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Systematic Review

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Epidemiology of Traumatic Spinal Cord Injury in Developing Countries: A Systematic Review

Rahimi-Movaghar V.a, c · Sayyah M.K.b · Akbari H.b · Khorramirouz R.b · Rasouli M.R.f · Moradi-Lakeh M.d · Shokraneh F.e · Vaccaro A.R.f

Author affiliations

aSina Trauma and Surgery Research Center, Department of Neurosurgery, Shariati Hospital, and bStudent Scientific Research Center, Faculty of Medicine, Tehran University of Medical Sciences, cResearch Centre for Neural Repair, University of Tehran, and dDepartment of Community Medicine, School of Medicine, Tehran University of Medical Sciences and Health Services, Tehran, and eResearch Center for Pharmaceutical Nanotechnology and Iranian Center for Evidence-Based Medicine, Tabriz University of Medical Sciences, Tabriz, Iran; fDepartment of Orthopedics and Neurosurgery, Thomas Jefferson University and the Rothman Institute, Philadelphia, Pa., USA

Corresponding Author

Vafa Rahimi-Movaghar, MD

Research Deputy, Sina Trauma and Surgery Research Center

Sina Hospital, Hassan-Abad Square, Imam Khomeini Avenue

Tehran University of Medical Sciences, Tehran 11365-3876 (Iran)

E-Mail v_rahimi@sina.tums.ac.ir

Related Articles for ""

Neuroepidemiology 2013;41:65-85

Abstract

Background/Aims: To describe the epidemiology of spinal cord injury (SCI) in the developing world. Methods: Developing countries were selected based on the definition proposed by the International Monetary Fund. A literature search was performed in July 2012 in Medline and Embase. Further article procurement was obtained via the reference lists of the identified articles, websites, and direct contact with the authors of the identified studies. We designed search strategies using the key words: SCI, epidemiology, incidence, and prevalence. According to the inclusion criteria, 64 studies from 28 countries were included. Results: The incidence of SCI in developing countries is 25.5/million/year (95% CI: 21.7-29.4/million/year) and ranges from 2.1 to 130.7/million/year. Males comprised 82.8% (95% CI: 80.3-85.2) of all SCIs with a mean age of 32.4 years (95% CI: 29.7-35.2). The two leading causes of SCI were found to be motor vehicle crashes (41.4%; 95% CI: 35.4-47.4) and falls (34.9%; 95% CI: 26.7-43.1). Complete SCIs were found to be more common than incomplete injuries (complete SCI: 56.5%; 95% CI: 47.6-65.3; incomplete SCI: 43.0%; 95% CI: 34.1-52.0). Similarly, paraplegia was found to be more common than tetraplegia (paraplegia: 58.7%; 95% CI: 51.5-66.0; tetraplegia: 40.6%; 95% CI: 33.3-48.0). Conclusion: Through an understanding of the epidemiology of SCI in developing countries, appropriate preventative strategies and resource allocation may decrease the incidence and improve the care of these injuries.

© 2013 S. Karger AG, Basel


Introduction

Spinal cord injury (SCI) is a devastating condition which occurs with an annual incidence of 12.1-57.8 cases per million [1]. SCI is associated with permanent disability and decreased life expectancy [2]. Although more than 80% of the world's population live in the more than 100 developing countries, little information is available regarding the epidemiology of SCI in these countries [3].

Since there is no curative treatment for SCI, prevention of SCI is paramount. Investigating the epidemiological pattern of SCI is the first step in planning for preventive strategies [4]. The epidemiology of SCI varies in different countries and the results of epidemiological studies from developed countries are not applicable to developing countries [5,6]. Given the poorly elucidated epidemiological pattern of SCI in developing countries, this systematic review aims to pool all available data to elucidate epidemiological patterns of SCI in these countries.

Materials and Methods

We designed search strategies using the following key words: SCI, epidemiology, incidence, and prevalence. The search strategy was repeated several times by our team and performed on July 16, 2012, with the help of an experienced research librarian (online supplementary material; for all online supplementary material, see www.karger.com/doi/10.1159/000350710). We pooled papers from Embase (via Ovid SP) and Medline (through Pubmed) in the End Note X3 software (Thomson Reuters 1988-2009 - Bld 4094). We reviewed the reference lists of the identified articles and identified papers describing the epidemiology of SCI in developing countries. We also searched reported data by the National Spinal Cord Injury Statistical Center (https://www.nscisc.uab.edu) [7] and International Spinal Cord Society (ISCoS) (https://www.iscos.org.uk) [8] websites. The 112 authors of the papers identified using the above search strategy were directly contacted via e-mail in search of any further published data. In total, 15 manuscripts were identified from these authors (fig. 1). Duplicated records were removed manually.

Fig. 1

Flow diagram of studies based on the PRISMA statement.

http://www.karger.com/WebMaterial/ShowPic/193226

Our definition for developing countries in this paper is based on the International Monetary Fund's World Economic Outlook Report, April 2012 [9]. The International Monetary Fund uses a flexible classification system that considers (1) per capita income level, (2) export diversification - so oil exporters that have high per capita gross domestic product would not make the advanced classification because around 70% of its exports are oil - and (3) degree of integration into the global financial system.

Titles of 1,441 records were reviewed in the integrated End Note file. In total, 1,296 articles were found to have irrelevant titles. However, 145 articles were found to be related to the epidemiology of SCI in both developing and developed countries and were thus further screened by evaluating their abstracts. Fifty-six papers were excluded, most of which due to their focus on epidemiology of SCI in developed countries. Eighty-nine full publications were retrieved for detailed evaluation. We evaluated all papers carefully to include papers that measured incidence, age, sex, complete/incomplete injuries, paraplegia/tetraplegia, or mechanism of injury. We excluded low-quality and heterogeneous studies in order to draw more precise conclusions. Further exclusion after detailed evaluation was performed for review articles, articles with data on pediatric or geriatric patients, articles describing a specific etiology for SCI, articles without any data, letters, and articles with an unrelated focus (SCI patients who have pressure ulcers, employment problem, pain, satisfaction/quality of life, morbidity, urology, and economy). We excluded articles with mixed data for spinal fractures and SCIs unless the data for spinal cord-injured patients was independently reported.

