Unveiling the Landscape of Traumatic Spinal Injuries in a Sub-Saharan African Setting: A Hospital-Based Cross-Sectional Study

Keywords

Cameroon - prevalence - retrospective studies - spinal cord - trauma

Introduction

Traumatic spinal injury (TSI) is a devastating neurological condition affecting the physical, psychological, and social well-being of patients, resulting in a high level of morbidity and mortality.[1] Globally, it places a challenging economic burden on its victims, close relatives, and the healthcare delivery system. This is worse in low- and middle-income countries (LMICs), where little attention is still paid to neurological pathologies despite the rise in trauma-related neurosurgical conditions in this part of the world.[2] [3] The global incidence of TSI is estimated at 10.5 cases per 100,000 persons.[4] This incidence is higher in LMICs, especially in sub-Saharan Africa, which despite the paucity of data on this pathology has an estimated incidence ranging from 13 to 75.6 cases per million population per year from extrapolated regional figures.[5] Yet, awareness of this problem and its preventability remains considerably low in LMICs such as Cameroon.[6]

The patterns of TSI vary significantly across African countries, influenced by a complex interplay of socioeconomic, cultural, and environmental factors.[7] For instance, while road traffic accidents are a leading cause of TSI in many African nations,[8] the prevalence of specific contributing factors such as the widespread use of motorbikes, enforcement of traffic laws, and availability of emergency medical services differ markedly between regions.[9] [10] In countries like South Africa, interpersonal violence is the leading cause, whereas in East African nations, MVAs and falls are notable causes.[11] [12] [13] These differences underscore the importance of region-specific studies in understanding and managing TSI effectively.

In Cameroon, the unique socio–cultural landscape, such as the high reliance on commercial motorized two-wheeled vehicles termed “bend skins” for transportation in the Southwest region (SWR), combined with varying levels of healthcare infrastructure and emergency response systems across the country, creates a distinct pattern of TSI that may not be fully captured by studies from other African regions.[14] [15] Additionally, physical factors like the diverse topography and the presence of conflict zones in certain areas further differentiate Cameroon's TSI landscape from that of other countries. As such, generating data specific to Cameroon is crucial, as it provides insights that are directly applicable to the local context, enhancing the ability to design targeted interventions and policies.[16] These localized data are more valuable for Cameroon's healthcare planning and resource allocation than extrapolating findings from studies conducted in other African countries, which may not reflect the unique challenges and needs of the Cameroonian population.

This study aimed to provide an overview of the prevalence and sociodemographic, prehospital, etiological, and clinical patterns of TSIs in Cameroon, with a focus on the major referral hospitals in one of the two English-speaking regions of the country, the SWR.

Materials and Methods

Study Design

We conducted a hospital-based cross-sectional study, with a retrospective collection of data on the prevalence, patterns, and clinical profile of TSI from the Buea Regional Hospital (BRH) and Limbe Regional Hospital (LRH) health databases over a 5-year period (January 1, 2017–December 31, 2021).

Study Area and Setting

This study was conducted at the surgical departments of the BRH, and LRH in SWR of Cameroon, with a population estimated at 1,534,232 inhabitants as of 2015.[17] Both hospitals are semi-urban, teaching hospitals in sub-Saharan Africa.[18] During our study period, both hospitals served as major referral centers for complex trauma pathologies, including head and spine trauma. This is due to the availability of trauma surgeons, and a neurosurgeon at both institutions and the BRH, respectively. Both hospitals offer similar services, including fully operational physical therapy and rehabilitation centers experienced in managing neurological, orthopedic, and chest pathologies for both admitted and outpatients. Both hospitals lacked functional magnetic resonance imaging at the time of our study. The LRH disposed of the only intensive care unit and computed tomographic scanner available in the entire region during our study period.

Study Population

This study included patients who were admitted and managed for TSI in the above-mentioned hospitals, within the indicated study time frame. All TSI patient files were included and files without the diagnosis of TSI were excluded. Also, missing files were excluded from further analysis.

Data Collection

During this study, a retrospective review of the above-mentioned hospital's surgical department's health databases was done. Only the files of patients meeting our inclusion criteria were retained from which data was collected. The following set of data was extracted: sociodemographic and prehospital characteristics, and etiological and clinical profiles. Regarding prehospital characteristics, nonmedicalized transportation was defined as a transportation method that lacks trained medical personnel or essential prehospital care equipment, such as private cars, motorcycles, taxis, or other informal transport options. This contrasts with medicalized transport, which includes ambulances staffed with healthcare providers and equipped for emergency medical interventions. A prestructured data collection form was developed on Google Forms (Google, USA; [Supplementary Tables S1]–[S3], available in the online version). The form was then piloted using five files of TSI patients admitted at the study sites to ensure usability and technical functionality.

