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Neurotrauma burden in a tropical urban conurbation level I trauma centre
Injury, Int. J. Care Injured 45 (2014) 1717–1721
Contents lists available at ScienceDirect
Injury journal homepage: www.elsevier.com/locate/injury
Neurotrauma burden in a tropical urban conurbation level I trauma centre O.E. Idowu a,b,*, O. Akinbo b a b
Neurosurgery Division, Department of Surgery, Lagos State University College of Medicine, Ikeja, Lagos, Nigeria Neurosurgery Division, Department of Surgery, Lagos State University Teaching Hospital, Ikeja, Lagos, Nigeria
A R T I C L E I N F O
A B S T R A C T
Article history: Accepted 22 May 2014
Background: Neurotrauma is a preventable public health problem whose quantum is said to be increasing in Third-World countries. This evaluation was performed to collate data which is needed to guide in designing, implementing, and evaluating public health prevention programmes with respect to neurotrauma. Methods: A single institution prospective study was carried out. Data was collected at the surgical emergency (SE) room over a year period (1st October 2012–30th September 2013). These included patients’ demographics, cause of injury, region of the body involved, Glasgow coma scale score, and outcome. The patients were further divided into patients with traumatic brain (TBI) and spine injury (TSI). Analysis of the variables was by simple proportion, percentages, Chi-square and analysis of variance was used to determine the differences between group means. A probability (p) of less than 0.05 was considered statistically significant. Results: A total of 2149 neurotrauma cases (38.8%) out of a total of 5541 surgical trauma cases were seen within the study period at our SE unit. Of the neurotrauma cases, 1621 were males, giving a male:female ratio of 3.1:1. The mean age was 31 years (median 30 years). The most common age group was 20–29 (29.6%) and 30–39 years (29.6%). Assault was the cause of neurotrauma in 903 patients (42%), closely followed by road traffic injury in 744 patients (34.6%). Brain and spine injury separately occurred in 93.2% and 5.3% of cases, respectively. Five hundred patients (23.3%) were resuscitated and referred to other centres due to lack of bed space. Forty (1.9%) patients were dead on arrival, while twenty-six (1.2%) died while on treatment at the emergency room. Conclusion: Neurotrauma is one of the most common form of trauma at our surgical emergency. Assault and road traffic injury (RTI) were the most common cause of TBI and TSI respectively, with RTI being the most common cause of moderate and severe TBI. The incidence and aetiology of TBI varies according to age and gender. ß 2014 Elsevier Ltd. All rights reserved.
Keywords: Assault Neurotrauma Road traffic injury Traumatic brain injury Traumatic spine injury
Introduction Neurotrauma is generally regarded as a public health problem that has earned the attention of the world’s health community. It may be in the form of traumatic brain injury (TBI) or traumatic spinal cord/caudal equinal injury (TSI). Their treatment and management frequently necessitates long-term care and consequently incurs economic cost to health systems.
* Corresponding author at: Neurosurgery Division, Department of Surgery, Lagos State University College of Medicine, Ikeja, Lagos, Nigeria. Tel.: +234 08023 451 369. E-mail address: [email protected] (O.E. Idowu). http://dx.doi.org/10.1016/j.injury.2014.05.028 0020–1383/ß 2014 Elsevier Ltd. All rights reserved.
The impairments leading to permanent disabilities and sometimes mortalities associated with neurotrauma account for substantial losses in terms of pains and economics to individuals, families, and communities. Traumatic brain injury may lead to an eclectic range of short- or long-term issues affecting: cognitive, emotion, motor and sensory functions. For individuals hospitalized after a TBI, almost half (43%) have a related disability one year after the injury [1]. When severe, TBI can adversely affect all aspects of an individual’s life [2]. This can include impaired interactions with family and friends, capability to do household tasks, and/or participate in other activities of daily living, ability to drive, to work or be employed. Among the many issues that can follow TBI (as part of post-concussion syndrome), are problems related to the eyes and vision [3].
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Blurred vision, photophobia, and diplopia have been reported [4–6]. These can occur subsequent to TBI from all causes, regardless of severity. Problems with binocular vision, extraocular muscle function, and the accommodative system have also been found at relatively high frequencies [4–6]. These and other TBI-related vision problems have the potential to affect daily functioning in affected patients. On the other hand TSI especially when the spinal cord is involved, results in complications affecting nearly all systems of the body, leading to an increased morbidity and mortality in this group of patients. The complications profile reported from the developing countries are similar to that of the developed world with notably increased incidence [7]. When compared with common conditions TBI occurs more than any other disease, including breast cancer, acquired immune deficiency syndrome, Parkinson’s disease and multiple sclerosis, and affects all age groups and both genders [8]. Traumatic brain injury (TBI) afflicts more Americans annually than Alzheimer’s and Parkinson’s disease combined [9]. In many countries, it affects the younger age group, but unlike some diseases the causes are known and quite preventable. With respect to TSI, the general demographics in the developing world share some similarities with the epidemiological pattern reported from the developed countries [10]. A retrospective study in Ilorin, Nigeria in 2008, over a 10-year period noted 648 patients aged 1–105 years (mean = 37 years) with TBI [11]. A cross-sectional study of all neurotrauma cases admitted to the neurosurgical service at Ile-Ife, southwestern Nigeria in 2013, over an 18-month period noted 143 patients [12]. A recent estimate indicates that each year 235,000 Americans are hospitalized for nonfatal TBI, 1.1 million are treated in emergency departments, and 50,000 die [13]. A northern Finland birth cohort study noted that the annual incidence of and mortality from TBI were 118 and 14/100,000, respectively; case fatality was 12%; an estimated prevalence of TBI at the age of 34 years was 269/100,000 [14]. On the other hand, a Christchurch New Zealand birth cohort article noted that the average incidence for 0–25 year age group ranged from 1.10 to 2.36 per 100 per year, with an overall prevalence of approximately 30% [15]. The common causes of TBI are road traffic crashes, falls and violence. The most common source of injury was falls for individuals 0–14 years of age and contact sports and motor vehicle accidents for 15–25 year olds [16]. Among all age groups, motor vehicle crashes and traffic-related incidents result in the largest percentage of TBI-related deaths (31.8%) [16]. The World Health Organization (WHO) predicts that unless there are changes in present policies including putting in place additional road safety countermeasures, there will be a major increase in road traffic fatalities over the next two decade and beyond [17]. In Nigeria, a developing, West African country, trauma system design has not been well addressed. Our Nation like most low-income and middle-income developing countries does not have established national trauma, TBI or TSI registries, which is an integral component of modern comprehensive trauma care systems. The quantum of TBI is on the rise in Third-World countries, where it over burdens an already inadequate health care resources [18]. The workload emanating from neurotrauma increase will also affect the ability of neurosurgeons to function in their specialty, particularly if working independently or in a small group practice. However, the number of deaths and burden of disability of neurotrauma can be reduced through preventive measures after an epidemiological survey on trauma. In the light of this, countries need to develop surveillance systems and conduct epidemiologic studies to measure the impact of neurotrauma among their people to guide in designing, implementing, and evaluating public health prevention programmes.
