Prevalence Of Secondary Medical Complications After Traumatic Spinal Cord Injury During Acute Care In Kenyatta National Hospital

Abstract

Background: There is paucity of data in low and middle income countries concerning the burden of traumatic spinal cord injury (tSCI). Despite advanced acute care and better awareness and identification of complications, many complications still occur during acute phase. These complications lengthen hospital stays and adversely affect rehabilitation. Attempt aimed at improving quality of care should be based on comprehensive and reliable data. This data is lacking in our local setting. Study Design: Hospital based Prospective Cohort Study. Objectives: To identify the prevalence of selected medical complications after tSCI during acute care and to identify predisposing factors for pressure ulcers. Study Population: Patients with acute tSCI or traumatic cauda equina syndrome aged 18 years and above at admission. Methods: Demographic, injury characteristics and neurological severity data were captured using International SCI Core Data Set. The predefined medical complications were screened for and recorded. Risk factors for pressure ulcers were assessed through logistic regression models. Results: A sample of 63 (92.65%) patients was analyzed. Overall, the most common secondary medical complication was Urinary Tract Infection (UTI) (n= 46 (73.02%)), followed by pulmonary complications (n=38 (60.32)) and pressure ulcers (n=26 (41.27%)). Other complications were neuropathic pain, (n =22 (34.92%)), spasticity (n =18 (28.57%)), autonomic dysreflexia, (n =14 (22.22%)) and venous thromboembolism (n =9 (14.29%)). Significant risk factors for development of pressure ulcers were development of urinary tract infections and pulmonary complications at risks of 3.5 and 11.7 times of developing PU, respectively (Odds Ratio (OR) =3.52; 95% CI: 1.15-10.75) (OR=11.75; 95% CI: 1.12-123.24). Additionally, those with more than one complication were 6.4 times more likely to develop PU, as compared to those with only one complication (95% CI: 1.05-39.33). Those aged between 46-60 years were 4.7 times more likely to develop PUs, compared with the younger (18-30) age group. This was only significant at 90% confidence interval. (OR = 4.7; 90% CI: 0.98–23.54). Conclusion: Secondary medical complications are common in traumatic Spinal Cord injury in Kenyatta National Hospital during acute care. Individual risk factors for development of pressure ulcers were urinary tract infections, pulmonary complications and patients having more than 2 complications. 1 1.0 INTRODUCTION Life expectancy for patients with tSCI has increased over the last few decades (1). This is due to medical advances that have led to improved health care (2). In this respect, it is noteworthy that tSCI not only results in paraplegia or tetraplegia but also adverse events (AEs) that have become frequent during acute care in patients with tSCI(3, 4). These complications lengthen hospital stays and affect the rehabilitation process. To prevent complications, more information about the number and nature of complications is needed (1). Over half of tSCI patients will have at least 1 complication during hospital stay. 75% of these adverse events present within 2 weeks. These adverse events associated with tSCI carry a significant risk of morbidity and mortality. Prompt diagnosis and treatment is critical in care of the tSCI patients (5). Most published and unpublished studies have reported the common secondary medical complications of traumatic spinal cord injuries to include, pulmonary complications, urinary tract infections, pressure ulcers, autonomic dysreflexia, deep vein thrombosis, pulmonary embolism, spasticity and neuropathic pain (1, 2, 6-9). Age, severity of neurological injury, associated traumatic brain injury, comorbid illnesses and mechanism of injury have all been shown to increase risk of complications (1, 5). There is limited local data regarding the prevalence of these secondary complications. One local study reported prevalence of 48.3% for neuropathic pain, 44.8% for pressure ulcers and 40.8% overall mortality within 3 months.(10) Above findings indicate that these complications are indeed a huge burden in management of traumatic spinal cord injuries in our local setting. Pressure ulcers are serious and common complications in patients with tSCI. Though an ancient, pressure ulcers are still a problem today. Pressure ulcers commonly occur over bony prominences such as the sacrum, ischial tuberosities, heels, malleoli and greater trochanters. Previous reports have identified reduced activity, insensibility, moisture from urinary or fecal incontinence, atrophy, prolonged time since injury, depression, smoking and malnutrition as 2 the main predisposing factors. However, identification of pre disposing factors in the local settings is lacking. Pressure ulcers constitute a huge burden in the management and rehabilitation of tSCI patients especially in resource limited settings in developing countries (11, 12). As well as other complications, pressure ulcers are associated with longer hospital stay with dire financial implications (1, 13).