Data Management and Analysis

All data collected was coded and stored on Google Drive in a password-protected account. The data was exported to SPSS v26 for analysis. We calculated the hospital prevalence of TSI and analyzed patterns of injury. The chi-square test was used to assess the relationship between time of presentation and mode of presentation. Descriptive statistics were used to summarize the demographic and clinical characteristics of TSI patients. Descriptive analysis was performed using frequencies and their respective proportions for categorical variables and means (and standard deviation) for continuous variables or using frequencies and percentages after categorizing them using predefined cutoffs. Bivariable relationships were done where appropriate with the chi-square or Fisher exact test. Confidence intervals (CIs) were reported for key prevalence estimates and proportions. A p-value of <0.05 was considered statistically significant, and the results were illustrated in tables and figures.

Results

Prevalence and Socio-Demographic Characteristics

During our study period, we recorded 7,508 admissions in the surgical wards (4,157 at LRH and 3,351 at BRH). We identified 74 hospital admissions for TSI (24 at LRH and 50 at BRH), giving us a hospital prevalence of 1% (95% CI: 0.8–1.2%; 0.6% [95% CI: 0.4–0.9%] at LRH and 1.5% [95% CI: 1.1–2.0%] at BRH). There was a progressive increase in the number of TSI admissions, with a more than threefold increase during the study period. Variations in prevalence between LRH and BRH were observed ([Table 1]). Two case files on TSI were missing, so 72 (97.3%) cases were eligible for inclusion and further analysis. The mean age of affected patients was 38.58 ± 16.0 years, and they were mostly within the early adult (25–44 years) age group (n = 40; 55.6%; 95% CI: 43.4–67.1%; [Table 1]). Most affected were males (n = 57; 79.2%; 95% CI: 67.7–87.5%), and those who had agriculture as an occupation (n = 22; 30.6%; 95% CI: 67.7–87.5%; [Table 1]). The majority were married (n = 39; 54.2%; 95% CI: 42.1–65.8%) and lived outside Limbe and Buea municipalities (n = 51; 70.8%; 95% CI: 58.8–80.7%; n = 52; 72.2%; 95% CI: 60.2–81.8%; [Table 1]).

Table 1 Sociodemographic characteristics of patients with traumatic spinal injuries at the Limbe and Buea Regional Hospitals

Variable	Limbe Regional Hospital (n = 23)		Buea Regional Hospital (n = 49)		Both hospitals (n = 72)
	Frequency (percentage, %)	95% CI (%)	Frequency (percentage, %)	95% CI (%)	Frequency (percentage, %)	95% CI (%)
Gender
Male	16 (69.6)	47.0–85.9	41 (83.7)	69.8–92.2	57 (79.2)	67.7–87.5
Female	7 (30.4)	14.1–53.0	8 (16.3)	7.8–30.2	15 (20.8)	12.5–32.3
Age group[a]
Pediatric	1 (4.3)	0.2–24.0	2 (4.1)	0.7–15.1	3 (4.2)	1.1–12.5
Adolescent	2 (8.7)	1.5–29.5	5 (10.2)	3.8–23.0	7 (9.7)	4.3–19.6
Early adult	14 (60.9)	38.8–79.5	26 (53.1)	38.4–67.2	40 (55.6)	43.4–67.1
Late adult	4 (17.4)	5.7–39.5	10 (20.4)	10.7–34.8	14 (19.4)	11.4–30.8
Elderly	2 (8.7)	1.5–29.5	6 (12.2)	5.1–25.5	8 (11.1)	5.3–21.3
Occupation[b]
Agriculture	1 (4.3)	0.2–24.0	21 (42.9)	29.1–57.7	22 (30.6)	20.5–42.7
Professional	6 (26.1)	11.1–48.7	5 (10.2)	3.8–23.0	11 (15.3)	8.2–26.1
Transportation	1 (4.3)	0.2–24.0	5 (10.2)	3.8–23.0	6 (8.3)	3.4–17.9
Clerical	0 (0.0)	0.0–17.8	1 (2.0)	0.1–12.2	1 (1.4)	0.1–8.5
Manual labor	0 (0.0)	0.0–17.8	1 (2.0)	0.1–12.2	1 (1.4)	0.1–8.5
Household	0 (0.0)	0.0–17.8	2 (4.1)	0.7–15.1	2 (2.8)	0.5–10.6
Unemployed	0 (0.0)	0.0–17.8	3 (6.1)	1.6–17.9	3 (4.2)	1.1–12.5
Managing	2 (8.7)	1.5–29.5	0 (0.0)	0.0–9.1	2 (2.8)	0.5–10.6
Student	2 (8.7)	1.5–29.5	5 (10.2)	3.8–23.0	7 (9.7)	4.3–19.6
Sales	4 (17.4)	5.7–39.5	2 (4.1)	0.7–15.1	6 (8.3)	3.4–17.9
Construction	3 (13.0)	3.4–34.7	2 (4.1)	0.7–15.1	5 (6.9)	2.6–16.1
Athlete	0 (0.0)	0.0–17.8	1 (2.0)	0.1–12.2	1 (1.4)	0.1–8.5
Unspecified	4 (17.4)	5.7–39.5	0 (0.0)	0.0–9.1	4 (5.6)	1.8–14.3
Marital status
Married	15 (65.2)	42.8–82.8	24 (49.0)	34.6–63.5	39 (54.2)	42.1–65.8
Single	4 (17.4)	5.7–39.5	21 (42.9)	29.1–57.7	25 (34.7)	24.1–46.9
Widow(er)	2 (8.7)	1.5–29.5	2 (4.1)	0.7–15.1	4 (5.6)	1.8–14.3
Unspecified	2 (8.7)	1.5–29.5	0 (0.0)	0.0–9.1	2 (2.8)	0.5–10.6
Residence
Limbe	8 (34.8)	17.2–57.2	5 (10.2)	3.8–23.0	13 (18.1)	10.3–29.3
Outside limbe	8 (34.8)	17.2–57.2	43 (87.8)	74.5–94.9	51 (70.8)	58.8–80.7
Buea	1 (4.3)	0.2–24.0	10 (20.4)	10.7–34.8	11 (15.3)	8.2–26.1
Outside Buea	15 (65.2)	42.8–82.8	37 (75.5)	60.8–86.2	52 (72.2)	60.2–81.8
Unspecified	7 (30.4)	14.1–53.0	1 (2.0)	0.1–12.2	8 (11.1)	5.3–21.3
Yearly cases[c]
2021	3 (12.5)		19 (38.0)		22 (28.4)
2020	6 (25.0)		15 (30.0)		21 (28.4)
2019	8 (33.3)		4 (8.0)		12 (16.2)
2018	5 (20.8)		7 (14.0)		12 (16.2)
2017	2 (8.3)		5 (10.0)		7 (9.4)

