SPINAL INJURIES IN DEVELOPING COUNTRIES

In Western countries, the incidence if neurological injury accompanying spinal fractures is approximately 1 per 30,000. In the United Kingdom, therefore, there are approximately 2,000 such spinal injuries a year requiring care and rehabilitation. The trend in the United Kingdom has been to simply manage these patients with early fixation and subsequent rehabilitation. The average in-patient stay for a paraplegic patient is approximately 90 days.

Rehabilitation of these patients has revolutionised the lives of the patients in the Western world. In the 1930s paraplegia and quadriplegia was a death sentence. These patients died the most horrific and inhumane death, with severe pressure sores, chest infections, urinary infections and death from over whelming sepsis. There was no means of managing these patients at home; they would linger and die in hospitals. Following the introduction of the rehabilitation of these patients including skin care, chest care and bladder care, the lives of there patients have been transformed, as paraplegia and quadriplegia in the 1920s and 1930s would have inevitably meant death. Today, a paraplegic has a life expectancy according to the national average in the United Kingdom, and quadriplegic patients (a patient who has use of neither upper nor lower limbs) live approximately five years less than the national average life expectancy. In addition, these patients are now able to function as fully independent members of the community, earning their livelihood and making a tremendous contribution to our society.

The situation as it was in the Western world is the current situation in the majority of third world countries. Paralysis of any form immediately renders an individual incapable of earning a living, needing to be looked after by his family or neighbour, unable to provide for his family and an unfortunate inhumane death in an under- funded, under-staffed and under-educated hospital system.

A Typical Patient :

A typical patient in the third world could be a patient who is probably involved in some form of road traffic accident, usually involving a motorcycle. In this country the most common causes of injury are 50 per cent road traffic accidents, 25 per cent sports related, 25 per cent jumping off heights, with very few due to gunshot wounds. As the level of violence in a country increases, then the causes of paralysis due to gunshot wounds rise. In the United States they count for a third of all spinal injuries.

This patient would be transferred to a local community hospital, where his paralysis would be noted. If he is fortunate enough, they will have the ability to catheterise the patient, as the patient would almost inevitably be unable to void spontaneously. If unfortunate, he would go on to develop overflowing incontinence, with bladder dilation. This patient would then be put into a hospital bed in a ward for non-medical patients. He would gradually develop increasing pressure sores and recurrent bladder infections. The initial sores would be treated by local methods, including ointments while the bladder infections would be treated by antibiotics. However, as these become increasingly disabled and die of overwhelming sepsis.

Alternatively, if resources are stretched, the patient may be sent home in a wheel chair, where he becomes a social stigma. He is kept away from family and friends and dies of pressure sores and sepsis in isolation.

In Sri Lanka, for example, 27 per cent of all hospital beds are occupied by such spinal injured patients. The resource implications and the inhumanity of this situation are obvious.

What Is To Be Done?

The ICRC started a pioneering project in Peshawar, Pakistan, aimed mainly at war injures personnel from the Afghan war. Since then several countries have taken up this rehabilitation model. Resources and the ability of personnel to travel to sites that are purpose built units and to teach local physicians and carers to look after these patients is now a very straightforward procedure, having been carried out in Cambodia and also in Indonesia. It is built according to carefully organised plans. The personnel are trained by both physicians and medical staff in both acute and long term management of the patients. The first patients themselves become the occupants of a workshop which then makes orthoses and wheelchairs using local materials for the next lot of patients. The ability of these patients to be involved and run various cottage industries may also be explored. It is possible, with very little resources, to change the prognosis of these patients from that of an inhumane death to one of a different, but totally independent and fully functional member of the host community. This challenge must be taken up without delay.

"In Sri Lanka, for example, 27 per cent of all hospital beds are occupied by such spinal injured patients. The resource implications and the inhumanity of this situation are obvious”

"The governments might blame lack of financial means but we fell that most countries can offer a good quality of care with very little money. In fact every effort should be made to encourage governments and international agencies to keep down the cost of running spinal injuries centers”