SPINE: Fixed in Abuja: October 2011

SPINAL CORD INJURY:We can reduce the number of Nigerians living in wheelchairs
Posted By nigerianhealthjournal On October 12, 2011 (6:33 am) In Features, General Health, Health Promotion, Health Systems, Viewpoint

With the right care, from the right specialist and at the right time, most Nigerians with spinal cord injury; now on wheel chairs or on sick beds may have been rescued and their conditions reversed. BIODUN OGUNGBO gives an insight into spinal cord injuries and surgical intervention that gives hope about the potentials of our health system and specialists to improve the quality of life for patients with spinal cord injuries.

In the past, farmers and palm wine tapers-who usually fall off trees, were the people who sustained spinal cord injuries. These days, road traffic accidents account for the majority. Many patients have been involved in accidents where the vehicle somersaults several times. The injuries occur often at the time of the accident or subsequently during extrication or transfer to the hospital.

Neck injuries resulting in damage to the spinal cord due mostly to road traffic accidents are common problems seen in emergency departments in Abuja. Reports suggest there is an increasing occurrence in other parts of the country. There are currently no firm statistics on the scale of the problem. Most patients present with partial or complete paralysis of the arms, the legs or both. This is because the spinal cord carries all the nerves that supply movement and sensation to the rest of the body. If the cord is severely damaged, the paralysis may be permanent. This includes loss of sexual function and loss of the ability to urinate or pass stool normally.

Image showing cervical spine injury,source: Biodun Ogungbo

Spinal cord trauma is damage to the spinal cord that eventually affects every part of the body. Good outcome depends on prompt and effective care from moment of injury and throughout the life of the paralysed person. In the developing countries, including Nigeria, there is still high morbidity and mortality rate as a result of inadequate facilities and care.

In the past, most patients with neck injuries in Nigeria were managed conservatively (without operative intervention). This was because of the paucity of experts trained in managing such injuries, lack of specialised equipment and of course the high cost of treatment. The cost in managing a paralysed person includes the hospital bills, costs of a carer to look after the person, loss of income and long term rehabilitation costs. This could easily run into millions of Naira. There are also significant material and emotional costs.

Prevention is Cheaper than Cure
I got into a taxi cab recently to travel a short distance. I usually sit in front and with the seat belt fastened. On this day, the driver said, ‘Oga, no need for seat belt, na short distance we dey go’.(meaning, sir, you DO NOT need the seat belt, we are ONLY going a short distance). “So you think I’m confident in your driving?”, I asked as I make to adjust the seat belt. He laughed, nodded his head in understanding and promptly put on his own seat belt. When I seat in front like this, I am also driving with the driver, watching the road and cautioning about care on the road and the need to observe speed limits. It is the least you should do. Wear a seat belt, drive carefully and be cautious, wary of other road users. Do not let anyone drive you crazily (this includes public and private vehicles). It’s your neck.

Initial Care of the Spinal Injured

Preventing road accidents like this would reduce cases of spinal cord injuries in Nigerian especially in Abuja with an increasing rate of ghastly road accidents.

Spinal cord injury with paralysis is often associated with lifetime morbidity, so early active management is crucial. The initial care of patients with acute traumatic lesions of the neck (cervical spine) is of paramount importance. Neurologic function at both the nerve root and cord levels can be adversely affected by excessive motion of the unstable spine. Many of the patients in Nigeria have been moved from different hospitals before treatment. Most patients in a report from Enugu, Nigeria, 69 (66.4%), were received from private hospitals after a mean duration of 7 days. This increases the related morbidity and mortality. Ideally, treatment should start at the site of trauma. Safe and careful extrication, safe transportation and immobilisation in solid neck braces are crucial. It is known that following neck trauma, in-line stabilization using a hard cervical collar reduces movement of the cervical spine. These patients cannot and should not be moved without adequate protection and care.

Airway management and maintenance of spinal immobilization are important factors in limiting the risk of secondary neurological injury. Patients with spinal cord injuries may have difficulty with breathing due to this and other injuries such as head or chest trauma. Early effective and efficient management is crucial to survival. Transporting patients to hospitals with the capability to manage these cases is vital and information about these hospitals should be widely available. In Abuja, the only hospitals capable of managing head and neck trauma are Cedarcrest Hospital and the National Hospital, Abuja. One problem I have noticed is that there is little communication or cooperation between these hospitals. This is in spite of efforts to stimulate better working relations between the hospitals. The National Hospital for instance will not refer to Cedarcrest Hospital for obscure health management policies. Primus Hospital may also be able to manage these cases, if they have the necessary experts available on ground. Otherwise, they will preach transfer of the patient to India!

Diagnosis
Early diagnostic and clinical evaluations are important in determining the severity of the injury and making plans for subsequent management. Timely and appropriate imaging studies using x-rays, CT and MRI scans are essential to the cervical spine evaluation. Hospitals must be able to offer early neurological evaluation, investigation, diagnosis and surgical management to the majority of patients.