^a Age group was classified according to generation.

^b Occupation was classified according to the International Standard Classification of Occupations.

^c Limbe Regional Hospital (n = 24), Buea Regional Hospital (n = 50).

Prehospital Characteristics

Overall, most patients presented with greater than 24 hours of prehospital delay (n = 31; 43.1%), and were referred from another health facility (n = 35; 48.6%; [Table 2]). There was a statistically significant association between the mode of presentation and the timing of the presentation. Eighty percent (n = 16) of patients who presented directly to the LRH and BRH following their injury, presented less than 24 hours following the injury, while 87% (n = 20) of those presenting as a referral from another health facility presented within or beyond 24 hours after the injury (p < 0.001; [Fig. 1]). All patients (100%) in our study used a nonmedicalized mode of transportation from the site of injury to the nearest hospital (this includes those who presented directly to both hospitals following injury). Of those who presented as referrals, fifteen (42.8%) used a medicalized means of transportation from the referring hospital.

Table 2 Prehospital delay, mode of presentation, and etiologies of traumatic spinal injury at the Buea and Limbe Regional Hospitals

Variable	Limbe Regional Hospital		Buea Regional Hospital		Both hospitals
	Frequency (n = 23)	Percentage (%)	Frequency (n = 49)	Percentage (%)	Frequency (n = 72)	Percentage (%)
Time range before admission
<1 h	5	21.7	2	4.1	7	9.7
1 to <6 h	4	17.4	3	6.1	7	9.7
6 to <24 h	0	0.0	5	10.2	5	6.9
24 to <72 h	2	8.7	9	18.4	11	15.3
72 h to <1 wk	1	4.3	9	18.4	10	13.9
≥1 wk	1	4.3	9	18.4	10	13.9
Nonspecific	10	43.5	12	24.5	22	30.6
Mode of admission
Direct presentation following injury	18	78.3	11	22.4	29	40.3
Referral from another health facility	4	17.4	31	63.3	35	48.6
Delayed presentation following injury	0	0.0	4	8.2	4	5.6
Unspecified	1	4.3	3	6.1	4	5.6
Etiology of injury
Falls	8	34.8	23	46.9	31	43.1
Motor vehicular accidents	9	39.1	14	28.6	23	31.9
Assault	2	8.7	2	4.1	4	5.6
Gunshot	1	4.3	3	6.1	4	5.6
Struck by a falling object	1	4.3	3	6.1	4	5.6
Sports accident	1	4.3	0	0.0	1	1.4
Others	1	4.3	2	4.1	3	4.2
Unspecified	0	0.0	2	4.1	2	2.8

Fig. 1 Association between the mode of admission and timing of presentation of patients with traumatic spinal injury at the Buea and Limbe Regional Hospitals (p < 0.001).

Etiological Profile

Overall, falls were the most prevalent etiology (n = 31; 43.7%) followed by MVAs (n = 23; 31.9%; [Table 2]). This trend was similar across most age groups, except in the elderly age group where MVAs were twice as common as falls, compared with the other groups (except for pediatric patients), where falls predominated. However, there was no statistical significance between the etiology of TSI and the age group in our study (p = 0.476; [Supplementary Tables S1]–[S3], available in the online version). Falls were the most common etiology among males (n = 27; 47.4%) while MVAs predominated among females (n = 6; 40.0%; [Fig. 2]).