Further, we excluded those papers with mixed traumatic and nontraumatic SCIs unless the traumatic SCI patient data was independently reported. For non-English papers (2 Portuguese papers, 2 Russian papers and 1 Polish paper), the manuscripts were translated into English prior to review. Two independent researchers (V.R.-M., M.K.S.) performed data extraction separately, and the results were compared.

The flow diagram for various stages of studies based on the PRISMA statement [10] is shown in figure 1. Data on demographics, incidence or prevalence of SCI (if reported), level of SCI (cervical, thoracic and lumbar), etiology of SCI, type of SCI (incomplete tetraplegia, complete tetraplegia, incomplete paraplegia and complete paraplegia) and classification of SCI were extracted from the articles by the reviewers. The study protocol was reviewed and approved by the Sina Trauma and Surgery Research Center ethical review board.

Meta-analysis was performed for pooled data for percentages of paraplegics versus tetraplegics, complete versus incomplete SCI and mechanism of injury [motor vehicle crashes (MVCs) and falls] using STATA software version 9.1 (Stata Corp., College Station, Tex., USA). A moment-based random model was used for estimating pooled measures because of heterogeneity of studies. We used metaregression for adjusting study period, male sex percent, mean age, relative frequency of MVC and fall-related SCI.

Results

Our search found 64 studies (fig. 1) [8,11,12,13,14,15,16,17,18,19,20,21,22,23,24,25,26,27,28,29,30,31,32,33,34,35,36,37,38,39,40,41,42,43,44,45,46,47,48,49,50,51,52,53,54,55,56,57,58,59,60,61,62,63,64,65,66,67,68,69,70,71,72,73] related to the 28 developing countries all around the world. Tables 1 and 2 show the study period, number of patients, age, sex, level of injury, completeness of SCI and etiology. A paper about SCI epidemiological characteristics had been written in the two cities of Kabul and Herat, Afghanistan, independently [11]. Therefore, we included the paper as two independent studies. One unpublished study from Saudi Arabia was extracted from the ISCoS. Our personal contact with the ISCoS office showed that they published data without estimation.

Table 1

Comparative analysis of SCIs in developing countries

http://www.karger.com/WebMaterial/ShowPic/193228

Table 2

Etiology and age distribution of SCI in developing countries (%)

http://www.karger.com/WebMaterial/ShowPic/193227

The proportion of male patients was higher than 66% in all studies. The random pooled estimate for male proportion among all countries was 82.8 (95% confidence interval, CI: 80.3-85.2). The data were heterogeneous (Q: 1,097, d.f.: 51, p < 0.001, moment-based estimate of between-studies variance = 0.007). Zimbabwe had the highest male-to-female ratio (12.4:1) [73] and Nigeria had the lowest (2:1) [40].

The random pooled estimate for mean age was 32.4 years (95% CI: 29.7-35.2, test for heterogeneity Q: 1,928, d.f.: 25, p < 0.001, moment-based estimate of between-studies variance = 50.4). The mean age of SCI patients ranged from 20.6 in Kuwait [36] to 46 years in China [23]. The most commonly affected age group was patients aged 20-30 years (Bangladesh, India and Pakistan; table 1).

In developing countries, the SCI incidence (25.5/million/year, 95% CI: 21.7-29.4/million/year) ranges from 2.1 in Saudi Arabia [8] to 130.7 in Bulgaria per million [21] (fig. 2; Q: 6,869, d.f.: 26, p < 0.001, moment-based estimate of between-studies variance = 99.9). In figures 2, 3, 4, 5, 6, 7, 8, the size of each square is correlated with the weight and inverse of variance of study in the meta-analysis.

Fig. 2

SCI incidence in developing countries.

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Fig. 3

Meta-analysis of SCI by completeness in developing countries.

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Fig. 4

Meta-analysis of SCI by incompleteness in developing countries.

http://www.karger.com/WebMaterial/ShowPic/193223

Fig. 5

Meta-analysis of SCI by paraplegia in developing countries.

http://www.karger.com/WebMaterial/ShowPic/193222

Fig. 6

Meta-analysis of SCI by tetraplegia in developing countries.

http://www.karger.com/WebMaterial/ShowPic/193221

Fig. 7

Meta-analysis of SCI by etiology of MVCs in developing countries.

http://www.karger.com/WebMaterial/ShowPic/193220

Fig. 8

Meta-analysis of SCI by etiology of falls in developing countries.

http://www.karger.com/WebMaterial/ShowPic/193219

The relative frequency of complete SCI was 56.5% (95% CI: 47.6-65.3; test for heterogeneity Q: 1,665, d.f.: 24, p < 0.001, moment-based estimate of between-studies variance = 0.048; fig. 3). The relative frequency of incomplete SCI was 43.0% (95% CI: 34.1-52.0; test for heterogeneity Q: 1,727, d.f.: 24, p < 0.001, moment-based estimate of between-studies variance = 0.050; fig. 4).

The relative frequency of paraplegia was 58.6% (95% CI: 51.3-66.0; test for heterogeneity Q: 6,295, d.f.: 47, p < 0.001, moment-based estimate of between-studies variance = 0.065; fig. 5). The relative frequency of tetraplegia was found to be 40.7% (95% CI: 33.3-48.1; test for heterogeneity Q: 6,816, d.f.: 47, p < 0.001, moment-based estimate of between-studies variance = 0.067; fig. 6).

Cervical SCI causes tetraplegia and T1-L1 SCI causes paraplegia. The comparison of reported data for level of injury (thoracolumbar vs. cervical) was almost the same as that for paraplegia versus tetraplegia. However, we did not perform meta-analysis for level of injuries, because there was no clear identification of conus medullaris (≥L1) versus cauda equina (<L1) in many papers.

Motor vehicle collisions were found to be the causative mechanism in 41.4% of patients (95% CI: 35.4-47.4; test for heterogeneity Q: 5,309, d.f.: 50, p < 0.001, moment-based estimate of between-studies variance = 0.046; fig. 7).

