safety standards, including road maintenance, may also have reduced the incidence of spinal cord injuries from road traffic accidents. Members of the public also need to be enlightened on the initial handling of suspected spinal cord-injured patients and prompt transportation to the nearest tertiary hospital must be stressed upon.

It is recommended that a National Registry for spinal cord injuries be established by the Federal Ministry of Health, so that the etiological pattern of spinal cord injuries in Nigeria can be known. Armed with this information, the government can formulate policies specific to our country, for preventing and establishing a better care system for traumatic spinal cord injured patients.

 
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    Figures

  [Figure 1], [Figure 2]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8], [Table 9], [Table 10], [Table 11], [Table 12], [Table 13]


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