Fig. 2 Gender differences in etiologies of traumatic spinal injury at the Limbe and Buea Regional Hospitals.

For all patients with MVAs as etiology, none of the patients used seat belts/protective helmets, the most common mechanism of MVAs was loss control of vehicles (n = 7; 30.4%), and the majority of the injured were drivers/riders (n = 9; 39.1%; [Supplementary Tables S1]–[S3], available in the online version).

Clinical Patterns

The cervical spine was the most affected (n = 32; 44.4%), followed by the lumbar spine (n = 21; 29.2%; [Table 3]). Forty (55.6%) patients had an associated injury, of which head and soft tissue injuries were the most common (n = 14; 19.4%; n = 13; 18.1%; [Table 3]). On admission, Frankel's A and D (n = 17; 23.6% each) were the leading trends, similar to incomplete TSI (n = 48; 66.7%). Clinical signs nonspecific to SCI were common ([Table 3]).

Table 3 Clinical characteristics of patients with traumatic spinal injuries at the Buea and Limbe Regional Hospitals

Variable	Frequency (n = 72)	Percentage (%)
Level of vertebral injury
Cervical	32	44.4
Thoracic	8	11.1
Thoracolumbar	3	4.2
Lumbar	21	29.2
Lumbosacral	3	4.2
Unspecified	5	6.9
Completeness of injury
Complete	17	23.6
Incomplete	48	66.7
Unspecified	7	9.7
Initial Frankel grade
Frankel A	17	23.6
Frankel B	8	11.1
Frankel C	7	9.7
Frankel D	17	23.6
Frankel E	12	16.7
Unspecified	11	15.3
Associated injuries[a]
Head injury	14	19.4
Soft tissue injury	13	18.1
Chest wall injury	5	6.9
Upper limb fracture	4	5.6
Lower limb fracture	1	1.4
Pneumothorax	2	2.8
Haemothorax	3	4.2
Lung contusion	3	4.2
Lung collapse	1	1.4
Radiculopathy	2	2.8
Haemoperitoneum	1	1.4
Pelvic fracture	1	1.4
None	32	44.4
Clinical presentation
Paraparesis	13	18.1
Paraplegia	22	30.6
Tetraparesis	5	6.9
Tetraplegia	11	15.3
Neck pain	20	27.8
Back pain	35	48.6
Urinary/fecal incontinence	4	5.6
Urinary/fecal retention	12	16.7
Hypoaesthesia	3	4.2
Anesthesia	15	20.8
Hyperaesthesia	1	1.4
Paraesthesia	2	2.8
Hemiplegia	1	1.4
Hemiparesis	1	1.4
Hyperreflexia	2	2.8
Hyporeflexia	6	8.3
Areflexia	5	6.9
Dyspnoea	1	1.4
Muscle spasm	1	1.4
Unspecified	2	2.8

^a Each patient had one, two (11 patients), or no associated injuries.

Discussion

This is, to the best of our knowledge, the first of the multiple published studies on trauma in the SWR of Cameroon that detailly describes TSI. Our findings provide novel knowledge that could be of importance to healthcare providers, and public health experts in this region, other regions of Cameroon, and other LMICs.

Key Finding

The hospital prevalence of TSI in Southwest Cameroon was 1%, and the number of cases kept increasing over the years. Males, the “early adult (25–44 years)” age group, farmers, married individuals, and those living out of Buea and Limbe, were the most affected. The majority of patients presented after 24 hours postinjury, as a referral, and using a nonmedicalized means of transportation. There was a significant association between the mode of presentation and the timing of the presentation. Falls were the leading cause of injury, followed by MVAs. The cervical and lumbar spines were mostly affected; most patients had an incomplete TSI on admission, with Frankel's grades A and D having the same predominance. Head and soft tissue injuries were commonly associated.

Implications

Prevalence of Traumatic Spinal Injuries at the Limbe and Buea Regional Hospitals

The hospital prevalence of TSI in our study is lower compared with other studies performed in the Yaounde urban area, and other sub-Saharan countries.[11] [19] [20] [21] [22] This can be explained by the poor awareness, attitudes, and beliefs toward access to neurosurgical care in this part of the country, limiting the number of patients who seek hospital care for this pathology.[23] Also, some cases might have been missed given the nature of our study design. This can be due to death at the scene of an injury or in the prehospital phase, which may have been missed due to the lack of organized national registries that register prehospital deaths as is the case in high-income countries, which reported approximately 53% of prehospital deaths with TSI.[24] [25] Thus, the prevalence in our study could be a reflection of a much bigger problem.