A fall was identified as the mechanism of injury in 34.9% of patients (95% CI: 26.7-43.1; test for heterogeneity Q: 8,392, d.f.: 44, p < 0.001, moment-based estimate of between-studies variance = 0.077; fig. 8).

MVCs and falls were the leading causes of SCI except 2 reports from South Africa, which showed violence was the cause of SCI in more than half of the patients [61,63], and 1 report from Brazil, which showed violence was more common than MVCs and falls [17]. In the Plateau State of Nigeria, collapsing tunnels in illegal mining are the most prevalent cause [44]. In 31 reported data, MVC was more common than falls and in 23 reported data, a fall was more common than MVC and in 1 report, both had similar percentages of SCI causes. In 2 reports from Nigeria [40,42] and 1 report from Saudi Arabia [8], MVCs accounted for more than 80% of SCI patients. Also, Iran has one of the highest mortality rates due to MVCs [74]. However, in 2 reports from Nepal [39] and Pakistan [50], falls accounted for more than 80% of SCI patients. Bangladesh has one of the highest SCI rates due to falls [12].

There was lack of information on the training and qualifications of the individuals identifying SCI patients in developing countries except in Iran, in which a registered nurse with specific training rechecked the patients in their home. In the Iran study, patients and their files were re-evaluated by a neurosurgeon in the neurotrauma clinic.

Based on meta-regression analysis, the relative frequency of complete or incomplete SCI does not increase significantly during the years of studies from 1975 to 2009. Addition of male gender and mean age to the model does not change the significance either.

The relative frequency of MVC-related SCI did not change significantly during the study period from 1975 to 2009. However, the relative frequency of fall-related SCI has increased in these years significantly. Share of fall has increased by 0.9% (95% CI: 0.2-1.5%) annually. Male gender, age and type of SCI (incomplete vs. complete) and neurological injury (tetraplegia vs. paraplegia) were found to have no association with the mechanism of injury.

There is a significant association between tetraplegia and male gender; each 1% increase in proportion of males:females is associated with a 1.8% (95% CI: 0.4-3.3%) increased risk of tetraplegia. Each 10-year increase in mean age is associated with a 0.15% (0.02-0.28%) increase in tetraplegia.

There are also specific common etiologies for SCI in specific seasons or groups. For example, in India there was seasonal variation in incidence of traumatic SCI, with a marked increase during summer [29,30], which is compatible with increased movement of people during this season. In Fiji [27], most injuries occurred in native-born individuals rather than in tourists or visitors. In South Africa, the etiology of SCI showed a shift from stab wounds (38% in 1988 to 17.5% in 1992) to gunshot injuries (28.5% in 1988 to 47% in 1992).

China [23] and Pakistan [50] reported the highest rate of cervical injury (71.5 and 68%, respectively). With respect to the classification of SCI (complete vs. incomplete), 19 countries reported complete and incomplete SCIs (table 1). Only 4 of these studies found that complete injuries were more common [23,30,33,49]. Similarly some studies from developed countries mention a trend toward complete over incomplete SCIs over the last decade [5,75]. In the study from South Africa [61], it has been mentioned that there is 74% involvement of the thoracic and lumbar area but 90.3% of patients are paraplegic. Also there are 26% cervical injuries, but only 9.7% have tetraplegia.

Most studies gave retrospective hospital-based data. However, 4 studies were prospective [14,42,48,66]. A paper from Romania showed mixed data in which the first 17 years of the study were retrospective and the last year was prospective [55]. Only 1 study was a population-based study in SCI [31].

Regarding secondary complications, pressure ulcers were relatively common after SCI [76,77]. Among studies reporting secondary complications of SCI, all except 3 from Bangladesh [12], Kuwait [36] and Zimbabwe [73] suggested pressure ulcer as the most common complication following SCI. In Iran, the prevalence of pressure ulcer was 71.8% among traumatic SCI cases [77]. The complications that are seen with SCI are related to almost all human body systems. However, in this review, we did not focus on the complications, which need a separate extensive review and just mentioned the 2 most common complications of pressure sore and urinary tract infection. Body systems and their SCI complications include: urinary tract with infection, renal stone, hydronephrosis, urinary incontinence, vesicouretral reflux; gastrointestinal tract with constipation, hemorrhoids, stool incontinence, cholecystitis, appendicitis, upper gastrointestinal bleeding, superior mesenteric artery syndrome, pancreatitis; skin with pressure sore; cardiovascular system with autonomic dysreflexia, thromboembolism; pulmonary tract with infection, ventilatory failure, sleep apnea; musculoskeletal system with osteoporosis, muscular weakness, paralysis, atrophy, spasticity, pain; endocrine system with hypercalcemia; sexual organs with erectile dysfunction, male infertility; psychiatry with depression.

Discussion

We identified 64 papers from 28 countries. The incidence of SCI in developing countries was 25.5/million/year. Males (82.8%) were more likely to sustain SCI than females. The mean age of SCI occurrence was 32.4 years. The relative frequency for following subgroups of SCI was: MVC 41.4% and falls 34.9%; complete and incomplete SCI were 56.5 and 43.0%, respectively; paraplegia and tetraplegia were 58.6 and 40.7%, respectively. However, there was no significant difference between MVC and falls, complete and incomplete SCI, paraplegia and tetraplegia. The most commonly reported complication was the development of pressure ulcers.

Incidence of SCI

The annual incidence of SCI ranged from 2.1 (Saudi Arabia) [8] to 130.7 (Bulgaria) [21] per million in developing countries compared to the reported incidence of SCI from developed countries of 12.1-57.8 cases per million [1]. In most developing countries, especially Arabic countries, the incidence of SCI was less than that in developed countries. The lack of organized national registries and death at the scene of an injury or in the prehospital phase in developing countries might explain the higher mortality of SCI in those developed countries who have registered prehospital death [78]. In many developing countries, there are limited numbers of hospitals capable of managing SCI patients. Therefore, examination of admission data from these centers retrospectively allows incidence to be estimated.

