Care Related and Transit Neuronal Injuries after Cervical Spine Trauma: State of Care and Practice in Nigeria

Introduction

T he potential for unguarded movement of the injured cervical spine to cause further spinal cord or root injury is the basis for the use of spinal immobilization for trauma patients with cervical spine injury. This practice has also been extended to patients with mechanisms of injury that could result in cervical spinal column injury. ^1,2 The level of morbidity resulting from accidental injuries, especially from road traffic accidents (RTAs), is unacceptable, particularly for developing countries where the available medical care is inadequate to cope with the burden on meager resources.

The frequency of spinal injuries in polytraumatized patients has been reported to range from 10% to more than 30%. ^{3 –5} Cervical spine injuries occur only in a proportion of RTAs but carry a high morbidity. Many of these patients sustain spinal cord injury (SCI) with an estimated incidence worldwide for acute traumatic SCI of 1–40 per million. ⁶ More than 50% of all SCI occur in the cervical region. ⁷ SCI occurs predominantly in young males with a male to female ratio of 4:1. ⁸ Approximately 3–25% of SCIs occur either during transit or early in the course of management. ^9,10 These transit injuries have been attributed to patient mishandling and lack of spinal immobilization, ¹⁰ supporting the need for pre-hospital spinal immobilization of trauma patients with potential spinal column injuries. Several reports of poor outcome from mishandling of cervical spinal injuries are available in the literature. ^11,12 The initial care of the severely injured patient should therefore include protection of the cervical spine.

The management of cord injury has advanced considerably in the last decades, but specific cure and reversal of neuronal injuries remains mostly experimental. The major advances in this field have been in prevention of primary and limitation of secondary injury. In this regard, pre-hospital care of cord-injured patients has major implications for outcome. Suboptimal care during extraction and transfer predispose patients to additional SCI. The currently accepted methods of protection and immobilization were pioneered by Kossuth ^13,14 and Farrington. ¹⁵ Immobilization for all trauma patients, particularly those with a low likelihood of traumatic cervical spinal injury is, however, not always beneficial. ^{16 –19} This is compounded by lack of Class I evidence for immobilization. ^{20 –22} Cervical collar immobilization is effective in limiting motion but is associated with some morbidity. ^{23 –25} Some authors have developed and advocate a triage system based on clinical criteria to select patients for pre-hospital spinal immobilization. ^{26 –28}

In spite of these, careful use of cervical immobilization by trained personnel remains the accepted best practice for care of spinal injured patients. ²⁹ With the introduction of Emergency Medical Services (EMS) and pre-hospital care including spinal immobilization in the early 1970s, the proportion of patients referred to SCI centers with complete neurologic lesions reduced significantly. ^30,31

Although data on cervical cord injuries in developing countries are limited, facilities are less robust to cope with any established injuries. There is, therefore, a greater need to prevent transit neuronal injuries. Unfortunately, there is a lack of trained manpower and support organizations at all levels to mediate the necessary care. In South East Nigeria, there are only three centers providing spinal care for more than 20 million patients (2006 census). There are no properly designated trauma centers, and units with neurosurgeons and orthopedic surgeons, some of whom are not trained spinal surgeons, provide spinal care in the main hospitals. This lack is more pronounced with support staff and facilities. Ambulance services are inadequate for basic interhospital services, pre-hospital ambulance services are almost non-existent, and trained paramedical or ambulance crew are not available. Private hospitals that can afford ambulances prefer to use them for the more financially rewarding business of transporting corpses. The low premium on health exhibited by lack of coordinated government investment in health is compounded by socioeconomic difficulties.

Nigeria is oil rich, but wealth is unevenly distributed. Health care expenditure is less than $8 per capita, much below the $34 recommended by the commission of microeconomics and health. ³² The attempt to establish a health insurance scheme has not been followed through, and patients and relations have to bear the cost of the ever increasing sophistication in medical care. It is estimated that more than 70% of the total expenditure is borne privately. ³² The greatest failure, however, remains a lack of public health education and awareness.

Although no data are available for cervical spine injuries in Nigeria, unpublished data from the University of Nigeria teaching hospital suggests that cervical spine injuries occur in 36% of polytraumatized patients arriving at the hospital. A pilot survey in the hospital indicated that these patients sustained further insult to the cord during extraction from an accident scene and/or transfer to the hospital. To evaluate this relationship further, this study undertook an audit of cervical injuries from RTA in patients admitted to the two major neurosurgical services in South East Nigeria, from the time of accident to arrival to definitive care. It is postulated that the degree of neuronal injury in some of these patients was a result of poor extraction from the scene, lack of adequate protection during transport, and poor early care in non-trauma centers. This article reports the finding of the audit, explores the causes, and examines mechanisms to limit such injuries.