Our aim is to collate data which is needed to be able to apply public health tools in prevention strategies, identify research and education priorities in neurotrauma. Patients and methods A single institution prospective study was carried out at the Lagos State University Teaching Hospital, Ikeja, Lagos, Nigeria, over a one-year period. Setting The hospital is a 750 bed hospital, a 2003 upgrading of the General Hospital at Ikeja (itself a 1967 upgrade of a Cottage Hospital built in 1955 during the British colonial rule in Nigeria). It is located in the most densely populated state in Nigeria with population of over 13 million in 2006 census and 18 million in 2012 estimate [19]. The State is located in the southwestern part of Nigeria and is the smallest in area of Nigeria’s states; it is the most populous state and the nation’s largest urban area, and arguably the most economically important state of the country and West Africa. The Nigerian population is 167 million – about 20% of population of Africa, the largest population of any African country. Traumatic brain injury was defined as brain dysfunction emanating from an external mechanical force, and subsequently classified as mild in a person who has had a traumatically induced physiological disruption of brain function, as manifested by at least one of the following, Glasgow coma scale score (GCS) of 13 or 14, any period of loss of consciousness, any loss of memory for events immediately before or after the accident, any alteration in mental state at the time of the accident (e.g., feeling dazed, disoriented, or confused); and focal neurological deficit that may or may not be transient; moderate was defined with a GCS of 9–12 and severe injury with a GCS of 3–8. Traumatic spine injury was defined as acute injury following trauma to the spinal cord and or cauda equina that leads to varying degrees of motor and/or sensory deficits and paralysis, the definition excludes isolated injuries to peripheral nerves. Data collection and analysis Data collection was from all surgical emergency (SE) room admissions from 1st October 2012 to 30th September 2013. This was commenced two months after a ban on two wheeler commercial vehicles on major highways in the state. The information collected included demographics, cause of injury, region of the body involved, severity and outcome. These were entered into an electronic database. Analysis of the variables was by simple proportion, percentages, Chi-square and analysis of variance was used to determine the differences between group means. A probability (p) of less than 0.05 was considered statistically significant. Data analysis was performed using Statistical Package for the social Sciences version 17, Chicago, Illinois. Results A total of 2149 neurotrauma cases out of a total of 5541 surgical trauma cases were seen within the study period at our SE unit. Of the neurotrauma cases, 1621 were males and the rest were females, giving a male:female ratio of 3.1:1. The mean age was 31 years (median 30 years). The most common age group were 20–29 and 30–39 years which accounted for 29.6% each (Fig. 1). Assault was the cause of neurotrauma in 903 patients (42%), closely followed by road traffic injury in 744 patients (34.6%). Road traffic injury was more common among young adults as compared
O.E. Idowu, O. Akinbo / Injury, Int. J. Care Injured 45 (2014) 1717–1721
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Fig. 1. Age distribution of all patients with neurotrauma.
to falls which was most common cause of neurotrauma in children (Table 1). Females had their injury resulting from assaults (excluding gunshot injuries) in 230 cases (43.6%) closely followed by road traffic injury (164 cases, 31.1%). There was significant relationship between mean age and gender (p = 0.015), mean age and cause of trauma (p = 0.000), gender and cause of trauma (p = 0.012), and region of the body injured and aetiology of injury (p = 0.000). The gender was also significant associated with the age stratification (p = 0.016), likewise age stratification with aetiology of injury (p = 0.000). However there was no significant relationship between gender and region of the body injured (p = 0.800). Traumatic brain injury was the main type of neurotrauma (2035 patients, 94.7%), 11 of which had associated spine injury. Most patients with TBI had mild brain injury (1801 patients, 88.5%); while 5.3% (108 patients) and 6.2% (126 patients) had Table 1 Age stratification and the cause of neurotrauma. Age (years)
Trauma type
Total
RTI
Falls
Assaults (excluding gunshot)
GSI
0–9 10–19 20–29 30–39 40–49 50–59 60–69 70–79 80–89 90–99
48 49 184 251 104 66 32 6 3 1
109 21 51 49 26 16 19 6 2 1
10 50 350 288 135 45 16 5 3 1
0 1 11 15 9 5 1 0 0 0
36 21 40 34 11 10 5 2 0 1
203 142 636 637 285 142 73 19 8 4
Total
744
300
903
42
160
2149
RTI, road traffic injury; GSI, gunshot injury.