Twenty-nine papers from the following 19 countries reported the annual incidence of SCI: Brazil [16,17,19], Bulgaria [21], Chile [22], China [23,25,26], Fiji Island [27], Greenland [28], Iran [31,32,34], Jordan [35], Kuwait [36], Qatar [55], Romania [56], Russia [57,58], Saudi Arabia [8], Sierra Leone [60], South Africa [61], Thailand [64,65], Turkey [67,69,70,71], Vietnam [72], Zimbabwe [73] (table 1). As mentioned before, the low incidence of SCI from some countries may not be accurate since data may be aggregated from hospitals or rehabilitation centers and not directly collected.

Etiology of SCI

There was no single classification used to organize SCI etiology, so it was somewhat difficult to compare different countries. Although fall and MVC were reported in the majority of the studies, there was discrepancy in reporting other causes of SCI. To address this problem, it is recommended that authors in future studies use the classification reported by De Vivo et al. [79], to standardize the reporting of the cause of injury. A recent study noted a trend toward an increased prevalence of falls and MVC in developing countries likely related to urbanization and increased use of motor vehicles [30]. Likewise, the World Health Organization predicts that there will be a major increase in MVCs in coming decades if preventative measures are not taken [80]. Many developing countries do not have defined programs to prevent MVCs. Therefore, the incidence of MVC is high [81,82,83]. In some developing countries in which urbanization and motorization processes have not developed, there is a lower incidence of MVC. In these countries such as Bangladesh, the large number of falls is a result of fruit harvesting, which is an important part of their largely agricultural economy [12]. Falls while carrying a heavy load is another common cause of SCIs in Bangladesh. The mean age is lower in developing countries than developed ones. Therefore, falls and SCIs related to osteoporosis are not as common as in developed countries. Sports-related SCIs have been mentioned for diving in Brazil [20]. It is notable that in India a large number of patients were illiterate, poor villagers. In future studies, assessments should be done to determine whether low socioeconomic situation and low educational level are associated with a higher SCI incidence. Since MVCs and falls are the two major etiologies of SCI, preventive measures should be employed to reduce the frequency of SCI in the majority of developing countries. However, in South Africa, preventive measures should be focused on curbing gun violence.

Age Distributions and Male-to-Female Ratios

Age groups were variably defined in the reviewed manuscripts. It is recommended that in future studies, age at the time of SCI should be reported as has been previously recommended by De Vivo et al. [79] with the aim of reaching a standard structure for reporting data on SCI. In most of the developing countries, the majority of patients were young adults (age group 20-40 years). The mean age of incident cases of SCI patients seems to be higher in developed countries [78] possibly due to longer life expectancies, a higher mean age of population and better medical care systems [78]. The younger mean age of patients with SCI in developing countries will inflict a high burden on these countries [78]. Regarding the gender of SCI victims, traumatic SCI is more prevalent in males than females [5]. The male-to-female ratio in developing countries (82.8% males; M/F: 4.8/1) is higher compared to developed ones as most studies in developed countries have a male-to-female ratio of approximately 3-4 [78]. This may reflect a higher level of social and sport activities of females in developed countries compared to developing ones. Additionally, women in developing countries often have more traditional home-based activities, which likely diminishes their risk of developing an SCI [12,35]. Authors from India suggested that gender distribution of SCI today compared to a few decades ago reflects the changing cultural and societal trends of the females' role in the home and workplace [29].

Level and Severity of SCI

Only 21 papers from 15 countries of Brazil, China, Fiji, India, Iran, Jordan, Kuwait, Nepal, Nigeria, Pakistan, Qatar, Romania, Russia, Thailand and Zimbabwe used a classification system for the assessment of level and severity of SCI (table 1). In contrast, the American Spinal Injury Association Impairment Scale classification has been used more frequently in reports from developed countries [78].

The summation of complete and incomplete SCI is not 100% (complete SCI: 56.5%; incomplete SCI: 43.0%) because of difficulties in defining complete/incomplete injuries in some studies. For example, an L1 conus medullaris injury with urinary and bowel incontinence but without lower extremity neurological deficit is difficult to classify as complete or incomplete SCI. Similarly, the above-mentioned SCI patient is neither paraplegic nor tetraplegic. Therefore, we reported complete/incomplete SCI and paraplegia/tetraplegia with summations of 99.5 and 99.3%, respectively (not 100%). However, in males and females, the summation was accurately 100% and in all studies, and the proportion of males was higher than that of females.

We performed random model pooling to have an estimate for our multiple variables. This extent of dissimilarity in 95% CI is expected.

The proportions of cervical, thoracic and lumbar injuries are not the same as the percentages of paraplegia/paresis and tetraplegia/paresis. This is because some authors included cauda equine injuries (which we subsequently excluded), and some T1 fractures may cause some upper extremity weakness and be classified as quadriparesis.

Secondary Complications following SCI

Comparing results of developing and developed countries showed that pressure ulcers and urinary tract infections are major secondary complications in all regions [78].

Limitations of the Study

There was lack of information on the training and qualifications of the individuals collecting the SCI data except in Iran, where a registered nurse with specific training rechecked the patients in their home. Patients and their files were also re-evaluated by a neurosurgeon in the neurotrauma clinic.

One important limitation of this review is that we relied on only a few published articles from each country that were available in the literature. There is no data about the prehospital admission, and it is not clear if the study settings are representative of the epidemiological pattern of SCI in that country. Moreover, it is not clear whether hospitals participating in the published studies treat all traumatic SCIs within that country or if there were any other hospitals in the region that also treat traumatic SCIs. The results drawn from the meta-analysis of etiology and level of SCI should be interpreted carefully due to a discrepancy in the collection period and variation in the collection and reporting methods of the different countries. However, it does provide important preliminary data in this poorly studied field.

Future Study

Due to the lack of SCI registries in developing countries, an accurate estimation of the incidence and epidemiological patterns of SCI in the majority of developing countries is not feasible. There is a need for large national epidemiological surveys in developing countries assessing the incidence, prevalence and etiology of SCI. Moreover, there is diversity in the standards of reporting epidemiology of SCI in developing countries. Future studies should follow the standard for reporting their results that have been published by the ISCoS.

