Clinical outcomes of posterior spinal stabilization with rigid vertical strut and spinal process wires (the Adeolu's technique) in a developing country

Long-term Clinical Outcomes of Posterior Spinal Stabilization Using Adeolu's Technique: A Prospective Study from Nigeria

Background

Due to resource constraints, advanced spinal stabilization methods such as pedicle screws are unavailable at our center. Adeolu's technique, which employs low-cost and readily available vertical struts and spinal process wires, has been used as an adjunct in treating various spinal conditions to achieve rigid spinal constructs. This study evaluates the long-term clinical outcomes of this technique.

Methods

Nineteen patients treated with Adeolu's technique were prospectively followed to assess clinical outcomes. Primary outcomes included symptom reduction, absence of adverse events or need for re-intervention, and radiological evidence of stabilization and unrestricted mobilization. Secondary outcomes included back pain intensity, implant-related complications (rotation, migration, back-out, fracture), wound infection, worsening neurological status, and need for implant removal Data were analyzed using SPSS with simple descriptive statistics.

Results

The average follow-up period was 4.1 years (Range: 0.1 - 9.0 years). Patients' ages ranged from 20 to 81 years (Mean: 48.5). Indications for surgery included lumbar spondylosis (7, 36.8%), spinal trauma with unstable fractures (4, 21.1%), spinal tumors (4, 21.1%), and Pott's disease (4, 21.1%). All patients achieved satisfactory primary outcomes. Implant rotation was observed in 4 patients (21.1%), and implant migration in 1 patient (5.3%), requiring removal. Superficial surgical site infection occurred in 2 patients (10.5%). No implant fractures, deep infections, or worsening neurological status were noted.

Conclusion

Adeolu's technique is effective for a range of spinal pathologies, with favorable long-term clinical outcomes.

Cost-Effectiveness of Operating on Traumatic Spinal Injuries in Low-Middle Income Countries: A Preliminary Report From a Major East African Referral Center

STUDY DESIGN

Retrospective cost-effectiveness analysis.

OBJECTIVES

While the incidence of traumatic spine injury (TSI) is high in low-middle income countries (LMICs), surgery is rarely possible due to cost-prohibitive implants. The objective of this study was to conduct a preliminary cost-effectiveness analysis of operative treatment of TSI patients in a LMIC setting.

METHODS

At a tertiary hospital in Tanzania from September 2016 to May 2019, a retrospective analysis was conducted to estimate the cost-effectiveness of operative versus nonoperative treatment of TSI. Operative treatment included decompression/stabilization. Nonoperative treatment meant 3 months of bed rest. Direct costs included imaging, operating fees, surgical implants, and length of stay. Four patient scenarios were chosen to represent the heterogeneity of spine trauma: Quadriplegic, paraplegic, neurologic improvement, and neurologically intact. Disability-adjusted-life-years (DALYs) and incremental-cost-effectiveness ratios were calculated to determine the cost per unit benefit of operative versus nonoperative treatment. Cost/DALY averted was the primary outcome (i.e., the amount of money required to avoid losing 1 year of healthy life).

RESULTS

A total of 270 TSI patients were included (125 operative; 145 nonoperative). Operative treatment averaged $731/patient. Nonoperative care averaged $212/patient. Comparing operative versus nonoperative treatment, the incremental cost/DALY averted for each patient outcome was: quadriplegic ($112-$158/DALY averted), paraplegic ($47-$67/DALY averted), neurologic improvement ($50-$71/DALY averted), neurologically intact ($41-$58/DALY averted). Sensitivity analysis confirmed these findings without major differences.

CONCLUSIONS

This preliminary cost-effectiveness analysis suggests that the upfront costs of spine trauma surgery may be offset by a reduction in disability. LMIC governments should consider conducting more spine trauma cost-effectiveness analyses and including spine trauma surgery in universal health care.

Nonoperative treatment of traumatic spinal injuries in Tanzania: who is not undergoing surgery and why?

STUDY DESIGN

Retrospective, cohort study of a prospectively collected database.

OBJECTIVES

In a cohort of patients with traumatic spine injury (TSI) in Tanzania who did not undergo surgery, we sought to: (1) describe this nonoperative population, (2) compare outcomes to operative patients, and (3) determine predictors of nonoperative treatment.

SETTING

Tertiary referral hospital.

METHODS

All patients admitted for TSI over a 33-month period were reviewed. Variables included demographics, fracture morphology, neurologic exam, indication for surgery, length of hospitalization, and mortality. Regression analyses were used to report outcomes and predictors of nonoperative treatment.

RESULTS

270 patients met inclusion criteria, of which 145 were managed nonoperatively. Demographics between groups were similar. The nonoperative group was young (mean = 35.5 years) and primarily male (n = 125, 86%). Nonoperative patients had 7.39 times the odds of death (p = 0.003). Patients with AO type A0/1/2/3 fractures (p < 0.001), ASIA E exams (p = 0.016), cervical spine injuries (p = 0.005), and central cord syndrome (p = 0.016) were more commonly managed nonoperatively. One hundred and twenty-four patients (86%) had indications for but did not undergo surgery. After multivariate analysis, the only predictor of nonoperative management was sustaining a cervical injury (p < 0.001).

CONCLUSIONS

Eighty-six percent of nonoperative TSI patients had an indication for surgery. Nonoperative management was associated with an increased risk of mortality. Cervical injury was the single independent risk factor for not undergoing surgery. The principle reason for nonoperative management was cost of implants. While a causal relationship between nonoperative management and inferior outcomes cannot be made, efforts should be made to provide surgery when indicated, regardless of a patient's ability to pay.

Surgical site infection in elective clean and clean-contaminated surgeries in developing countries

BACKGROUND

Surgical site infection (SSI) is both the most frequently studied healthcare-associated infection and the most common healthcare-associated infection in the developing world. A systematic review and meta-analysis was conducted to evaluate the relative size of this burden and to estimate the prevalence of SSI in clean and clean-contaminated surgeries in a large sample of countries in the developing world.

METHODS

A systematic search of the MEDLINE/PubMed, Scopus, and LILACS databases was conducted to identify studies providing the prevalence of SSI in elective clean and clean-contaminated surgeries in 39 countries or regions around the world. Data of interest were limited to publications from January 2000 to December 2017. Studies with information on the number of cases of SSI and number of total elective clean and clean-contaminated surgeries during the same period were included in this evaluation. Studies lacking clear definition of the total number of exposed patients were excluded.

RESULTS

Based on the combined data from the 99 articles evaluated in this analysis, the overall prevalence of SSI in elective clean and clean-contaminated surgeries was estimated to be 6% (95% confidence interval (CI) 5-7%). This increased to 15% (95% CI 6-27%) when considering only those reports with post-discharge surveillance data. The overall prevalence of SSI in Africa/Middle East, Latin America, Asia, and China was 10% (95% CI 6-15%), 7% (95% CI 5-10%), 4% (95% CI 4-5%), and 4% (95% CI 2-6%), respectively. Significant variability in the data was confirmed by both the funnel plot and the Egger test (p=0.008).

CONCLUSIONS

Although the data are variable, it is clear that the incidence of SSI in the developing world is higher than that in the developed world.