Others
moderate and severe brain injury, respectively. Mild brain injury was usually caused by assault (48.3%) while moderate and severe brain injury usually results from road traffic injury (RTI), 75.9% and 73.0%, respectively (Table 2). One hundred and twenty-five patients had spine injury, 11 of which had spine injury in conjunction with brain injury. The aetiology of the spine injury was secondary to RTI in 47.2% (50 cases), falls in 24.8% (29 cases) and assault in 13.6% (17 cases) (Fig. 2). Five hundred out of the total 2149 patients (23.3%) were referred after resuscitation due to bed space challenges. Of these 500 patients, 462 (92.4%), 21 (4.2%) and 17 (3.4%) of them had mild, moderate and severe brain injury, respectively. Patients that were referred were more likely to have mild brain injury than those who were admitted after resuscitation (p = 0.002). Forty (1.9%) patients were dead on arrival (DOA). They were all TBI cases. Twenty-six (1.6%) died while on treatment at the emergency room. Forty-seven patients required neurosurgical intervention which is available in our centre (one of the two public hospital rendering neurosurgical services in the state). Road traffic injury was the cause of injury in 25 and 22 of the DOA and in-hospital deaths, respectively.
Table 2 Severity of traumatic brain injury. Aetiology
Mild (%)
Moderate (%)
Severe (%)
Total
RTI Falls Assault GSI Others Total
520 233 870 32 146 1801
82 15 7 1 3 108
92 23 9 2 0 126
694 271 886 35 149 2035
(28.9) (12.9) (48.3) (1.8) (8.1)
(75.9) (13.9) (6.5) (0.9) (2.8)
(73) (18.6) (7.1) (1.6) (0)
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Fig. 2. Spine injury aetiology.
Discussion Neurotrauma is associated with potentially devastating and sometimes irreversible neurological injury, resulting in varying degrees of deficits. There are no established national trauma or SCI registries in most developing countries. Similarly there is no population based data on neurotrauma available from majority of the third-world countries. This is complicated by the fact that medical record keeping is poorly managed in most of the hospitals [20]. Nigeria where our study was conducted is not left out. Most of the available data in the literature are single centre hospital based studies and retrospective surveys. Ours is also a hospital based study due to our local shortfalls. The quantum of neurotrauma in our environment is quite high. Nearly 40% of our trauma burden is related to neurotrauma. There is great disparity between the neurotrauma burden and the available neurosurgical manpower in our region. There is a very strong need to reduce the burden of work on these specialists, by increasing the number of available doctors in the service. Neurotrauma was more common in males and the age at presentation is similar to most studies [11,12]. In our study there was a significant gender difference (p = 0.015). Most our patients presented between 20–29 years (29.6%) and 30–39 years (29.6%). Odebode [11] noted that injuries occurred mostly in males and in the third decade. In a Pakistani study of patients with neurotrauma admitted to various neurosurgical centres from July 1, 1995 to June 30, 1999. A total of 260,000 patients were admitted over a 4-year period. The majority of patients presented during the second decade (33.2%) followed by first and third decade; there were 195,000 (75%) males and 65,000 (25%) females with a ratio of 3:1 [18]. In general, this study showed that violence was a major cause of neurotrauma; accounting for 44% (assault and gunshot injury) of all cases. This was closely followed by RTI (34.6%). The assault aetiology rate was higher in females (females – 43.6%, males – 41.55%) when compared with RTI aetiology (females – 31.1%, males – 35.8%). This is at variant with the study of Odebode [11] from mid-western Nigeria, Faul et al. [16] from Georgia, United States of America, and Raja et al. [18] from Pakistan, where TBI was usually secondary to RTI. In Ile-Ife, a relatively suburban city in Nigeria, 81% of the traumas were due to RTI. Our findings may be due to the peculiar nature of Lagos. It is the smallest state in Nigeria (356,861 hectares of which 75,755 hectares are wetlands), most urban, a conurbation of cities with the high population of 18 million; associated with this is the persistent bubbling and hustling emanating from its being the main commercial hub. In addition our study revealed that in the first decade of life, fall was the usual cause of neurotrauma (53.7%), more than doubling the impact of RTI. In older adults between 50 and 80 years, RTI was the most common cause of TBI; with RTI quite common between
60 and 69 years of age group (Table 1). In the patients with moderate and severe TBI the main cause of injury was RTI (Table 2). Similarly, almost 50% of spine injury resulted from RTI. McKinlay et al. [15] also noted that falls was the usual cause of TBI in patients within the first one and half decade. The case frequency of DOA is an index of prehospital care. Significantly this study shows RTI and gunshot injuries (34 out of 40 cases of DOA) accounted for most of the DOA. This finding is a further call to develop legislation on prehospital care. All the patients that died while on treatment at the Emergency room were victims of RTI (22 patients) and falls (4 patients). Injuries still cause the death of over five million people world-wide each year despite it no longer being perceived as inevitable, but largely preventable events [21]. Out of this huge number, 1.2 million are due to RTI, 90 per cent of which take place in low and middle income countries [22,23]. It is predicted that by 2020, RTI will become a major culprit in the total disease burden [22,24]. Most of our patients had mild TBI (88.5%) and 6.2% of them had severe TBI. In Raja et al. [18] study, mild, moderate, and severe TBI was observed in 52%, 30%, and 18% of patients, respectively. Unfortunately, many individuals who sustain a form of TBI are prone to various medical, psychological, social, academics and alcohol abuse amongst others [25,26]. Mild brain injury is usually associated with concussions. Severity of concussion is measured using various concussion grading scales. A slightly greater injury is associated with both anterograde and retrograde amnesia. The amount of time that the amnesia is present correlates with the severity of the injury. In some cases persistent post-concussion syndrome (PCS) develops. The symptoms of PCS may persist for days, months, or years after the injury and often include fatigue, dizziness, headache, poor concentration, memory impairment and depression, many of which can impede daily activities. Many American soldiers, even those undiagnosed but likely suffering from mild TBI, displays Alzheimer’s disease (AD)-like cognitive impairments, suggesting a pathological overlap between TBI and AD [27]. A non-fatal severe TBI may result in long term disability or mortality. In the elderly, people aged 75 years old and older are said to have the highest rates of TBI-related hospitalizations and death [16]. A prior Nigerian study noted that older patients had the poorest outcome with a mortality rate of 48.7% [11]. The study reaffirms that outcome of brain injury worsens with advancing age and indicates that severity of brain injury and higher frequency of multi-system trauma may contribute to worse outcome in older patients [11]. In Nigeria, as in many Third-world countries, Neurological rehabilitation is still at an infancy stage in Nigeria. Neurotrauma is a growing public health concern. To reduce the overall burden of neurotrauma the action to be taken will have to extend from the political scene to the basic patient care. There have been remarkable advances in the understanding of acute brain and spinal cord injury and encouraging possibilities for effective neuroprotection, repair and regeneration but in the broader context prevention of neurotrauma is the urgent imperative. Pre-injury education (assault avoidance and traffic laws enforcement) and road engineering is encouraged. Public health mechanisms (health education- assault avoidance, and traffic laws enforcement, and road engineering) to reduce the burden of neurotrauma while the development and adoption of national clinical guidelines for neurotrauma is advocated. In this endeavour the neuroscientist has knowledge which informs and encourages policy makers to take the steps necessary to reduce injury. These steps require political will and community support for hard decisions which impact on the way people conduct their daily lives. The workload demand will affect the ability of neurosurgeons to function in their specialty, particularly if working independently or in a small group practice.