Acknowledgments

The authors wish to thank the following international medical scientists whose collaboration in the book entitled Epidemiology of Spinal Cord Injuries had a great role in the comprehensiveness of the paper: Professors/Drs. Kemal Nas, Ricardo Vieira Botelho, Marcos Masini, Emilio Afonso França Fontoura, Dra. Garcia, Ana Cristina Ferreira, Farooq A. Rathore, Sahibzada Nasir Mansoor, Jagdish C. Maharaj, Nalina Gupta, Roop Singh, Soheil Saadat, Seyed Behzad Jazayeri, and Amirali Sayadipour.

This study was supported by grant number 159-2.3.2012 of Sina Trauma and Surgery Research Center. The corresponding author received the grant.

Disclosure Statement

There is no conflict of interest for any contributing author.


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  28. Pedersen V, Müller PG, Biering-Sørensen F: Traumatic spinal cord injuries in Greenland 1965-1986. Paraplegia 1989;27:345-349.
  29. Singh R, Sharma SC, Mittal R, Sharma A: Traumatic spinal cord injuries in Haryana: an epidemiological study. Indian J Community Med 2003;28:184.
  30. Manjeet S, Siddhartha S, Iftikhar WH, Agnivesh T, Farid MH, Nirdosh M, et al: Spine injuries in a tertiary health care hospital in Jammu: a clinico-epidemiological study. Internet J Neurosurg 2009;5:2.
  31. Rahimi-Movaghar V, Saadat S, Rasouli MR, Ganji S, Ghahramani M, Zarei MR, et al: Prevalence of spinal cord injury in Tehran, Iran. J Spinal Cord Med 2009;32:428-431.
  32. Rahimi-Movaghar V, Moradi-Lakeh M, Rasouli MR, Vaccaro AR: Burden of spinal cord injury in Tehran, Iran. Spinal Cord 2010;48:492-497.
  33. Yousefzadeh CS, Safaee M, Alizadeh A, Ahmadi Dafchahi M, Taghinnejadi O, Koochakinejad L: Epidemiology of traumatic spinal injury: a descriptive study. Acta Med Iran 2010;48:308-311.
    External Resources
  34. Fakharian E, Tabesh H, Masoud SA: An epidemiologic study on spinal injuries in Kashan. J Guilan Univ Med Sci 2004;13:79-84.
  35. Otom AS, Doughan AM, Kawar JS, Hattar EZ: Traumatic spinal cord injuries in Jordan - an epidemiological study. Spinal Cord 1997;35:253-255.
  36. Raibulet T, Fakhri S, Khamees MF, Eyadeh AA: Spinal cord injury patients in the Physical Medicine and Rehabilitation Hospital, Kuwait - a nine-year retrospective study. Kuwait Med J 2001;33:211-215.
  37. Toe T: Spinal injuries in Rangoon, Burma. Paraplegia 1978;16:118-120.
  38. Bajracharya S, Singh M, Singh GK, Shrestha B: Clinico-epidemiological study of spinal injuries in a predominantly rural population of eastern Nepal: a 10 years' analysis. Indian J Orthop 2007;41:286-289.
  39. Lakhey S, Jha N, Shrestha BP, Niraula S: Aetioepidemiological profile of spinal injury patients in Eastern Nepal. Trop Doct 2005;35:231-233.
  40. Olasode BJ, Komolafe IE, Komolafe M, Olasode OA: Traumatic spinal cord injuries in Ile-Ife, Nigeria, and its environs. Trop Doct 2006;36:181-182.
  41. Obalum DC, Giwa SO, Adekoya-Cole TO, Enweluzo GO: Profile of spinal injuries in Lagos, Nigeria. Spinal Cord 2009;47:134-137.
  42. Udosen A, Ikpeme A, Ngim N: A prospective study of spinal cord injury in the University of Calabar Teaching Hospital, Calabar, Nigeria. Internet J Orthop Surg 2007;5:1.
  43. Iwegbu CG: Traumatic paraplegia in Zaria, Nigeria: the case for a centre for injuries of the spine. Paraplegia 1983;21:81-85.
  44. Igun GO, Obekpa OP, Ugwu BT, Nwadiaro HC: Spinal injuries in the Plateau State, Nigeria. East Afr Med J 1999;76:75-79.
  45. Solagberu BA: Spinal cord injuries in Ilorin, Nigeria. West Afr J Med 2002;21:230-232.
    External Resources
  46. Nwankwo OE, Katchy AU: Outcome of a 12-week programme for management of the spinal cord injured with participation of patient's relations at Hilltop Orthopaedic Hospital, Enugu, Nigeria. Spinal Cord 2003;41:129-133.
  47. Nwadinigwe CU, Iloabuchi TC, Nwabude IA: Traumatic spinal cord injuries (SCI): a study of 104 cases. Niger J Med 2004;13:161-165.
  48. Rathore MF, Hanif S, Farooq F, Ahmad N, Mansoor SN: Traumatic spinal cord injuries at a tertiary care rehabilitation institute in Pakistan. J Pak Med Assoc 2008;58:53-57.
    External Resources
  49. Masood Z, Wardug GM, Ashraf J: Spinal injuries: experience of a local neurosurgical centre. Pak J Med Sci 2008;24:368-371.
    External Resources
  50. Raja IA, Vohra AH, Ahmed M: Neurotrauma in Pakistan. World J Surg 2001;25:1230-1237.
  51. Qureshi AA, Irfan A, Memon MA: Spinal injuries: a prospective study. Biomedica 2001;17:27-29.
  52. Gee RW, Sinha SN: The epidemiology of spinal cord injuries in Papua New Guinea. PNG Med J 1982;25:97-99.
  53. Jankowski R, Zukiel R, Nowak S, Czekanowska-Szlandrowicz R, Stachowska-Tomczak B: Vertebral column and spinal cord injuries: isolated and concomitant with multiple injury. Chir Narz Ruchu Ortop Pol 1993;58:353-359.
  54. Mena Quinones PO, Nassal M, Al Bader KI, Al Muraikhi AE, Al Kahlout SR: Traumatic spinal cord injury In Qatar: an epidemiological study. Middle East J Emerg Med 2002;2:1-4.