Sociodemographic Patterns of Traumatic Spinal Injuries at the Limbe and Buea Regional Hospitals

The preponderance of males in the young adult age group in this study is in accordance with most studies from LMICs.[5] [26] In Cameroon and most African countries, younger males are considered stronger and safer to undertake activities such as tree climbing to harvest fruits and firewood than the older men, and women who take part in less risky activities.[27] [28] Also, they are more likely to be involved in using transportation resources on a daily basis compared with the elderly and females amidst the poor quality of existing road infrastructure. This pattern of TSI sidelines working-aged males who are no longer able to pursue their careers, provide income for their families, and/or contribute to the national economy. Most patients in our study were married, thus highlighting disturbances in the sexual behavior and function of the patient, which adds to the negative impact afflicted by TSI.[29] Agriculture, the most prevalent occupation in our study, is the mainstay of Cameroon's economy.[30] Despite the fact that those affected by TSI may not be significant relative to all those involved in agriculture in the SWR of Cameroon, this nevertheless highlights how trauma could influence the national economy of LMICs if proper trauma systems are not in place.[31] All this therefore highlights the need for inter-ministerial cooperation in addressing this pressing public health issue.

Prehospital Characteristics of Traumatic Spinal Injuries at the Limbe and Buea Regional Hospitals

The delayed presentation (majority presenting within or more than 24 hours of injury) in our study was more common amongst those who presented as a referral. This finding is similar to that reported by Bello et al, in the Yaounde urban area.[20] Malomo et al, also reported delayed referral, and far distance from the site of TSI to the neurosurgical center as the main causes of delayed presentation in Nigeria.[32] Despite reports from multiple authors of well-defined referral systems in Cameroon, this delay could be a result of inadequate implementation of this system in this region of Cameroon.[33] Cameroon's referral system is more hospital-based than prehospital-driven.[34] [35] This means that patients are usually transferred to a specialized center after first presenting at a lower-level health facility. Also, at the time of our study, most district hospitals in the SWR of Cameroon lacked neurosurgical expertise, emergency transport services, or advanced imaging capabilities, forcing patients to rely on nonmedicalized transport to reach regional referral hospitals. This contrasts with well-structured trauma systems in HICs nation, where dedicated prehospital and emergency medical services play an important role in early stabilization and rapid transfer. Delayed referral could also be a result of nonrecognition of the disease entity at the primary health care center, a lack of funds, or poor road infrastructure.[36] This can be improved by establishing neurosurgical centers with extensions at the district level and improving communication between health facilities. This is in addition to increasing the workforce, and infrastructure, and upgrading to a cost-effective medicalized referral system, given that in our study, most referred patients used a nonmedicalized means of transportation from the referring hospital.[37] [38] [39] Also, hands-on training of primary health care providers on the early recognition through standardized triage protocols and initial management of this pathology with the help of local and national surgical and neurosurgical organizations.[40] [41]

Etiological Patterns of Traumatic Spinal Injury at the Limbe and Buea Regional Hospitals

The results regarding the two most common etiologies in this study are in line with studies from sub-Saharan Africa.[5] As in our case, falls predominated over MVAs in fewer studies on the topic of LMICs.[22] [42] Also, most of them were from trees and, most patients with TSI were farmers. Given that studies from LMICs have shown that fall injuries result predominantly as a result of falls from trees, there is therefore a need to regulate the adoption of already established safety measures when climbing trees by the local authorities.[43] [44] Also, given the sociocultural aspects of this etiology, educating this population and encouraging involvement in safer sociocultural activities is important.[45] The lower proportion of falls as a leading cause of TSI in older adults in our study contrasts with global epidemiological trends, where falls predominate as etiology in this age group.[46] Studies conducted in high-income countries have reported falls as the leading cause of spinal trauma among the elderly, linking this to age-related factors such as osteoporosis (leading to fragility fractures), decreased balance, and frailty.[47] Despite the aforementioned trend, our study could not draw significant conclusions given the paucity of elderly patients included in this study. MVAs are the second leading etiology, of which none of the victims in this study used helmets nor seatbelts in a region where the nature of the roads is below standards.[48] The joint prevalence of poor adherence to road safety measures and poor road infrastructure faced by the SWR of Cameroon, further adds to existing evidence of the multidimensional nature of trauma-related pathologies in low-resource settings.[31] This highlights the importance of enforcing the adoption of road safety measures, improvements to the road infrastructure, and other multifaceted interventions enforced in Cameroon.[49]

Clinical Patterns of Traumatic Spinal Injuries at the Limbe and Buea Regional Hospitals

The predominance of cervical spine injuries in our study is similar to findings from both HICs and LMICs.[50] This forecasts the importance of improving attitudes toward neurosurgical care in the SWR of Cameroon. The “American Spinal Injury Association Impairment Scale” is considered the international gold standard to assess the severity of TSI due to its superiority over Frankel's grading system. However, the latter is still widely used in Cameroon.[20] [51] Patients with a higher initial Frankel grade are more likely to have a high in-hospital mortality rate and a poor neurological outcome, according to global findings.[52] TSI may present differently depending on the level and severity of the injury,[53] and an associated injury involving another system or region of the body may delay the diagnosis.[54] This finding and the fact that some of the clinical manifestations in this study were nonspecific, add to the existing body of evidence on the need for all health practitioners in the emergency department to assess all trauma patients using the Advanced Trauma Life Support Algorithm and spine trauma assessment guidelines.[55] The predominance of paraplegia over tetraplegia is consistent with reports from LMICs, and from sub-Saharan Africa.[56] This can be explained by the high proportion of noncervical spine injuries in our study.