O.E. Idowu, O. Akinbo / Injury, Int. J. Care Injured 45 (2014) 1717–1721
In conclusion, neurotrauma is one of the most common form of trauma at our surgical emergency. Assault and RTI were the most common cause of TBI and TSI, respectively, with RTI being the most common cause of moderate and severe TBI. The incidence and aetiology of TBI varies according to age and gender. The number of deaths and burden of disability of TBI can be reduced through preventive measures after an epidemiological survey on trauma. The goal can be achieved to a significant extent through the use of guidelines. In the light of this, countries need to develop surveillance systems and conduct epidemiologic studies to measure the impact of neurotrauma among their people. Designing, implementing, and evaluating public health prevention programmes including health education, traffic laws enforcement, and appropriate road engineering is encouraged will help in reducing neurotrauma burden. Development, establishment and adoption of a national trauma registry and of national clinical guidelines for neurotrauma are also advocated. Conflict of interests None. References [1] Selassie AW, Zaloshnja E, Langlois JA, Miler T, Jones P, Steiner C. Incidence of long-term disability following traumatic brain injury hospitalization, United States, 2003. J Head Trauma Rehabil 2008;23:123–31. [2] Thurman D, Alverson C, Dunn K, Guerrero J, Sniezek J. Traumatic brain injury in the United States: a public health perspective. J Head Trauma Rehabil 1999;14: 602–15. [3] King NS. Post-concussion syndrome: clarity amid the controversy? Br J Psychiatry 2003;183:276–8. [4] Brahm KD, Wilgenburg HM, Kirby J, Ingalla S, Chang CY, Goodrich GL. Visual impairment and dysfunction in combat-injured service members with traumatic brain injury. Optom Vis Sci 2009;86:817–25. [5] Stelmack JA, Frith T, Van Koevering D, Rinne S, Stelmack TR. Visual function in patients followed at a Veterans affairs polytrauma network site: an electronic medical record review. Optometry 2009;80:419–24. [6] Ciuffreda KJ, Kapoor N, Rutner D, Suchoff IB, Han ME, Craig S. Occurrence of oculomotor dysfunctions in acquired brain injury: a retrospective analysis. Optometry 2007;78:155–61. [7] Chacko V, Joseph B, Mohanty SP, Jacob T. Management of spinal cord injury in a general hospital in rural India. Paraplegia 1986;24:330–5.