  55. Soopramanien A: Epidemiology of spinal injuries in Romania. Paraplegia 1994;32:715-722.
  56. Silberstein B, Rabinovich S: Epidemiology of spinal cord injuries in Novosibirsk, Russia. Paraplegia 1995;33:322-325.
  57. Kondakov EN, Simonova IA, Poliakov IV: The epidemiology of injuries to the spine and spinal cord in Saint Petersburg (in Russian). Zh Vopr Neirokhir Im N N Burdenko 2002;2:50-52.
    External Resources
  58. Fromovich-Amit Y, Biering-Sorensen F, Baskov V, Juocevicius A, Hansen HV, Gelernter I, et al: Properties and outcomes of spinal rehabilitation units in four countries. Spinal Cord 2009;47:597-603.
  59. Al-Arabi KM, Al-Sebai MW: Epidemiological survey of spinal cord injury: a study of 377 patients. Ann Saudi Med 1992;12:269-273.
  60. Gosselin RA, Coppotelli C: A follow-up study of patients with spinal cord injury in Sierra Leone. Int Orthop 2005;29:330-332.
  61. Velmahos GC, Degiannis E, Hart K, Souter I, Saadia R: Changing profiles in spinal cord injuries and risk factors influencing recovery after penetrating injuries. J Trauma 1995;38:334-337.
  62. Key AG, Retief PJM: Spinal cord injuries: an analysis of 300 new lesions. Int Med Soc Paraplegia Annu Sci Meet, Tel-Aviv, 1968, pp 243-249.
  63. Hart C, Williams E: Epidemiology of spinal cord injuries: a reflection of changes in South African society. Paraplegia 1994;32:709-714.
  64. Pajareya K: Traumatic spinal cord injuries in Thailand: an epidemiologic study in Siriraj Hospital, 1989-1994. Spinal Cord 1996;34:608-610.
  65. Kovindha A: A retrospective study of spinal cord injuries at Maharaj Nakorn Chiang Mai Hospital, during 1985-1991. Chiang Mai Med Bull 1993;32:85-92.
  66. Kuptniratsaikul V: Epidemiology of spinal cord injuries: a study in the Spinal Unit, Siriraj Hospital, Thailand, 1997-2000. J Med Assoc Thai 2003;86:1116-1121.
    External Resources
  67. Karacan I, Koyuncu H, Pekel O, Sumbuloglu G, Kirnap M, Dursun H, et al: Traumatic spinal cord injuries in Turkey: a nation-wide epidemiological study. Spinal Cord 2000;38:697-701.
  68. Dincer F, Oflazer A, Beyazova M, Celiker R, Basgoze O, Altioklar K: Traumatic spinal cord injuries in Turkey. Paraplegia 1992;30:641-646.
  69. Karamehmetoglu SS, Unal S, Karacan I, Yilmaz H, Togay HS, Ertekin M, et al: Traumatic spinal cord injuries in Istanbul, Turkey. An epidemiological study. Paraplegia 1995;33:469-471.
  70. Gur A, Kemaloglu MS, Cevik R, Sarac AJ, Nas K, Kapukaya A, et al: Characteristics of traumatic spinal cord injuries in south-eastern Anatolia, Turkey: a comparative approach to 10 years' experience. Int J Rehabil Res 2005;28:57-62.
  71. Karamehmetoglu SS, Nas K, Karacan I, Sarac AJ, Koyuncu H, Ataoglu S, et al: Traumatic spinal cord injuries in Southeast Turkey: an epidemiological study. Spinal Cord 1997;35:531-533.
  72. Weerts E: Final reporting of project outcomes. Spinal Cord Injury Care Orthoped Workshop, Hanoi, 2009.
  73. Levy LF, Makarawo S, Madzivire D, Bhebhe E, Verbeek N, Parry O: Problems, struggles and some success with spinal cord injury in Zimbabwe. Spinal Cord 1998;36:213-218.
  74. Rahimi-Movaghar V, Zarei MR, Saadat S, Rasouli MR, Nouri M: Road traffic crashes in Iran from 1997 to 2007. Int J Inj Contr Saf Promot 2009;16:179-181.
  75. Elovic E, Kirschblum S: Epidemiology of spinal cord injury and traumatic brain injury: the scope of the problem. Top Spinal Cord Inj Rehabil 1999;5:1-20.
  76. Gelis A, Dupeyron A, Legros P, Benaïm C, Pelissier J, Fattal C: Pressure ulcer risk factors in persons with spinal cord injury. 2. The chronic stage. Spinal Cord 2009;47:651-661.
  77. Taghipoor KD, Arejan RH, Rasouli MR, Saadat S, Moghadam M, Vaccaro AR, et al: Factors associated with pressure ulcers in patients with complete or sensory-only preserved spinal cord injury: is there any difference between traumatic and nontraumatic causes? J Neurosurg Spine 2009;11:438-444.
  78. Ackery A, Tator C, Krassioukov A: A global perspective on spinal cord injury epidemiology. J Neurotrauma 2004;21:1355-1370.
  79. De Vivo M, Biering-Sorensen F, Charlifue S, Noonan V, Post M, Stripling T, et al: International spinal cord injury core data set. Spinal Cord 2006;44:535-540.
  80. Reilly P: The impact of neurotrauma on society: an international perspective. Prog Brain Res 2007;161:3-9.
  81. Rasouli MR, Nouri M, Zarei MR, Saadat S, Rahimi-Movaghar V: Comparison of road traffic fatalities and injuries in Iran with other countries. Chin J Traumatol 2008;11:131-134.
  82. Rasouli MR, Nouri M, Rahimi-Movaghar V: Spinal cord injuries from road traffic crashes in southeastern Iran. Chin J Traumatol 2007;10:323-326.
    External Resources
  83. Rahimi-Movaghar V: Factors involved in the past and present history of road traffic injuries and deaths in Iran. Arch Iran Med 2010;13:172-173.