The preliminary result of the audit was presented in February 2011 to the State Ministry of Health and contributed to the introduction of State Ambulance Services in June 2011. A second audit to examine the impact of the ambulance services on limiting transitional injuries is under way.

Methods

This is a questionnaire-based prospective study of 68 consecutive patients admitted with cervical cord injury to the two neurosurgical centers in Enugu, South East Nigeria, between March 2009 and October 2010. Three centers provide trauma and spine care to Enugu and four other neighboring states, covering a population of more than 20 million people. One of these centers could not participate, and thus the study population does not represent all spinal patients.

The questionnaire was administered to all patients who presented with unstable cervical spine injury necessitating stabilization. Only patients with neurological abnormalities on admission and who sustained their injury from RTAs were included in the study. Patients sustaining injuries from falls from trees represent a small number from more remote areas and were excluded to limit variability in methods of extraction and transport. Patients who were unconscious at the scene were also excluded. The patients needed to answer the questions themselves, although a nurse or relation may write down the answers. Ethical approval for the study was obtained from the ethics committee of the two hospitals.

The responses were analyzed for patient demographic data, mechanism of injury, and mode of extraction from the scene and transportation to the first visited hospital. When the limb weakness was first noticed, the place of initial treatment, precautions taken during transportation, and time from injury to arriving definitive care were also analyzed. Patients were not asked to compare the degree of initial weakness and any increase in severity to avoid subjectivity. Admission American Spinal Injury Association (ASIA) impairment score and discharge Spinal Cord Independence Measure were used for clinical assessment and to measure outcomes.

Data were entered on an SPSS database. Correlation between dependent variables (e.g., method of extraction, transportation from scene, and additional neurological morbidity was analyzed using the Pearson chi-square test.

Results

A total of 68 questionnaires were administered with a 100% response rate, because patients were keen to identify with the study. The patients studied represent only those who reached neurosurgical care. Many patients are treated in non-trauma centers and in the community. Fifty-three (77.9%) patients were males with a male to female ratio of 3.5:1, and the mean age was 33.9 years (range 15–69 years) (Table 1). Motor vehicle collisions were responsible for 75% of the injuries, and 25% were from motorbike injuries.

Most of the victims (94.1%) were extracted or moved out of further danger by untrained passersby and the rest by road safety personnel with basic training. None of the patients received cervical spine protection either during extraction from the scene or in the course of transportation to initial care. Only eight (11.8%) of the patients were transported to the place of initial care in an ambulance (Table 2). Neither the patients nor the transporters to hospital have had basic training in EMS or essential precautions to prevent further neurological deterioration after trauma. About 35.3% were sitting, either in a closed vehicle or supported on a motorbike on their way to initial care. Of the 43 patients transported lying down, 41.9% were in the back seat of a sedan. One patient walked to the hospital (Table 2).

Only 18 (26.5%) of the patients presented directly to orthopedic or neurosurgery centers with trauma care, 57.3% were initially admitted into non-trauma designated hospitals, and 16.2% to alternative care (Table 2). Half of the victims presented within 48 h of the injury. There was an average of 3.5 h delay between trauma and presentation to the hospital of initial care and an average of 10.4 days (range 2 h – 18 weeks) before presentation to definitive care (Table 2).

About 41.2% noticed inability to move the limbs during/after removal from the scene while 7.4% noticed it on the way to the hospital. One of the victims was ambulating to hospital before deterioration (Table 3). On subsequent transfer to definitive centers, only 18 (36%) had cervical support, although 39 (78%) were transported in an ambulance. Neither the patients nor the transporters to the hospital had information or training on essential precautions to prevent further neurological deterioration after trauma (Table 4).

Discussion

SCI demonstrates a biphasic pathophysiology. ⁷ The primary or immediate phase begins at the time of injury and lasts approximately 2 hours. ³³ This results from the initial mechanical injury and the accompanying spinal shock. ³⁴ The secondary phase involves a cascade that results in protracted tissue destruction divided into acute (2–48 h), sub-acute (2–14 days), intermediate (2 weeks–6 months), and chronic (>6 months) stages. ⁷ Transit injuries tend to occur during the primary phase and the acute and subacute stages in the secondary phase.