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[8] Prins M, Greco T, Alexander D, Giza CC. The pathophysiology of traumatic brain injury at a glance. Dis Model Mech 2013;6:1307–15. [9] Ottens AK, Kobeissy FH, Golden EC, Zhang Z, Haskins WE, Chen SS, et al. Neuroproteomics in neurotrauma. Mass Spectrom Rev 2006;25:380–408. [10] Rathore MF, Hanif S, Farooq F, Ahmad N, Mansoor SN. Traumatic spinal cordinjuries at a tertiary care rehabilitation institute in Pakistan. J Pak Med Assoc 2008;58:53–7. [11] Odebode TO. Age related pattern and outcome of head injury in indigenous Africa. Niger J Clin Pract 2008;11:265–9. [12] Adeolu AA, Abiona TC, Komolafe EO, Adeolu JO, Adegbehingbe OO. Epidemiology of neurotrauma in Ife-Ijesha zone of Nigeria. World Neurosurg 2013;80: 251–4. [13] Corrigan JD, Selassie AW, Orman JA. The epidemiology of traumatic brain injury. J Head Trauma Rehabil 2010;25:72–80. [14] Winqvist S, Lehtilahti M, Jokelainen J, Luukinen H, Hillbom M. Traumatic brain injuries in children and young adults: a birth cohort study from northern Finland. Neuroepidemiology 2007;29:136–42. [15] McKinlay A, Grace RC, Horwood LJ, Fergusson DM, Ridder EM, MacFarlane MR. Prevalence of traumatic brain injury among children, adolescents and young adults: prospective evidence from a birth cohort. Brain Inj 2008;22:175–81. [16] Faul M, Xu L, Wald MM, Coronado VG. Traumatic brain injury in the United States: emergency department visits, hospitalizations, and deaths. Atlanta, GA: Centers for Disease Control and Prevention, National Center for Injury Prevention and Control; 2010. [17] World Health Organisation. (2004). Available from: www.who.int. [18] Raja IA, Vohra AH, Ahmed M. Neurotrauma in Pakistan. World J Surg 2001;25: 1230–7. [19] National Population Commission of Nigeria. Population and housing census; 2006, http://www.population.gov.ng/images/Vol_7_educational_attainment. pdf. [20] Thanni LO, Kehinde OA. Trauma at a Nigerian teaching hospital: pattern and documentation of presentation. Afr Health Sci 2008;6:104–7. [21] Kalaiselvan G, Dongre AR, Mahalakshmy T. Epidemiology of injury in rural Pondicherry. J Inj Violence Res 2003;3:62–7. [22] McGee K, Sethi D, Peden M, Habibula S. Guidelines for conducting community surveys on injuries and violence. Inj Contr Saf Promot 2004;11:303–6. [23] Peden M, Scurfield R, Sleet D, Mohan D, Hyder AA, Jarawan E, et al. World report on road traffic injury prevention. Geneva: World Health Organization; 2004. [24] Peden M, McGee K, Sharma G. The injury chart book. A graphical overview of global burden of injuries. Geneva: World Health Organization; 2002. [25] TBI Community [Internet]. Resources and publications. Houston, TX: RRTC on Community Integration of Persons with Traumatic Brain Injury; 2013 Available from:http://www.tbicommunity.org/resources/index.htm. [26] Hoge CW, McGurk D, Thomas JL, Cox AL, Engel CC, Castro CA. Mild traumatic brain injury in U.S. Soldiers returning from Iraq. N Engl J Med 2008;358(5): 453–63. [27] Tajiri N, Kellogg SL, Shimizu T, Arendash GW, Borlongan CV. Traumatic brain injury precipitates cognitive impairment and extracellular ab aggregation in Alzheimer’s disease transgenic mice. PLoS ONE 2013;8(November (11)): e78851. http://dx.doi.org/10.1371/journal.pone.0078851.
Contents lists available at ScienceDirect
Injury journal homepage: www.elsevier.com/locate/injury
Neurotrauma burden in a tropical urban conurbation level I trauma centre O.E. Idowu a,b,*, O. Akinbo b a b
Neurosurgery Division, Department of Surgery, Lagos State University College of Medicine, Ikeja, Lagos, Nigeria Neurosurgery Division, Department of Surgery, Lagos State University Teaching Hospital, Ikeja, Lagos, Nigeria
A R T I C L E I N F O
A B S T R A C T
Article history: Accepted 22 May 2014
Background: Neurotrauma is a preventable public health problem whose quantum is said to be increasing in Third-World countries. This evaluation was performed to collate data which is needed to guide in designing, implementing, and evaluating public health prevention programmes with respect to neurotrauma. Methods: A single institution prospective study was carried out. Data was collected at the surgical emergency (SE) room over a year period (1st October 2012–30th September 2013). These included patients’ demographics, cause of injury, region of the body involved, Glasgow coma scale score, and outcome. The patients were further divided into patients with traumatic brain (TBI) and spine injury (TSI). Analysis of the variables was by simple proportion, percentages, Chi-square and analysis of variance was used to determine the differences between group means. A probability (p) of less than 0.05 was considered statistically significant. Results: A total of 2149 neurotrauma cases (38.8%) out of a total of 5541 surgical trauma cases were seen within the study period at our SE unit. Of the neurotrauma cases, 1621 were males, giving a male:female ratio of 3.1:1. The mean age was 31 years (median 30 years). The most common age group was 20–29 (29.6%) and 30–39 years (29.6%). Assault was the cause of neurotrauma in 903 patients (42%), closely followed by road traffic injury in 744 patients (34.6%). Brain and spine injury separately occurred in 93.2% and 5.3% of cases, respectively. Five hundred patients (23.3%) were resuscitated and referred to other centres due to lack of bed space. Forty (1.9%) patients were dead on arrival, while twenty-six (1.2%) died while on treatment at the emergency room. Conclusion: Neurotrauma is one of the most common form of trauma at our surgical emergency. Assault and road traffic injury (RTI) were the most common cause of TBI and TSI respectively, with RTI being the most common cause of moderate and severe TBI. The incidence and aetiology of TBI varies according to age and gender. ß 2014 Elsevier Ltd. All rights reserved.
Keywords: Assault Neurotrauma Road traffic injury Traumatic brain injury Traumatic spine injury
Introduction Neurotrauma is generally regarded as a public health problem that has earned the attention of the world’s health community. It may be in the form of traumatic brain injury (TBI) or traumatic spinal cord/caudal equinal injury (TSI). Their treatment and management frequently necessitates long-term care and consequently incurs economic cost to health systems.
* Corresponding author at: Neurosurgery Division, Department of Surgery, Lagos State University College of Medicine, Ikeja, Lagos, Nigeria. Tel.: +234 08023 451 369. E-mail address: [email protected] (O.E. Idowu). http://dx.doi.org/10.1016/j.injury.2014.05.028 0020–1383/ß 2014 Elsevier Ltd. All rights reserved.
The impairments leading to permanent disabilities and sometimes mortalities associated with neurotrauma account for substantial losses in terms of pains and economics to individuals, families, and communities. Traumatic brain injury may lead to an eclectic range of short- or long-term issues affecting: cognitive, emotion, motor and sensory functions. For individuals hospitalized after a TBI, almost half (43%) have a related disability one year after the injury [1]. When severe, TBI can adversely affect all aspects of an individual’s life [2]. This can include impaired interactions with family and friends, capability to do household tasks, and/or participate in other activities of daily living, ability to drive, to work or be employed. Among the many issues that can follow TBI (as part of post-concussion syndrome), are problems related to the eyes and vision [3].
