A Systematic Review of Non-Traumatic Spinal Cord Injuries in Sub-Saharan Africa and a Proposed Diagnostic Algorithm for Resource-Limited Settings

Abstract

BackgroundNon-traumatic myelopathy is common in Africa and there are geographic differences in etiology. Clinical management is challenging due to the broad differential diagnosis and the lack of diagnostics. The objective of this systematic review is to determine the most common etiologies of non-traumatic myelopathy in sub-Saharan Africa to inform a regionally appropriate diagnostic algorithm.MethodsWe conducted a systemic review searching Medline and Embase databases using the following search terms: “Non traumatic spinal cord injury” or “myelopathy” with limitations to epidemiology or etiologies and Sub-Saharan Africa. We described the frequencies of the different etiologies and proposed a diagnostic algorithm based on the most common diagnoses.ResultsWe identified 19 studies all performed at tertiary institutions; 15 were retrospective and 13 were published in the era of the HIV epidemic. Compressive bone lesions accounted for more than 48% of the cases; a majority were Pott’s disease and metastatic disease. No diagnosis was identified in up to 30% of cases in most studies; in particular, definitive diagnoses of non-compressive lesions were rare and a majority were clinical diagnoses of transverse myelitis and HIV myelopathy. Age and HIV were major determinants of etiology.ConclusionCompressive myelopathies represent a majority of non-traumatic myelopathies in sub-Saharan Africa, and most were due to Pott’s disease. Non-compressive myelopathies have not been well defined and need further research in Africa. We recommend a standardized approach to management of non-traumatic myelopathy focused on identifying treatable conditions with tests widely available in low-resource settings.

Epidemiology of non-traumatic spinal cord injury in Uganda: a single center, prospective study with MRI evaluation

“…This would give us a proportion of 38% (39/103) participants with lesions that can be diagnosed by bone-based investigations like X-rays and CTs leaving 62% undiagnosed. Historically, most of the spinal cord pathology in Africa with a diagnosis has been compressive bone lesions with about 60% from Potts’ disease and tumors [1, 8]. Our results show a change in the trend with more non-bone extradural lesions and intradural lesions.…”

“…Our results highlight the increasing significance of MRI among patients with non-traumatic SCI admitted on in the medical or neurology ward since over 60% of the patients will not benefit from the radiation-based investigations X rays and CT. The differential diagnosis of non-traumatic spinal cord injury is wide [1, 8]. This provides a challenge in choosing the appropriate cheaper investigational modalities.…”

“…Vascular injuries can be evaluated using CT or MR angiography [6] While CT and X-ray are limited to diagnose bony compressive lesions or extradural compressive lesions, MRI is useful in the diagnosis of all types of lesions. Few reliable national data concerning the etiology of non-traumatic SCI in sub-Sahara Africa exists, mainly because of the limitations of diagnostic imaging [1, 2, 8]. These are both expensive and mostly unavailable in several resource-limited settings.…”

Bone morphogenic protein signaling in spinal cord injury

“…Spinal cord injury (SCI) can be either traumatic or non-traumatic damage to the spinal cord and has a peak prevalence of approximately 906-1800 cases per million people in the United States [1][2][3] . SCI usually causes complete or partial motor and sensory neurological deficits with deleterious outcomes [4] .…”

Secondary health conditions and their impact on the wellbeing of people with spinal cord injury, South Africa: Patients perspective.

“…Spinal cord injury (SCI) is a physical disability caused by a complete or incomplete lesion in the spine either due to trauma (gunshot, vehicle accidents, sports-related injuries and falls) or diseases like HIV, cancer, arthritis, cancer, and tuberculosis (TB) (1)(2)(3). The prevalence of SCI was estimated to range from 698-827 per million population among high-income countries and 220-519 per million people in low-income countries (4).…”