Abstract

Background:  Spinal cord injury (SCI) is a life threating condition which has a profound impact in the morbidity and mortality. SCI causes lifetime sufferings and mostly occur among the young adults. Not only in Bangladesh but also worldwide, SCI is a devastating and burdensome condition. This research was conducted to see the demographic profile of SCI patients in Bangladesh.


Methods and Materials: This is a retrospective analysis where data was collected from medical records of all SCI patients admitted in between January 2012 to December 2014 from Centre for the Rehabilitation of the Paralysed (CRP), Savar.


Results: A total of 1172 SCI patients were analyzed. Most of the patients were in their second to third decade of life which consisted 28.8% (n=338). Among total respondents, 86.2% (n=1010) were male and 13.8% (n=162) were female. Most of the participants 61.1% (n=716) were from rural area. The main cause of SCI was fall from height (FFH) {45.8% (n = 537)} followed by the road traffic accidents (RTA) {24.7% (n = 288)}. Overall, 52.3% (n = 613) of participants suffered from traumatic paraplegia while 60.9% (n = 714) had complete lesion. Among the total participants, 30.70% (n = 359) of participants had skeletal level C1-C7 injury. Division-wise distribution shows that FFH is a major cause of SCI {14.84% (n = 174)} followed by the RTA which is a second most common cause in 8.95% (n = 105) of participants in Dhaka division while SCI due to bull attacks and bullet injury are a major cause in Khulna division {1.02% (n = 12)} and Chittagong division respectively.


Conclusion: The data is collected from a tertiary level of rehabilitation centre where extensive demographic data was not previously represented. In many developing countries SCI is neglected, poorly managed and deprived from society. In addition, the present study suggests that demographic factors may affect the characteristics of SCI.


Introduction

In South- Asia region Bangladesh is a developing country, with a burden of a large population which is about 160 million [1, 2, 3]. Population growth rate of Bangladesh per year 1.59 percent which includes in urban area 27% and in rural is 73%. Bangladesh is a densely over populated country where literacy rate of about 61.0% among the age of 15 years and above [4, 5]. Not only in Bangladesh but also worldwide Spinal cord injury (SCI) is a devastating and burdensome life threating condition which has a profound impact on the morbidity and mortality (1, 6, 7). SCI affects mostly young and middle-age adults, and recovery depends on the type and severity of lesion, rehabilitation time, and individual performance how effectively he/she completes every day task [8, 9]. Globally a trend has been observed that most of the traumatic spinal cord injuries occurred by fall from height or either road traffic accident [1, 3, 5]. Spinal cord injury from traumatic or non-traumatic both has a profound impact on many factors like physical, mental, domestic and social life of an individual [1, 5]. There are different type of secondary complications usually suffered by spinal cord injured patients among them pressure sore, urinary complications, sexual dysfunctions, bowel bladder problems are main among them some are preventable and some are need re-hospitalization and eventually it lead to a great deal of disability, morbidity, degree of dependence and mortality [5]. Different study has been conducted in developing and developed country to find out the cause and characteristics of SCI and it seems that it depends on geographic area and socioeconomic status. Life expectancy after SCI is markedly reduced due to secondary complication, severity of injury, social deprivation and lack of proper rehabilitation [6, 7] Evidence from 2011, Cripps et al showed global prevalence of SCI was 236 and 1,009 per million which was similar to a result found in 1995 by Blumer and Quine (about 110-1,120 per million of population) [10]. The current study was aimed to look into the demographic profile of spinal cord injury patients and also try to find out the impact factor of cause of injury in different division of Bangladesh which will help us to identify the etiology, risk factor and preventive measure.

Methods and Materials

Ethical considerations

Formal permission was taken from the physiotherapy department of Bangladesh health professions institute (BHPI) as it was an academic institute of Centre for the rehabilitation of the paralysed (CRP). At the beginning of data collection, permission was obtained from the concerned authorities ensuring the safety of the participants. All information was kept in secure. Confidentiality of the person and the information was maintained and observed and unauthorized persons did not have any access to the collected data.

Data collection

Data were collected from all admitted patients to the CRP in between January 2012 to December 2014. Patient with complete information is included in this study. Patients with incomplete information and those who are discharge on request bond (DORB) are excluded. Data that were recorded consisted of age, sex, mode of injury, diagnosis, skeletal level and American Spinal Injury Association (ASIA) Impairment Scale (AIS) [11]. Recovery was categorized as a complete and incomplete lesion. Etiology of injury was categorized into different groups like fall from height (FFH), road traffic accident (RTA), heavy object fall over head/back, are the leading cause and shallow diving water, scarf injury, bull attack, physical assault are the diverse cause. Non-traumatic causes like tuberculosis of spine (TB), transverse myelitis (TM) are associated causes of spinal cord injuries.