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Blurred vision, photophobia, and diplopia have been reported [4–6]. These can occur subsequent to TBI from all causes, regardless of severity. Problems with binocular vision, extraocular muscle function, and the accommodative system have also been found at relatively high frequencies [4–6]. These and other TBI-related vision problems have the potential to affect daily functioning in affected patients. On the other hand TSI especially when the spinal cord is involved, results in complications affecting nearly all systems of the body, leading to an increased morbidity and mortality in this group of patients. The complications profile reported from the developing countries are similar to that of the developed world with notably increased incidence [7]. When compared with common conditions TBI occurs more than any other disease, including breast cancer, acquired immune deficiency syndrome, Parkinson’s disease and multiple sclerosis, and affects all age groups and both genders [8]. Traumatic brain injury (TBI) afflicts more Americans annually than Alzheimer’s and Parkinson’s disease combined [9]. In many countries, it affects the younger age group, but unlike some diseases the causes are known and quite preventable. With respect to TSI, the general demographics in the developing world share some similarities with the epidemiological pattern reported from the developed countries [10]. A retrospective study in Ilorin, Nigeria in 2008, over a 10-year period noted 648 patients aged 1–105 years (mean = 37 years) with TBI [11]. A cross-sectional study of all neurotrauma cases admitted to the neurosurgical service at Ile-Ife, southwestern Nigeria in 2013, over an 18-month period noted 143 patients [12]. A recent estimate indicates that each year 235,000 Americans are hospitalized for nonfatal TBI, 1.1 million are treated in emergency departments, and 50,000 die [13]. A northern Finland birth cohort study noted that the annual incidence of and mortality from TBI were 118 and 14/100,000, respectively; case fatality was 12%; an estimated prevalence of TBI at the age of 34 years was 269/100,000 [14]. On the other hand, a Christchurch New Zealand birth cohort article noted that the average incidence for 0–25 year age group ranged from 1.10 to 2.36 per 100 per year, with an overall prevalence of approximately 30% [15]. The common causes of TBI are road traffic crashes, falls and violence. The most common source of injury was falls for individuals 0–14 years of age and contact sports and motor vehicle accidents for 15–25 year olds [16]. Among all age groups, motor vehicle crashes and traffic-related incidents result in the largest percentage of TBI-related deaths (31.8%) [16]. The World Health Organization (WHO) predicts that unless there are changes in present policies including putting in place additional road safety countermeasures, there will be a major increase in road traffic fatalities over the next two decade and beyond [17]. In Nigeria, a developing, West African country, trauma system design has not been well addressed. Our Nation like most low-income and middle-income developing countries does not have established national trauma, TBI or TSI registries, which is an integral component of modern comprehensive trauma care systems. The quantum of TBI is on the rise in Third-World countries, where it over burdens an already inadequate health care resources [18]. The workload emanating from neurotrauma increase will also affect the ability of neurosurgeons to function in their specialty, particularly if working independently or in a small group practice. However, the number of deaths and burden of disability of neurotrauma can be reduced through preventive measures after an epidemiological survey on trauma. In the light of this, countries need to develop surveillance systems and conduct epidemiologic studies to measure the impact of neurotrauma among their people to guide in designing, implementing, and evaluating public health prevention programmes.
Our aim is to collate data which is needed to be able to apply public health tools in prevention strategies, identify research and education priorities in neurotrauma. Patients and methods A single institution prospective study was carried out at the Lagos State University Teaching Hospital, Ikeja, Lagos, Nigeria, over a one-year period. Setting The hospital is a 750 bed hospital, a 2003 upgrading of the General Hospital at Ikeja (itself a 1967 upgrade of a Cottage Hospital built in 1955 during the British colonial rule in Nigeria). It is located in the most densely populated state in Nigeria with population of over 13 million in 2006 census and 18 million in 2012 estimate [19]. The State is located in the southwestern part of Nigeria and is the smallest in area of Nigeria’s states; it is the most populous state and the nation’s largest urban area, and arguably the most economically important state of the country and West Africa. The Nigerian population is 167 million – about 20% of population of Africa, the largest population of any African country. Traumatic brain injury was defined as brain dysfunction emanating from an external mechanical force, and subsequently classified as mild in a person who has had a traumatically induced physiological disruption of brain function, as manifested by at least one of the following, Glasgow coma scale score (GCS) of 13 or 14, any period of loss of consciousness, any loss of memory for events immediately before or after the accident, any alteration in mental state at the time of the accident (e.g., feeling dazed, disoriented, or confused); and focal neurological deficit that may or may not be transient; moderate was defined with a GCS of 9–12 and severe injury with a GCS of 3–8. Traumatic spine injury was defined as acute injury following trauma to the spinal cord and or cauda equina that leads to varying degrees of motor and/or sensory deficits and paralysis, the definition excludes isolated injuries to peripheral nerves. Data collection and analysis Data collection was from all surgical emergency (SE) room admissions from 1st October 2012 to 30th September 2013. This was commenced two months after a ban on two wheeler commercial vehicles on major highways in the state. The information collected included demographics, cause of injury, region of the body involved, severity and outcome. These were entered into an electronic database. Analysis of the variables was by simple proportion, percentages, Chi-square and analysis of variance was used to determine the differences between group means. A probability (p) of less than 0.05 was considered statistically significant. Data analysis was performed using Statistical Package for the social Sciences version 17, Chicago, Illinois. Results A total of 2149 neurotrauma cases out of a total of 5541 surgical trauma cases were seen within the study period at our SE unit. Of the neurotrauma cases, 1621 were males and the rest were females, giving a male:female ratio of 3.1:1. The mean age was 31 years (median 30 years). The most common age group were 20–29 and 30–39 years which accounted for 29.6% each (Fig. 1). Assault was the cause of neurotrauma in 903 patients (42%), closely followed by road traffic injury in 744 patients (34.6%). Road traffic injury was more common among young adults as compared
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Fig. 1. Age distribution of all patients with neurotrauma.