Author Contacts

Vafa Rahimi-Movaghar, MD

Research Deputy, Sina Trauma and Surgery Research Center

Sina Hospital, Hassan-Abad Square, Imam Khomeini Avenue

Tehran University of Medical Sciences, Tehran 11365-3876 (Iran)

E-Mail v_rahimi@sina.tums.ac.ir


Article / Publication Details

First-Page Preview
Abstract of Systematic Review

Received: October 15, 2012
Accepted: March 11, 2013
Published online: June 13, 2013
Issue release date: August 2013

Number of Print Pages: 21
Number of Figures: 8
Number of Tables: 2

ISSN: 0251-5350 (Print)
eISSN: 1423-0208 (Online)

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  24. Feng HY, Ning GZ, Feng SQ, Yu TQ, Zhou HX: Epidemiological profile of 239 traumatic spinal cord injury cases over a period of 12 years in Tianjin, China. J Spinal Cord Med 2011;34:388-394.
  25. Li J, Ye C, Sun T, Zhang F: Pattern of sports- and recreation-related spinal cord injuries in Beijing. Spinal Cord 2009;47:857-860.
  26. Wang D, Wu X, Shi G, Wang Y: China's first total care unit for the spinal cord injured. Paraplegia 1990;28:318-320.
  27. Maharaj JC: Epidemiology of spinal cord paralysis in Fiji: 1985-1994. Spinal Cord 1996;34:549-559.
  28. Pedersen V, Müller PG, Biering-Sørensen F: Traumatic spinal cord injuries in Greenland 1965-1986. Paraplegia 1989;27:345-349.
  29. Singh R, Sharma SC, Mittal R, Sharma A: Traumatic spinal cord injuries in Haryana: an epidemiological study. Indian J Community Med 2003;28:184.
  30. Manjeet S, Siddhartha S, Iftikhar WH, Agnivesh T, Farid MH, Nirdosh M, et al: Spine injuries in a tertiary health care hospital in Jammu: a clinico-epidemiological study. Internet J Neurosurg 2009;5:2.
  31. Rahimi-Movaghar V, Saadat S, Rasouli MR, Ganji S, Ghahramani M, Zarei MR, et al: Prevalence of spinal cord injury in Tehran, Iran. J Spinal Cord Med 2009;32:428-431.
  32. Rahimi-Movaghar V, Moradi-Lakeh M, Rasouli MR, Vaccaro AR: Burden of spinal cord injury in Tehran, Iran. Spinal Cord 2010;48:492-497.
  33. Yousefzadeh CS, Safaee M, Alizadeh A, Ahmadi Dafchahi M, Taghinnejadi O, Koochakinejad L: Epidemiology of traumatic spinal injury: a descriptive study. Acta Med Iran 2010;48:308-311.
    External Resources
  34. Fakharian E, Tabesh H, Masoud SA: An epidemiologic study on spinal injuries in Kashan. J Guilan Univ Med Sci 2004;13:79-84.
  35. Otom AS, Doughan AM, Kawar JS, Hattar EZ: Traumatic spinal cord injuries in Jordan - an epidemiological study. Spinal Cord 1997;35:253-255.
  36. Raibulet T, Fakhri S, Khamees MF, Eyadeh AA: Spinal cord injury patients in the Physical Medicine and Rehabilitation Hospital, Kuwait - a nine-year retrospective study. Kuwait Med J 2001;33:211-215.
  37. Toe T: Spinal injuries in Rangoon, Burma. Paraplegia 1978;16:118-120.
  38. Bajracharya S, Singh M, Singh GK, Shrestha B: Clinico-epidemiological study of spinal injuries in a predominantly rural population of eastern Nepal: a 10 years' analysis. Indian J Orthop 2007;41:286-289.
  39. Lakhey S, Jha N, Shrestha BP, Niraula S: Aetioepidemiological profile of spinal injury patients in Eastern Nepal. Trop Doct 2005;35:231-233.
  40. Olasode BJ, Komolafe IE, Komolafe M, Olasode OA: Traumatic spinal cord injuries in Ile-Ife, Nigeria, and its environs. Trop Doct 2006;36:181-182.
  41. Obalum DC, Giwa SO, Adekoya-Cole TO, Enweluzo GO: Profile of spinal injuries in Lagos, Nigeria. Spinal Cord 2009;47:134-137.
  42. Udosen A, Ikpeme A, Ngim N: A prospective study of spinal cord injury in the University of Calabar Teaching Hospital, Calabar, Nigeria. Internet J Orthop Surg 2007;5:1.
  43. Iwegbu CG: Traumatic paraplegia in Zaria, Nigeria: the case for a centre for injuries of the spine. Paraplegia 1983;21:81-85.
  44. Igun GO, Obekpa OP, Ugwu BT, Nwadiaro HC: Spinal injuries in the Plateau State, Nigeria. East Afr Med J 1999;76:75-79.
  45. Solagberu BA: Spinal cord injuries in Ilorin, Nigeria. West Afr J Med 2002;21:230-232.
    External Resources
  46. Nwankwo OE, Katchy AU: Outcome of a 12-week programme for management of the spinal cord injured with participation of patient's relations at Hilltop Orthopaedic Hospital, Enugu, Nigeria. Spinal Cord 2003;41:129-133.
  47. Nwadinigwe CU, Iloabuchi TC, Nwabude IA: Traumatic spinal cord injuries (SCI): a study of 104 cases. Niger J Med 2004;13:161-165.
  48. Rathore MF, Hanif S, Farooq F, Ahmad N, Mansoor SN: Traumatic spinal cord injuries at a tertiary care rehabilitation institute in Pakistan. J Pak Med Assoc 2008;58:53-57.
    External Resources
  49. Masood Z, Wardug GM, Ashraf J: Spinal injuries: experience of a local neurosurgical centre. Pak J Med Sci 2008;24:368-371.
    External Resources
  50. Raja IA, Vohra AH, Ahmed M: Neurotrauma in Pakistan. World J Surg 2001;25:1230-1237.
  51. Qureshi AA, Irfan A, Memon MA: Spinal injuries: a prospective study. Biomedica 2001;17:27-29.
  52. Gee RW, Sinha SN: The epidemiology of spinal cord injuries in Papua New Guinea. PNG Med J 1982;25:97-99.
  53. Jankowski R, Zukiel R, Nowak S, Czekanowska-Szlandrowicz R, Stachowska-Tomczak B: Vertebral column and spinal cord injuries: isolated and concomitant with multiple injury. Chir Narz Ruchu Ortop Pol 1993;58:353-359.