Limitations and Strength

This is a hospital-based study that relies on medical records; hence, it is not completely representative of the total population, as not all patients with TSI presented at the health institutions where our study was performed. Some may have been referred to different towns such as Douala, or deceased without the diagnosis made, especially in the context of polytrauma. Our study, which uses a retrolective cross-sectional design, could not appreciate important fine details of the prehospital management of the patients, such as; reliable information on care at the site of injury, and timing from referral to admission. Also, some data in the patient's files were missing, incomplete, or poorly registered. The multicenter approach of our study, which included the only two centers that manage TSI, gave us an overview of the hospital prevalence and patterns of TSI in Southwest Cameroon. The use of ward registers helped us to have a real estimate of admitted patients for TSI, which could not have been accounted for by missing medical records.

Conclusion and Future Directions

Our study gives an appraisal of the TSI in the SWR of Cameroon. TSI is a significant but underrecognized health issue in the SWR of Cameroon. The working population, especially those engaged in agricultural activities and who reside far from a health facility with the minimum neurosurgical infrastructure and workforce, was disproportionately affected. The prehospital delay was long, especially for referred patients, who mostly use nonmedicalized modes of transportation. The most common etiologies of TSI in the SWR of Cameroon were falls, followed by MVAs in the context of nonadoption of occupational, and road safety measures. The cervical and lumbar spines were mostly affected, and the most common pattern of the severity of neurological injury on admission was Frankel's grades A and D. Associated injuries and clinical signs nonspecific to SCI were common.

These findings highlight the burden of TSI in Southwest Cameroon and underscore the need for targeted interventions to improve early recognition, prehospital care, and prevention strategies tailored to the region's unique socio–cultural and economic context. Strategies and policies focusing on raising awareness about safety measures, including the use of protective equipment when climbing heights, and safe transportation practices, could help mitigate the incidence of TSI. Additionally, efforts could be made to improve prehospital care and reduce delays in seeking medical attention, as early intervention is crucial for optimal outcomes in TSI cases. Also, efforts should be made to regularly educate staff on trauma assessment guidelines to help with the early identification of TSI. Moreover, more health strategies and inter-ministerial collaborations aimed at strengthening the surgical, trauma, and neurosurgical systems in Cameroon should be put in place. Lastly, future research could explore management approaches and their impact on patient outcomes in this setting.