to falls which was most common cause of neurotrauma in children (Table 1). Females had their injury resulting from assaults (excluding gunshot injuries) in 230 cases (43.6%) closely followed by road traffic injury (164 cases, 31.1%). There was significant relationship between mean age and gender (p = 0.015), mean age and cause of trauma (p = 0.000), gender and cause of trauma (p = 0.012), and region of the body injured and aetiology of injury (p = 0.000). The gender was also significant associated with the age stratification (p = 0.016), likewise age stratification with aetiology of injury (p = 0.000). However there was no significant relationship between gender and region of the body injured (p = 0.800). Traumatic brain injury was the main type of neurotrauma (2035 patients, 94.7%), 11 of which had associated spine injury. Most patients with TBI had mild brain injury (1801 patients, 88.5%); while 5.3% (108 patients) and 6.2% (126 patients) had Table 1 Age stratification and the cause of neurotrauma. Age (years)
Trauma type
Total
RTI
Falls
Assaults (excluding gunshot)
GSI
0–9 10–19 20–29 30–39 40–49 50–59 60–69 70–79 80–89 90–99
48 49 184 251 104 66 32 6 3 1
109 21 51 49 26 16 19 6 2 1
10 50 350 288 135 45 16 5 3 1
0 1 11 15 9 5 1 0 0 0
36 21 40 34 11 10 5 2 0 1
203 142 636 637 285 142 73 19 8 4
Total
744
300
903
42
160
2149
RTI, road traffic injury; GSI, gunshot injury.
Others
moderate and severe brain injury, respectively. Mild brain injury was usually caused by assault (48.3%) while moderate and severe brain injury usually results from road traffic injury (RTI), 75.9% and 73.0%, respectively (Table 2). One hundred and twenty-five patients had spine injury, 11 of which had spine injury in conjunction with brain injury. The aetiology of the spine injury was secondary to RTI in 47.2% (50 cases), falls in 24.8% (29 cases) and assault in 13.6% (17 cases) (Fig. 2). Five hundred out of the total 2149 patients (23.3%) were referred after resuscitation due to bed space challenges. Of these 500 patients, 462 (92.4%), 21 (4.2%) and 17 (3.4%) of them had mild, moderate and severe brain injury, respectively. Patients that were referred were more likely to have mild brain injury than those who were admitted after resuscitation (p = 0.002). Forty (1.9%) patients were dead on arrival (DOA). They were all TBI cases. Twenty-six (1.6%) died while on treatment at the emergency room. Forty-seven patients required neurosurgical intervention which is available in our centre (one of the two public hospital rendering neurosurgical services in the state). Road traffic injury was the cause of injury in 25 and 22 of the DOA and in-hospital deaths, respectively.
Table 2 Severity of traumatic brain injury. Aetiology
Mild (%)
Moderate (%)
Severe (%)
Total
RTI Falls Assault GSI Others Total
520 233 870 32 146 1801
82 15 7 1 3 108
92 23 9 2 0 126
694 271 886 35 149 2035
(28.9) (12.9) (48.3) (1.8) (8.1)
(75.9) (13.9) (6.5) (0.9) (2.8)
(73) (18.6) (7.1) (1.6) (0)
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Fig. 2. Spine injury aetiology.
Discussion Neurotrauma is associated with potentially devastating and sometimes irreversible neurological injury, resulting in varying degrees of deficits. There are no established national trauma or SCI registries in most developing countries. Similarly there is no population based data on neurotrauma available from majority of the third-world countries. This is complicated by the fact that medical record keeping is poorly managed in most of the hospitals [20]. Nigeria where our study was conducted is not left out. Most of the available data in the literature are single centre hospital based studies and retrospective surveys. Ours is also a hospital based study due to our local shortfalls. The quantum of neurotrauma in our environment is quite high. Nearly 40% of our trauma burden is related to neurotrauma. There is great disparity between the neurotrauma burden and the available neurosurgical manpower in our region. There is a very strong need to reduce the burden of work on these specialists, by increasing the number of available doctors in the service. Neurotrauma was more common in males and the age at presentation is similar to most studies [11,12]. In our study there was a significant gender difference (p = 0.015). Most our patients presented between 20–29 years (29.6%) and 30–39 years (29.6%). Odebode [11] noted that injuries occurred mostly in males and in the third decade. In a Pakistani study of patients with neurotrauma admitted to various neurosurgical centres from July 1, 1995 to June 30, 1999. A total of 260,000 patients were admitted over a 4-year period. The majority of patients presented during the second decade (33.2%) followed by first and third decade; there were 195,000 (75%) males and 65,000 (25%) females with a ratio of 3:1 [18]. In general, this study showed that violence was a major cause of neurotrauma; accounting for 44% (assault and gunshot injury) of all cases. This was closely followed by RTI (34.6%). The assault aetiology rate was higher in females (females – 43.6%, males – 41.55%) when compared with RTI aetiology (females – 31.1%, males – 35.8%). This is at variant with the study of Odebode [11] from mid-western Nigeria, Faul et al. [16] from Georgia, United States of America, and Raja et al. [18] from Pakistan, where TBI was usually secondary to RTI. In Ile-Ife, a relatively suburban city in Nigeria, 81% of the traumas were due to RTI. Our findings may be due to the peculiar nature of Lagos. It is the smallest state in Nigeria (356,861 hectares of which 75,755 hectares are wetlands), most urban, a conurbation of cities with the high population of 18 million; associated with this is the persistent bubbling and hustling emanating from its being the main commercial hub. In addition our study revealed that in the first decade of life, fall was the usual cause of neurotrauma (53.7%), more than doubling the impact of RTI. In older adults between 50 and 80 years, RTI was the most common cause of TBI; with RTI quite common between