  54. Mena Quinones PO, Nassal M, Al Bader KI, Al Muraikhi AE, Al Kahlout SR: Traumatic spinal cord injury In Qatar: an epidemiological study. Middle East J Emerg Med 2002;2:1-4.
  55. Soopramanien A: Epidemiology of spinal injuries in Romania. Paraplegia 1994;32:715-722.
  56. Silberstein B, Rabinovich S: Epidemiology of spinal cord injuries in Novosibirsk, Russia. Paraplegia 1995;33:322-325.
  57. Kondakov EN, Simonova IA, Poliakov IV: The epidemiology of injuries to the spine and spinal cord in Saint Petersburg (in Russian). Zh Vopr Neirokhir Im N N Burdenko 2002;2:50-52.
    External Resources
  58. Fromovich-Amit Y, Biering-Sorensen F, Baskov V, Juocevicius A, Hansen HV, Gelernter I, et al: Properties and outcomes of spinal rehabilitation units in four countries. Spinal Cord 2009;47:597-603.
  59. Al-Arabi KM, Al-Sebai MW: Epidemiological survey of spinal cord injury: a study of 377 patients. Ann Saudi Med 1992;12:269-273.
  60. Gosselin RA, Coppotelli C: A follow-up study of patients with spinal cord injury in Sierra Leone. Int Orthop 2005;29:330-332.
  61. Velmahos GC, Degiannis E, Hart K, Souter I, Saadia R: Changing profiles in spinal cord injuries and risk factors influencing recovery after penetrating injuries. J Trauma 1995;38:334-337.
  62. Key AG, Retief PJM: Spinal cord injuries: an analysis of 300 new lesions. Int Med Soc Paraplegia Annu Sci Meet, Tel-Aviv, 1968, pp 243-249.
  63. Hart C, Williams E: Epidemiology of spinal cord injuries: a reflection of changes in South African society. Paraplegia 1994;32:709-714.
  64. Pajareya K: Traumatic spinal cord injuries in Thailand: an epidemiologic study in Siriraj Hospital, 1989-1994. Spinal Cord 1996;34:608-610.
  65. Kovindha A: A retrospective study of spinal cord injuries at Maharaj Nakorn Chiang Mai Hospital, during 1985-1991. Chiang Mai Med Bull 1993;32:85-92.
  66. Kuptniratsaikul V: Epidemiology of spinal cord injuries: a study in the Spinal Unit, Siriraj Hospital, Thailand, 1997-2000. J Med Assoc Thai 2003;86:1116-1121.
    External Resources
  67. Karacan I, Koyuncu H, Pekel O, Sumbuloglu G, Kirnap M, Dursun H, et al: Traumatic spinal cord injuries in Turkey: a nation-wide epidemiological study. Spinal Cord 2000;38:697-701.
  68. Dincer F, Oflazer A, Beyazova M, Celiker R, Basgoze O, Altioklar K: Traumatic spinal cord injuries in Turkey. Paraplegia 1992;30:641-646.
  69. Karamehmetoglu SS, Unal S, Karacan I, Yilmaz H, Togay HS, Ertekin M, et al: Traumatic spinal cord injuries in Istanbul, Turkey. An epidemiological study. Paraplegia 1995;33:469-471.
  70. Gur A, Kemaloglu MS, Cevik R, Sarac AJ, Nas K, Kapukaya A, et al: Characteristics of traumatic spinal cord injuries in south-eastern Anatolia, Turkey: a comparative approach to 10 years' experience. Int J Rehabil Res 2005;28:57-62.
  71. Karamehmetoglu SS, Nas K, Karacan I, Sarac AJ, Koyuncu H, Ataoglu S, et al: Traumatic spinal cord injuries in Southeast Turkey: an epidemiological study. Spinal Cord 1997;35:531-533.
  72. Weerts E: Final reporting of project outcomes. Spinal Cord Injury Care Orthoped Workshop, Hanoi, 2009.
  73. Levy LF, Makarawo S, Madzivire D, Bhebhe E, Verbeek N, Parry O: Problems, struggles and some success with spinal cord injury in Zimbabwe. Spinal Cord 1998;36:213-218.
  74. Rahimi-Movaghar V, Zarei MR, Saadat S, Rasouli MR, Nouri M: Road traffic crashes in Iran from 1997 to 2007. Int J Inj Contr Saf Promot 2009;16:179-181.
  75. Elovic E, Kirschblum S: Epidemiology of spinal cord injury and traumatic brain injury: the scope of the problem. Top Spinal Cord Inj Rehabil 1999;5:1-20.
  76. Gelis A, Dupeyron A, Legros P, Benaïm C, Pelissier J, Fattal C: Pressure ulcer risk factors in persons with spinal cord injury. 2. The chronic stage. Spinal Cord 2009;47:651-661.
  77. Taghipoor KD, Arejan RH, Rasouli MR, Saadat S, Moghadam M, Vaccaro AR, et al: Factors associated with pressure ulcers in patients with complete or sensory-only preserved spinal cord injury: is there any difference between traumatic and nontraumatic causes? J Neurosurg Spine 2009;11:438-444.
  78. Ackery A, Tator C, Krassioukov A: A global perspective on spinal cord injury epidemiology. J Neurotrauma 2004;21:1355-1370.
  79. De Vivo M, Biering-Sorensen F, Charlifue S, Noonan V, Post M, Stripling T, et al: International spinal cord injury core data set. Spinal Cord 2006;44:535-540.
  80. Reilly P: The impact of neurotrauma on society: an international perspective. Prog Brain Res 2007;161:3-9.
  81. Rasouli MR, Nouri M, Zarei MR, Saadat S, Rahimi-Movaghar V: Comparison of road traffic fatalities and injuries in Iran with other countries. Chin J Traumatol 2008;11:131-134.
  82. Rasouli MR, Nouri M, Rahimi-Movaghar V: Spinal cord injuries from road traffic crashes in southeastern Iran. Chin J Traumatol 2007;10:323-326.
    External Resources
  83. Rahimi-Movaghar V: Factors involved in the past and present history of road traffic injuries and deaths in Iran. Arch Iran Med 2010;13:172-173.
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