Primary injury mechanisms rarely transect or fully disrupt the anatomical continuity of the cord, ^35,36 but the spinal cord remains subject to additional acute injury as long as the unstable bony injury remains, irrespective of the phase of cord pathophysiological response. There is, therefore, a risk of further direct injury if sufficient care is not observed during extraction of the patient from the scene and transport to definitive care.

In this study, 44% of patients sustained their neuronal injuries on impact and further neuronal injuries developed in 53% before they arrived at the point of definitive care, either during extraction, on transit, or during initial care. Although some of these may be attributed to the acute stage of the secondary phase, there is a higher probability that unguarded handling is the primary cause. About 73.5% were initially cared for in non-trauma centers. This reflects both the poor development of health care and the attitude and understanding of the public. In South East Nigeria, there are only three centers providing spinal care for the more than 20 million population, indicating a dire need for human and material resources to cope with the problem. In addition, although specialized units are few, these are poorly used because the majority of the target population are either unaware of their existence or are uninformed about what services they provide. In a report from Enugu, most (66.4%) patients with SCI were received from private hospitals after a mean duration of 7 days. ³⁷ In addition, cost consideration in a society where health costs are borne by the individual and their families encourage primary recourse to the cheapest and not necessary the best available care, at least in the first instance. ³⁸ A combination of inadequate information and financial considerations may therefore contribute to the high proportion of secondary neuronal injuries witnessed in our patients.

The longer the delay in reaching definitive care, the worse the outcome at discharge (p<0.000). The causes of the delays were lack of awareness of the availability of specialization in medical care, desire to get the patient to a point of care as soon as possible, but unfortunately also lack of professionalism among some medical practitioners who hold onto the patients longer than necessary. This unwillingness to refer patients to different services has been noted by other workers in Nigeria and has been attributed to poor regulation and perhaps a desire to maximize profit on the part of private practitioners. ³⁹

Medical and support services have come a long way in Nigeria, but the efforts are poorly coordinated. Most hospitals have available ambulances, but none of these is designated for EMS; they are mostly used for inter- and intra-hospital transfers and movement of corpses. This is reflected in the proportion of ambulances involved in secondary transfers. A road safety service exists that provides most of the support services on the major motorways, but these are understaffed, undertrained, and underequipped.

This study has established ignorance of pre-hospital treatment of cervically injured patients in the Nigerian population and even among medical personnel. There is inadequacy of support for the spinal patients in the early secondary phase of their injuries. These result in many patients sustaining further injuries from uninformed but well intentioned volunteers, increasing morbidity and mortality (Table 5). Even secondary transfers from initial care centers were poorly coordinated without the support of trained personnel and in 64% were without any neck support. There is a need to provide ambulances with fully trained EMS personnel to work with the road safety corps.

Secondary or transit neuronal injuries are preventable if a safe mode of evacuation and early transportation to a competent center can be achieved. There is need for recognition of the problem by the health community and the provision of relevant information to responsible government bodies. Urgent training and provision of paramedical services and public enlightenment involving both the patients and caregivers is needed.

The preliminary result of this audit was presented in February 2011 to the Enugu State Ministry of Health. This helped convince the State Government to introduce an Enugu State Medical Emergency Response Team (ESMERT) in June 2011. A second audit to examine the impact of the ambulance services on limiting secondary cervical injuries is under way. As of the time of this report, 21 patients have been recruited in the follow-up audit. About six (28.6%) were transported by ambulance and rescue personnel of ESMERT, three (14.3%) were transported in ambulances manned by personal with only basic training, and the rest (57.1%) still find their way to hospitals (compared with 88.2% previously). This is disappointing, but a trend toward improvement is indicated. The major problem appears to be poor training and coordination of the service. The Enugu State Ministry of Health is still trying to source help with training of personnel.

Conclusion

The availability of response teams and the level of equipment necessary to cope with cervical spine injured patients are both lacking in many developing countries. In Nigeria, this is not entirely because of poverty and lack of investment in health but largely is because of non-availability of research data and education of those involved, including the general public, the health personnel, and the policy makers. The latter is supported by the response of the Enugu State Ministry of Health with prompt institution of ESMERT ambulance services. These preventable injuries need urgent training and provision of paramedical services and public enlightenment.