Setting and participants

In Bangladesh there are very few spinal injury centers. Among them CRP is recognized as the tertiary level of spinal injury center, it receives all types of spinal injury patients either directly, through referral, after surgery for rehabilitation or admitted with complex secondary complication like pressure ulcer. CRP is a well-known not for profit organization (7, 12) in Bangladesh for rehabilitation of the SCI patients. As a mother organization CRP receives referrals from different hospitals and from all over the Bangladesh for rehabilitation of the SCI patients. CRP provides acute care for SCI patients and admits approximately 390 SCI patients in each year [12]. In CRP patients pay very small amount as their income source ability but care is primarily funded by the government and not-for-profit organizations.

Analysis

After managing data properly, it was analyzed in SPSS (Statistical Package of Social Science) 16 version and Microsoft Excel Software 2007 version.

Results

Among 1172 respondents, most of the patients were in their second and third decade of age which consisted 28.8% (n=338), followed by 24.5% (n=287) in between 31-40 years and 17.8% (n=209) in between 41-50. In this study 86.2% (n=1010) were male and 13.8% (n=162) were female. 716 of the respondent 61.1% were from rural areas and 456 were from urban areas (38.9%) (Table1).

Table 1. . Distribution of demographic variables of the respondents (n=1172).
Demographic Variable Frequency Percent
Age
0-10 years 15 1.3
11-20 years 187 16.0
21-30 years 338 28.8
31-40 years 287 24.5
41-50 years 209 17.8
51-60 years 98 8.4
61-70 years 28 2.4
71-80 years 10 .9
Gender:
Male 1010 86.2
Female 162 13.8
Living Area
Rural 716 61.1
Urban 456 38.9

Out of 1172 respondents, 52.3% (n=613) had the diagnosis of traumatic paraplegia and 43.5% (n=510) had traumatic tetraplegia whereas Non-traumatic paraplegia, Non-traumatic tetraplegia was the other diagnosis having the distribution of 3.3% (39) and 0.9% (10) respectively (Table 2).

Table 2. . Distribution of diagnoses of spinal cord injury among the respondents (n=1172).
Diagnosis Frequency Percent
Traumatic paraplegia 613 52.3
Traumatic tetraplegia 510 43.5
Non traumatic paraplegia 39 3.3
Non traumatic tetraplegia 10 .9

(*TP: Traumatic paraplegia, * TT: Traumatic tetraplegia *NTP: Non traumatic paraplegia, * NTT: Non traumatic tetraplegia)

537 of the participants (45.8%) had fallen from the height (FFH) and road traffic accident (RTA) was the second common cause having the distribution of 288 patients (24.7%). 112 (9.6%) gave history of fall of object overhead and back was 106 (9%). Spinal TB was observed in 38 (3.2%), while bull attacks and physical assault were seen in 24 (2%) and 23 (2%) patients respectively. Interestingly, scarf injury and shallow diving water were observed in 13 (1.1%) and 11 (0.9%) patients respectively (Table 3).

Table 3. . Distribution of cause of spinal cord injury among the respondents (n=1172).
Cause of injury Frequency Percent
Fall from height 537 45.8
Road traffic accident 288 24.7
Fall heavy object over head 112 9.6
Fall heavy object over back 106 9.0
Spinal tuberculosis 38 3.2
Bull attack 24 2.0
Physical assault 23 2.0
Scarf injury 13 1.1
Shallow water diving 11 .9
Transverse myelitis 11 .9
Bullet injury 8 .7
Sports injury 1 .1
* FFH: Fall from height; RTA: Road traffic accident; TM: Transverse myelitis.

According this assessment table shows fall from height is the leading cause of SCI and FOH was the second most common cause according to the 1995 to 2009 assessments but after 2009 fall from height is the leading cause of SCI and RTA was the second most common cause for SCI in Bangladesh (Table 4. ).

Table 4. . Mode of injury in different studies from Bangladesh literature (n=1172).
Author Assessment Year Cause of Injury
FFH RTA FOH FOB Physical Assault Bullet injury Bull Attack
Hoque MF et al. 19 ] 1994-1995 43% 18% 20% - - - -
Islam MS et al. 20 ] Jan 2009-June 2009 50.5% 11.1% 15.2% 12.1% - - -
Abdur Razzak AT et al. 21 ] 1979 -1999 40.3% 14% 16% 9% - - -
Rahman A et al.[1] 2011-2016 45.4% 25.9% 17.8% - - 1.8%
Present study 2012-2014 45.8% 24.7% 9.6% 9.0% 2% .7% 2%
*Fall from height (FFH), Fall heavy object overhead (FOH), Fall heavy object over back (FOB), Road traffic accident (RTA)

Regarding the extent of injury, 60.9% (n=714) participants had complete lesion on admission whereas 53.2% (n=624) on discharge that are category A in ASIA scale. Category B, C, D and E had the distribution of 19.6%, 11.3%, 7.3% and .8% on admission and 12.5%, 13%, 19.2% and 2.1% on discharge respectively (Table 4).

