Spinal Cord diagram
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.
In the past, farmers and palm wine tappers, falling off trees, were the people who sustained spinal injuries. Today, road traffic accidents account for the majority. The injuries occur often at the time of the accident or subsequently during extrication or transfer to hospital. Neck injuries resulting in damage to the spinal cord due mostly to road traffic accidents are common problems seen in emergency departments of many hospitals in Abuja. Reports suggest same 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 or 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.
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 the moment of injury and throughout the life of the paralysed person. In many developing countries, like Nigeria, there is still a high morbidity and mortality rate of such patients because 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, cost 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.
Initial care of the spinal injured
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 are moved from different hospitals before they find the suitable hospital for treatment. A report from Enugu indicates that most patients are 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.
Not many hospitals are truly capable of managing head and neck trauma in our country because of its delicate and expert requirement. In Abuja, these include the National Hospital and Cedarcrest Hospital. Primus Hospital may also be able to manage these cases, if they have the necessary experts available on ground. Interestingly, there is little communication or cooperation between these hospitals. This is in spite of efforts to stimulate better working relations between them. Cooperation and collaboration seems to be a problem between health institutions in Nigeria. It should not be. Knowledge and facility sharing is an integral part of modern, contemporary medical practice where the welfare of the patient is the paramount focus.
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 & 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 to have neck and spinal injuries. We do not also have enough hospitals to treat the patients.
The three National Orthopaedic Hospitals (NOH) in Nigeria, namely, National Orthopaedic Hospital, Igbobi, Lagos, National Orthopaedic Hospital, Enugu and National Orthopaedic Hospital, Dala-Kano, lack adequate equipment and manpower to cope with the ever increasing number of patients that report daily to the hospitals. The facilities and manpower in these hospitals just cannot cope with the number of patients that are brought there.
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 equipment 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.
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.