60 and 69 years of age group (Table 1). In the patients with moderate and severe TBI the main cause of injury was RTI (Table 2). Similarly, almost 50% of spine injury resulted from RTI. McKinlay et al. [15] also noted that falls was the usual cause of TBI in patients within the first one and half decade. The case frequency of DOA is an index of prehospital care. Significantly this study shows RTI and gunshot injuries (34 out of 40 cases of DOA) accounted for most of the DOA. This finding is a further call to develop legislation on prehospital care. All the patients that died while on treatment at the Emergency room were victims of RTI (22 patients) and falls (4 patients). Injuries still cause the death of over five million people world-wide each year despite it no longer being perceived as inevitable, but largely preventable events [21]. Out of this huge number, 1.2 million are due to RTI, 90 per cent of which take place in low and middle income countries [22,23]. It is predicted that by 2020, RTI will become a major culprit in the total disease burden [22,24]. Most of our patients had mild TBI (88.5%) and 6.2% of them had severe TBI. In Raja et al. [18] study, mild, moderate, and severe TBI was observed in 52%, 30%, and 18% of patients, respectively. Unfortunately, many individuals who sustain a form of TBI are prone to various medical, psychological, social, academics and alcohol abuse amongst others [25,26]. Mild brain injury is usually associated with concussions. Severity of concussion is measured using various concussion grading scales. A slightly greater injury is associated with both anterograde and retrograde amnesia. The amount of time that the amnesia is present correlates with the severity of the injury. In some cases persistent post-concussion syndrome (PCS) develops. The symptoms of PCS may persist for days, months, or years after the injury and often include fatigue, dizziness, headache, poor concentration, memory impairment and depression, many of which can impede daily activities. Many American soldiers, even those undiagnosed but likely suffering from mild TBI, displays Alzheimer’s disease (AD)-like cognitive impairments, suggesting a pathological overlap between TBI and AD [27]. A non-fatal severe TBI may result in long term disability or mortality. In the elderly, people aged 75 years old and older are said to have the highest rates of TBI-related hospitalizations and death [16]. A prior Nigerian study noted that older patients had the poorest outcome with a mortality rate of 48.7% [11]. The study reaffirms that outcome of brain injury worsens with advancing age and indicates that severity of brain injury and higher frequency of multi-system trauma may contribute to worse outcome in older patients [11]. In Nigeria, as in many Third-world countries, Neurological rehabilitation is still at an infancy stage in Nigeria. Neurotrauma is a growing public health concern. To reduce the overall burden of neurotrauma the action to be taken will have to extend from the political scene to the basic patient care. There have been remarkable advances in the understanding of acute brain and spinal cord injury and encouraging possibilities for effective neuroprotection, repair and regeneration but in the broader context prevention of neurotrauma is the urgent imperative. Pre-injury education (assault avoidance and traffic laws enforcement) and road engineering is encouraged. Public health mechanisms (health education- assault avoidance, and traffic laws enforcement, and road engineering) to reduce the burden of neurotrauma while the development and adoption of national clinical guidelines for neurotrauma is advocated. In this endeavour the neuroscientist has knowledge which informs and encourages policy makers to take the steps necessary to reduce injury. These steps require political will and community support for hard decisions which impact on the way people conduct their daily lives. The workload demand will affect the ability of neurosurgeons to function in their specialty, particularly if working independently or in a small group practice.
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In conclusion, neurotrauma is one of the most common form of trauma at our surgical emergency. Assault and RTI were the most common cause of TBI and TSI, respectively, with RTI being the most common cause of moderate and severe TBI. The incidence and aetiology of TBI varies according to age and gender. The number of deaths and burden of disability of TBI can be reduced through preventive measures after an epidemiological survey on trauma. The goal can be achieved to a significant extent through the use of guidelines. In the light of this, countries need to develop surveillance systems and conduct epidemiologic studies to measure the impact of neurotrauma among their people. Designing, implementing, and evaluating public health prevention programmes including health education, traffic laws enforcement, and appropriate road engineering is encouraged will help in reducing neurotrauma burden. Development, establishment and adoption of a national trauma registry and of national clinical guidelines for neurotrauma are also advocated. Conflict of interests None. References [1] Selassie AW, Zaloshnja E, Langlois JA, Miler T, Jones P, Steiner C. Incidence of long-term disability following traumatic brain injury hospitalization, United States, 2003. J Head Trauma Rehabil 2008;23:123–31. [2] Thurman D, Alverson C, Dunn K, Guerrero J, Sniezek J. Traumatic brain injury in the United States: a public health perspective. J Head Trauma Rehabil 1999;14: 602–15. [3] King NS. Post-concussion syndrome: clarity amid the controversy? Br J Psychiatry 2003;183:276–8. [4] Brahm KD, Wilgenburg HM, Kirby J, Ingalla S, Chang CY, Goodrich GL. Visual impairment and dysfunction in combat-injured service members with traumatic brain injury. Optom Vis Sci 2009;86:817–25. [5] Stelmack JA, Frith T, Van Koevering D, Rinne S, Stelmack TR. Visual function in patients followed at a Veterans affairs polytrauma network site: an electronic medical record review. Optometry 2009;80:419–24. [6] Ciuffreda KJ, Kapoor N, Rutner D, Suchoff IB, Han ME, Craig S. Occurrence of oculomotor dysfunctions in acquired brain injury: a retrospective analysis. Optometry 2007;78:155–61. [7] Chacko V, Joseph B, Mohanty SP, Jacob T. Management of spinal cord injury in a general hospital in rural India. Paraplegia 1986;24:330–5.
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