Management, manpower and resources
Research conducted in 2009 by a group of orthopaedic surgeons at the Department of Surgery University of Calabar and University of Calabar Teaching Hospital, revealed that spinal injuries occur to young and active persons in their adolescence or early adulthood. But despite the frequent occurrence of this, the sad thing is that Nigeria has inadequate man power and equipment to treat accident victims diagnosed with neck and spinal injuries. We do not also have enough hospitals to treat the patients. The three National Orthopedic Hospitals (NOH) in Nigeria, namely, National Orthopedic Hospital, Igbobi, Lagos, National Orthopedic Hospital, Enugu and National Orthopedic Hospital, Dala-Kano, lack adequate equipment and the expertise to treat the ever increasing number of patients that report daily to the hospitals.
Despite the fact that the National Hospitals cannot perform the required surgeries, they continue to accept patients instead of referring them to appropriate hospitals where they can get help early. This situation, contributes to the complications of patients, since operation on spinal injury needs to be performed within the shortest time of the accident. Such complications include pneumonia, bedsore, hyperpyrexia, urinary tract infections, and respiratory difficulty and early death.

Because of the inadequacies of the hospitals and equipments to perform the operations and rehabilitation, it has become very expensive to treat patients with this kind of condition. This is why many patients with spine problems get abandoned by their relatives because they could not afford the cost of treatment. Many families also take their patients home, where many of them later die.

Early Surgical Management
Rafeal Ode, 31, suffered a neck injury following a road traffic accident. He was paralysed immediately due to damage to his spinal cord. He was recovered from the scene of the accident and transported to hospital in good condition. There he underwent an operation within hours, which removed the pressure on his spinal cord. Six weeks later, he was able to walk with the aid of a nurse and using a walking support frame. “I spent over two million before I could get myself partially back to shape. My doctor said I was lucky, because my spinal cord was not badly damaged due to proper handling at the scene and the operation I got immediately,” he said. However, many Nigerians who have similar problems like this may not be so lucky, especially if they are poor-the reason why many are bed ridden for life while others die due to complications from the injuries. We have successfully operated on more than 30 spinal cord injury patients since 2009 with encouraging results. Some have improved beyond expectation and some remained permanently paralysed. A few have died as a result of their injuries or complications as discussed above. Of course, some have also died directly due to the operative intervention.

Conservative Management of Cervical Spinal Instability
Patients and their families have to pay for all investigations, operative interventions and acute care: the cost of a CT scan examination (CT spine) is uniformly about N40, 000 ($250 approximately) and MRI is double that (average monthly salary in Nigeria is about N20, 000 or $120 approximately). The operation cost about N1 million (One million Naira or equivalent of $6250 on average). The cost is therefore challenging for the average Nigerian. In this regards, conservative management remains a viable alternative and is often practiced. Management such as hard cervical collar, skull traction, Minerva jackets and plaster casts are sometimes used. The halo fixator has a well defined place in the management of fractures of the cervical spine. Available evidence suggests that management of upper cervical spine fracture with halo fixator is safe and effective. It is also however unavailable and unaffordable for most Nigerians.

Rehabilitation
Prolonged survival has resulted from better understanding of the pathophysiology of cord damage, as well as from the advances in antibiotic and ventilatory therapy. Regional spinal injury centers have done much to increase the survival of and quality of life of cord injured patients. Rehabilitation is also very important whether the patient has been operated or not. The importance of the role of post-injury rehabilitation cannot be over emphasised. The establishment of rehabilitation centres would go a long way in improving the social rehabilitation and survival of the patients. Some patients travelled abroad for rehabilitation. This cost on average about N20 million for 3 months of rehab. We have yet to see the benefit and that money could be better spent creating similar units here in Nigeria. There is need to congregate these patients in spinal rehabilitation centres where dedicated experts and facilities exist for improving the outcome of treatment through physical and mental rehabilitation.

You Need to know the following Facts:
The high morbidity associated with spinal cord injury could be reduced through public enlightenment on road safety measures and personal awareness. You cannot be too careful. We need to establish or refurbish spinal and trauma centres that are equipped to function. Improved outcomes can be achieved with a careful approach and multidisciplinary integrated care including improvements in intensive care and effective rehabilitation centres. This report should be a template for stimulating better understanding, care, early surgical treatment and efficient rehabilitation for this group of patients in the country as a whole.

Finally, you guessed right, I am an advocate for early surgical management.

Dr.Biodun Ogungbo is a Consultant Neurosurgeon at Cedarcrest Hospitals, Abuja and member,Editorial Board of the Nigerian Health Journal (NHJ).

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Article taken from Nigerian Health Journal - http://nigerianhealthjournal.com
URL to article: http://nigerianhealthjournal.com/?p=1447

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