• References

• 1 Wang TY, Park C, Zhang H. et al. Management of acute traumatic spinal cord injury: a review of the literature. Front Surg 2021; 8: 698736
• 2 Oyemolade TA, Adeleye AO, Ehinola BA, Olusola AJ, Ekanem IN, Adesola DJ. Neurotrauma: a burgeoning, yet understudied disease of rural areas in developing countries. J Neurosurg 2022; 138 (04) 1069-1076
• 3 Veerappan VR, Gabriel PJ, Shlobin NA. et al. Global neurosurgery in the context of global public health practice–a literature review of case studies. World Neurosurg 2022; 165: 20-26
• 4 Kumar R, Lim J, Mekary RA. et al. Traumatic spinal injury: global epidemiology and worldwide volume. World Neurosurg 2018; 113: e345-e363
• 5 Jesuyajolu D, Ayantayo T, Oyesiji E. et al. Burden of traumatic spinal cord injury in sub-Saharan Africa: a scoping review. World Neurosurg 2023; 179: 216-221.e2
• 6 Mbiydzenyuy NE, Pieme CA, Brown RE, Nguemeni C. Neuroscience education and research in Cameroon: current status and future direction. IBRO Neurosci Rep 2021; 10: 216-224
• 7 Alayande B, Chu KM, Jumbam DT. et al. Disparities in access to trauma care in sub-Saharan Africa: a narrative review. Curr Trauma Rep 2022; 8 (03) 66-94
• 8 Kassahun Bekele B, Boluwatife Samuel F, Soufan F. et al. Acute spinal cord injury in Africa: exploring the long-term outcomes and future directions of acute spinal cord injury - short communication. Ann Med Surg (Lond) 2023; 85 (12) 5847-5851
• 9 Cholo W, Odero W, Ogendi J. The burden of motorcycle crash injuries on the public health system in Kisumu City, Kenya. Glob Health Sci Pract 2023; 11 (01) e2200197
• 10 Oltaye Z, Geja E, Tadele A. Prevalence of motorcycle accidents and its associated factors among road traffic accident patients in Hawassa University Comprehensive Specialized Hospital, 2019. Open Access Emerg Med 2021; 13: 213-220
• 11 Joseph C, Delcarme A, Vlok I, Wahman K, Phillips J, Nilsson Wikmar L. Incidence and etiology of traumatic spinal cord injury in Cape Town, South Africa: a prospective, population-based study. Spinal Cord 2015; 53 (09) 692-696
• 12 Löfvenmark I, Mogome W, Sekakela K. Outcomes 10-years after traumatic spinal cord injury in Botswana - a long-term follow-up study. Spinal Cord Ser Cases 2024; 10 (01) 57
• 13 Zuckerman SL, Haghdel A, Lessing NL. et al. Cervical spine trauma in East Africa: presentation, treatment, and mortality. Int J Spine Surg 2021; 15 (05) 879-889
• 14 ErickTandi T, Kim K, Gilbert TN. et al. Motorcycle-related head and limbs injuries from road traffic accident at a second-level hospital in Cameroon. J Prev Med Care 2019; 2 (03) 20-28
• 15 Nyagwui AE, Fredinah N, Che LB, Yulia B. Motorcycle injury among secondary school students in the Tiko municipality, Cameroon. Pan Afr Med J 2016; 24 (116) 116
• 16 Kanmounye US, Nguembu S, Djiofack D. et al. Patient attitudes toward neurosurgery in low- and middle-income countries: a systematic review. Neurol India 2021; 69 (01) 12-20
• 17 South-West - Cameroon | data and statistics - knoema.com. Knoema. Accessed June 18, 2024 at: https://knoema.com//atlas/Cameroon/South-West
• 18 Health in Cameroon. In: Wikipedia.; 2021. Accessed June 18, 2024 at: https://en.wikipedia.org/w/index.php?title=Health_in_Cameroon&oldid=998938516
• 19 Barbiellini Amidei C, Salmaso L, Bellio S, Saia M. Epidemiology of traumatic spinal cord injury: a large population-based study. Spinal Cord 2022; 60 (09) 812-819
• 20 Bello F, Oumarou H, Nchufor RN. et al. Aspects diagnostiques, thérapeutiques et pronostiques des traumatismes du rachis à yaoundé. Health Sci Dis 2020; 21 (12)
• 21 Ibikunle P, Okoro EO. A fifteen years retrospective study of spinal cord injury in South-eastern Nigeria. In: 2018. Accessed June 18, 2024 at: https://www.semanticscholar.org/paper/A-Fifteen-Years-Retrospective-Study-of-Spinal-Cord-Ibikunle-Okoro/4370b5dce72c17258f9203a6db2a1e8bec786711
• 22 Moshi H, Sundelin G, Sahlen KG, Sörlin A. Traumatic spinal cord injury in the north-east Tanzania - describing incidence, etiology and clinical outcomes retrospectively. Glob Health Action 2017; 10 (01) 1355604
• 23 Ikwuegbuenyi CA, Umutoni A, Atabe Ngwene NN. et al. Public awareness, knowledge of availability, and willingness to use neurosurgical care services in Sub-Saharan Africa: a cross-sectional study. PLoS One 2022; 17 (03) e0264955
• 24 Ackery A, Tator C, Krassioukov A. A global perspective on spinal cord injury epidemiology. J Neurotrauma 2004; 21 (10) 1355-1370
• 25 Vlayen A, Marquet K, Schrooten W. et al. Design of a medical record review study on the incidence and preventability of adverse events requiring a higher level of care in Belgian hospitals. BMC Res Notes 2012; 5: 468
• 26 Rahimi-Movaghar V, Sayyah MK, Akbari H. et al. Epidemiology of traumatic spinal cord injury in developing countries: a systematic review. Neuroepidemiology 2013; 41 (02) 65-85
• 27 Culture of Cameroon - history, people, clothing, traditions, women, beliefs, food, customs, family. Accessed June 18, 2024 at: https://www.everyculture.com/Bo-Co/Cameroon.html
• 28 Ingram V, Schure JM, Tieguhong JC, Ndoye O, Awono A, Iponga DM. Gender implications of forest product value chains in the Congo basin. For Trees Livelihoods 2014; 23 (1–2): 67-86