Table 5. . Distribution of ASIA Score on Admission and During Admission of the respondents (n=1172).
ASIA On Admission During Discharge
Frequency Percent Frequency Percent
A 714 60.9 624 53.2
B 230 19.6 146 12.5
C 133 11.3 152 13.0
D 86 7.3 225 19.2
E 9 .8 25 2.1

Among the 1172 participants 30.70% (n=359) had skeletal level C1-C7, 30.10% (n=353) had skeletal level T1-T12, 22.10% (n=259) had skeletal level L1-L5 and 17.10% (n=201) had no impression was seen in magnetic resonance imaging (MRI) and x-ray view (Figure 1).

Fig 1. . Distribution of Skeletal Level on Admission of the respondents (n=1172)

Figure 2 depicts the geographical location of persons with SCI in the study. A total of 38.9% (456) of the persons with SCI were from the urban areas whereas 61.1% (716) were from rural areas. In this study among eight division most vulnerable were Dhaka 33.2% (389) then Khulna 20.4% (239). Fall from height is the major cause of SCI and second most common is Road traffic accident (Figure 2).

Fig 2. . Division-wise Distribution of the respondents (n=1172)

Discussion

Demographic studies have been conducted but the information from these studies may not be representative of the country. There is no structured health care delivery system for spinal injuries in Bangladesh. Bangladesh has not had any registry or proper demography study so far. People having spinal injury can go to any hospital of their choice for management. In this study gender, age, place of habitat and marital status were taking into consideration as demographic variables. Our study found that 86.2% (n=1010) were male and 13.8% (n=162) were female and this is usual because majority of women work remain in the home while men are exposed to work in outside activities and this result is similar with previously reported in both local [5, 13] and global [14, 13, 15] study. Most of our SCI patients are young adult injured in the second decade and third decade of life which was different from Hossain et al.’s study where the mean age was 47.44 years [16] and goel et al.’s study where the average age was 46.65 ± 16 years [6] and similar with Ulrich et al.’s study who found the mean age to be 36.1 years [17]. In our country the main cause of SCI is the fall from a significant height whereas in other countries like India, the main cause is RTA [18]. Our study is reveal that SCI is more prone to rural area rather than in urban area about 61.1% of the respondent was from rural area which is similar to Rahman et al. and Hoque et al. [1, 19]. Majority of the participants of this study had traumatic paraplegia (52.3%) and the principle cause was the fall from height (45.8%) due to large number of people connected with fruit harvesting which is important part of our agricultural economy in our country [19] and road traffic accident (24.7%) which was found to be consistent with other global literatures [13]. Scarf injury 1.1% (n=13) and bull attack 2% (n=24) are new cause of SCI where the scarf injury causes severe type of sufferings for patients with SCI which was not previously reported. Most of the SCI patients with complete spinal cord injury evident by category A in ASIA scale was noted as 60.9% which is common with Sridharan et al., Hoque et al. and Islam et al. [15, 19, 20. Most exposed trauma area of Spinal cord injury noted as C1-C7 about 30.70% (n=359) which is common with Hoque et al. [19]. The division wise distribution of person with spinal cord injury in our study revealed fall from height was the major cause {14.84% (n=174)} while the second most common cause was road traffic accident {8.95% (n=105)} in Dhaka Division whereas injury due to bull attack was a major cause of SCI in Khulna (1.02%) while bullet injury was major in Chittagong (0.34%) which are also not reported previously in Bangladesh.

Conclusion

In many parts of the developing world, SCI is neglected, socially deprived and poorly managed. The demographics pattern of SCI in the developing world is different from the developed world due to extensive research sparse and data is missing. The data collected from a tertiary level of Rehabilitation centre where demographic data was not previously represent and this data mostly represent Bangladeshi population. If it is possible to further exploration like national survey with expansion of this data can be the good statistics for government legislation and for prevention of SCI.

Supplementary information

Acknowledgments: The Authors thank to Md. Ahnaf Al Mukit for his help in data arrangement and Ecommerce Research Project 2020 for their support.

Data Archiving: There were no data to deposit.

Conflict of Interest: The authors declare no conflict of interest.

Funding: Self fund.

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