Traumatic spine injuries (TSIs) and spinal cord injuries (SCIs) are serious global public health problems with significant financial and emotional burdens on the patients and their families [123]. Although the epidemiology of SCIs has been described in several low-and-middle-income countries (LMICs) such as Pakistan, Nigeria, and Ethiopia, little is still known about the current state of clinical management of TSIs and SCIs in these regions of lower economic status [45678910].

In LMICs, the limited resources that clinicians work with present a formidable challenge for adhering to the latest practice guidelines developed in higher-income countries. Because of the discrepancies between these guidelines and available resources, there is a need for clinical data that reflects the socioeconomic conditions of a region so that practice guidelines can be tailored to its specific needs and capabilities. In this regard, there is a paucity of information regarding the epidemiology or the surgical techniques currently being utilized to treat TSI and SCI patients in Cambodia. In order to better understand these, we performed a cross-sectional study at Preah Kossamak Hospital, a major government hospital in Phnom Penh, Cambodia. The aims of this study were to: (1) characterize the epidemiology of TSI patients presenting to Preah Kossamak Hospital, (2) elucidate any pattern of TSIs in relation to causes of trauma, (3) describe the surgical management of TSIs, and (4) determine outcomes of the patients. In addition to our study aims, we believe that our study data can serve as baseline for future progress in the clinical management of TSI and SCI patients in LMICs.

We present here the first description of the epidemiology and the current clinical management of TSIs in Cambodia. Although our sampling is limited to 80 patients, the histogram analysis of thoracolumbar spinal injury levels in our patients resembles that of Magerl et al. [13], in which the thoracolumbar injury patterns of 1,445 patients were analyzed. Overall, the thoracolumbar junction was shown to be the most vulnerable site of injury in our analysis. Stratification by causes of injury showed that falls were most often associated with lumbar spine injuries, whereas motorcycle accidents were most often associated with cervical spine injuries. Within the cervical spine, C5 was the most vulnerable site of injury followed by C4 and C6. No injuries were observed at C1, C2, T1, and T2.

The SCI status (complete, incomplete, or no SCI) did not determine whether a patient was treated surgically or conservatively. The surgical treatment for complete SCI is controversial. Although many spine surgeons advocate early fusion of patients with complete SCI to enable maximal participation in physical rehabilitation, Shamim et al. [9] showed that in Pakistan, complete SCI patients who had surgery took longer time to go to rehabilitation, had higher rates of complications, and had longer hospital stays. Based on their findings, the authors recommended surgery for complete SCI patients only if their rehabilitation was impeded by pain or deformity. Continuing studies monitoring the clinical progression of SCI patients in rehabilitation programs who did and did not have surgery would reveal more accurate information about whether surgery should be performed readily on patients with complete SCI. At the of this study, we recognized that there was a paucity of inpatient rehabilitation programs in Cambodia, which would make such monitoring difficult.

Due to familiarity and simplicity of posterior approaches as well as lack of anterior instrumentation, all thoracolumbar cases were performed through a posterior approach. Although PSF with pedicle screw fixation was the treatment of choice for most injuries, the availability of pedicle screw sets were limited and therefore were used judiciously. In more severe injuries that required 5 or more levels of fusion, the Luque rod fixation with sublaminar wiring was employed [12]. Luque rod instrumentation is an older PSF technique that has gone out of fashion in developed countries. However, because a Luque rod can be purchased for $15 (USD) in Cambodia, it is an attractive and cost-effective means for treating severe spinal injuries. Its multipoint fixation gives the Luque system high rigidity and strength. However, operating times are longer, and the stainless steel Luque rod and sublaminar can make interpretation of MRI scans more difficult due to artifacts. In the cervical spine, PSF with interspinous wiring was also a highly cost-effective technique that was used since lateral mass fixation sets were not available. Rationale for choosing spinal implants in resource-limited setting has been described in more detail elsewhere [14].

Excluding sacral decubitus ulcers, the overall surgically-related complication rate was 16% (10/62), of which wrong level surgery was the most common complication (6%; 4/62). This finding emphasizes the value of a C-arm and intraoperative plain film X-rays in reducing wrong level surgeries. On a cultural note, while institutional policies in high-income countries tend to view wrong level surgeries as sentinel events, both the Cambodian neurosurgeons and the patients viewed the errors as an acceptable risk to the surgery, especially in light of the limited resources with which they worked [1516].

Although five sacral decubitus ulcers were recorded (all surgical patients), we believe that lower grade sacral decubitus ulcers were not documented. Therefore, the 8% sacral decubitus ulcer rate is likely an underestimate of its overall occurrence. In Cambodia, family members often stay with the patient during the hospitalization and perform much of the nursing care. Although some families provided water filled padding for the patients, the hospital beds were very firm, making SCI patients susceptible to developing pressure sores. Furthermore, physical rehabilitation was almost nonexistent. With this realization, efforts were directed at educating family members of SCI patients about prevention of sacral decubitus ulcers and importance of rehabilitation activities.

Interestingly, there were no clinically evident cases of deep venous thrombosis, pulmonary embolism, myocardial infarction, intestinal obstruction/ileus, pneumonia, or urinary tract infection during the hospitalization of our patients. However, subclinical forms of these complications cannot be ruled out since these conditions were not routinely screened. Furthermore, our infection rates were unexpectedly low (2%), and it is uncertain whether the generous use of prophylactic antibiotics may have contributed to this phenomenon. As a cautionary measure, the nurses performed meticulous wound care with daily betadine washes until sutures were removed. Besides antibiotic use, the lack of central line use may have contributed to reducing infection and sepsis rates.

The average length of hospital stay (18 days) represented the usual time required for complete wound healing and suture removal, which were prerequisites for discharge. Although in-hospital mortality rates of 9.3%–17.5% have been reported among SCI patients in Pakistan and Nigeria mostly due to infectious or thromboembolic events, none of our patients died during hospitalization [569]. The reason for this is not clear. It is conceivable that the patients in our study were self-selected; given that only 10% of our patients were admitted within 4 hours of their injury, it is likely that patients with severe injury had died before reaching the hospital. A study in India, Lalwani et al. [17] found that 11.7% of the mortality among their TSI patients occurred on route or in less than 3 hours of admission to the hospital. Preadmission deaths may also explain why we did not observe any injuries at the atlantoaxial complex, which can compromise the brainstem leading to cardiorespiratory demise. Furthermore, given that 56% (45/80) of our patients were lost to follow-up, it is possible that some of our patients may have died following discharge; a study in Ethiopia with 23 month average follow-up revealed that 17% of patients who underwent surgery for spine fractures died, all after discharge [4]. Efforts to improve patient follow-up through family members may help clarify this concern in the future.

Despite the poor follow-up, the short-term as well as the mid-term outcomes (at 1–6 months) were encouraging. Improvements were seen in patients admitted with all grades of SCI even though the average delay to surgery was 5 days. Historically, the timing of decompressive surgery following TSI has been controversial with some reviews recommending consideration of early intervention 8 to 24 hours following acute TSI [131418].

Despite significant limitations in medical resources, spine surgery in Cambodia appears promising with reasonable complication rates, no in-hospital mortality, and trends of clinical improvement. The overall surgical rate for TSI patients was 78% with no significant difference between the surgical rates of complete, incomplete, and non-SCI patients. Prophylactic antibiotics were used generously, and it is uncertain if antibiotic resistance is becoming a problem. Establishment of physical rehabilitation programs is needed to maximize functional outcomes and minimize secondary complications, and efforts should be made to improve follow-up of TSI patients.