• 29 Hess MJ, Hough S. Impact of spinal cord injury on sexuality: broad-based clinical practice intervention and practical application. J Spinal Cord Med 2012; 35 (04) 211-218
• 30 Food and agriculture. Accessed June 18, 2024 at: https://cameroon.panda.org/our_work/food_and_agriculture/
• 31 Wesson HKH, Boikhutso N, Bachani AM, Hofman KJ, Hyder AA. The cost of injury and trauma care in low- and middle-income countries: a review of economic evidence. Health Policy Plan 2014; 29 (06) 795-808
• 32 Malomo TA, Oyemolade TA, Adeleye AO. Determinants of timing of presentation of neurotrauma patients to a neurosurgical center in a developing country. J Neurosci Rural Pract 2018; 9 (04) 545-550
• 33 Agoubi L, Carvalho M, Fewer S. et al. Integrating political prioritisation into national surgical planning: a scoping review of surgical, obstetric and anaesthesia care in Cameroon. BMJ Glob Health 2024; 9 (12) e014730
• 34 O'Connor K, Driban M, Oke R. et al. Bystander intervention is associated with reduced early mortality among injury victims in Cameroon. PLOS Glob Public Health 2024; 4 (07) e0002875
• 35 Ngekeng S, Kibu O, Oke R. et al. Prehospital factors associated with mortality among road traffic injury patients: analysis of Cameroon trauma registry data. BMC Emerg Med 2024; 24 (01) 194
• 36 Mansouri A, Chan V, Njaramba V, Cadotte DW, Albright AL, Bernstein M. Sources of delayed provision of neurosurgical care in a rural Kenyan setting. Surg Neurol Int 2015; 6: 32
• 37 Accorsi S, Somigliana E, Solomon H. et al. Cost-effectiveness of an ambulance-based referral system for emergency obstetrical and neonatal care in rural Ethiopia. BMC Pregnancy Childbirth 2017; 17 (01) 220
• 38 Heng YW, Yiek SH, Tan BP, Yap NKB. Review of neurosurgical services in a rural area of Sarawak, Malaysia: the benefits, prospects and challenges. Interdiscip Neurosurg 2022; 28: 101490
• 39 Kah E, Bate GN. Socio-economic impact of tarring the Cameroon section of the Lagos-Mombasa trans-African highway through Mamfe in Manyu division. Open J Soc Sci 2020; 8 (08) 393-411
• 40 Kanmounye US, Mbonda AN, Djiofack D, Daya L, Pokam OF, Ghomsi NC. Exploring the knowledge and attitudes of Cameroonian medical students towards global surgery: a web-based survey. PLoS One 2020; 15 (04) e0232320
• 41 Kanmounye US, Zolo Y, Nguembu S. et al. Training the next generation of academic global neurosurgeons: experience of the association of future African neurosurgeons. Front Surg 2021; 8: 631912
• 42 Lee BB, Cripps RA, Fitzharris M, Wing PC. The global map for traumatic spinal cord injury epidemiology: update 2011, global incidence rate. Spinal Cord 2014; 52 (02) 110-116
• 43 Ajns – african journal of neurological sciences | » traumatismes secondaires à la chute du haut d'un arbre. Accessed June 18, 2024 at: https://ajns.paans.org/traumatismes-secondaires-a-la-chute-du-haut-dun-arbre/
• 44 Preventing falls from trees for trainers and supervisors. Accessed June 18, 2024 at: https://ohioline.osu.edu/factsheet/aex-892242
• 45 Durowaiye BE, Khan S. The relativity of socio-cultural factors on young people's access to higher education Africa. S Afr J High Educ 2017; 31 (05) 31-48
• 46 Lu Y, Shang Z, Zhang W. et al. Global incidence and characteristics of spinal cord injury since 2000-2021: a systematic review and meta-analysis. BMC Med 2024; 22 (01) 285
• 47 Sunder A, Chhabra HS, Aryal A. Geriatric spine fractures - Demography, changing trends, challenges and special considerations: a narrative review. J Clin Orthop Trauma 2023; 43: 102190
• 48 Needs assessment report: South-west region, Cameroon - July 2018 - Cameroon | reliefweb. November 9, 2018. Accessed June 18, 2024 at: https://reliefweb.int/report/cameroon/needs-assessment-report-south-west-region-cameroon-july-2018
• 49 Staton C, Vissoci J, Gong E. et al. Road traffic injury prevention initiatives: a systematic review and metasummary of effectiveness in low- and middle-income countries. PLoS One 2016; 11 (01) e0144971
• 50 Kang Y, Ding H, Zhou H. et al. Epidemiology of worldwide spinal cord injury: a literature review. J Neurorestoratology 2018; 6 (01)
• 51 Mathieu MM, Ndoumbe A, Kuate C. et al. Prise en charge pré-hospitalière des patients victimes de traumatisme vertébro-médullaire en milieu Africain. Health Sci Dis 2014; 15 (02)
• 52 Wilson JR, Cadotte DW, Fehlings MG. Clinical predictors of neurological outcome, functional status, and survival after traumatic spinal cord injury: a systematic review. J Neurosurg Spine 2012; 17 (1, suppl): 11-26
• 53 Alizadeh A, Dyck SM, Karimi-Abdolrezaee S. Traumatic spinal cord injury: an overview of pathophysiology, models and acute injury mechanisms. Front Neurol 2019; 10: 282
• 54 Chu D, Lee YH, Lin CH, Chou P, Yang NP. Prevalence of associated injuries of spinal trauma and their effect on medical utilization among hospitalized adult subjects–a nationwide data-based study. BMC Health Serv Res 2009; 9 (01) 137
• 55 Schmidt OI, Gahr RH, Gosse A, Heyde CE. ATLS(R) and damage control in spine trauma. World J Emerg Surg 2009; 4: 9
• 56 Chiu WT, Lin HC, Lam C, Chu SF, Chiang YH, Tsai SH. Review paper: epidemiology of traumatic spinal cord injury: comparisons between developed and developing countries. Asia Pac J Public Health 2010; 22 (01) 9-18