Outcomes 10-years after traumatic spinal cord injury in Botswana - a long-term follow-up study

To describe outcomes, survival, and attendance to routine follow-up visits 10 years post-SCI.

All persons who were admitted with traumatic SCI during a 2-year period, 2011–2013, and survived up to 2 years post-injury were included. Data were collected from the medical records from

the follow-up assessment closest to 10 years post-SCI and included demographic and clinical characteristics, functional outcomes, and secondary complications. Data regarding mortalities were

received from relatives. Statistical comparisons were made, when possible, between those who attend follow-up assessment and those who did not, and between those who survived up to 10 years

post-SCI and those who died.

The follow-up rate was 76% (19/25) of known survivors. No statistically significant factors were found to affect the follow-up rate. Secondary complications rates were for pressure ulcers

and urinary tract infections 21%. Self-catheterisation and suprapubic catheter were the preferred methods to manage neurogenic bladder dysfunction. Ten persons (26%) had deceased since 2nd

follow-up assessment. The causes of death were probably SCI-related in more than half of the cases.

This was a follow-up study at year 10 after acute TSCI in Botswana conducted at the national SCI-rehabilitation center. The study supports previous reports regarding the importance of that

having specialized SCI units and the need of structured follow-ups, a responsible person in charge of scheduling, and updated patient registers. We found high follow-up rate, low rates of

complications and of patients being lost to follow-up.

Three studies were previously conducted on the same cohort as in the current study, namely all persons admitted with acute TSCI during a 2-years period. These studies followed three phases

within the chain of SCI-care: acute admission, discharge, and follow-up two years post-injury. The main results of the studies are presented below, for detailed information, articles are

published in Spinal Cord.

Acute admission [15]: 52 persons with acute SCI were admitted; however, three persons did not consent therefore 49 participants were included, 71% male, age range was 4–81 years with 80% ⩽45

years, 59% had tetraplegia with 39% having a high tetraplegia (C1–C4 level), mainly incomplete. Causes of injury were traffic related (68%), assault (16%), and falls (10%). Mortality prior

to admission to the SCI-rehabilitation center was 20%, where all, but one, had tetraplegia, resulting in that 39 persons were admitted for rehabilitation.

At discharge [16]: 38 persons were discharged after completed rehabilitation; one person deceased prior to discharge after having completed rehabilitation. Median length of stay was 20 weeks

with complete injuries and presence of PU being the factors that mostly prolonged hospitalization. Clean intermittent catheterization (CIC) or suprapubic catheter (SPC) were the main

methods for bladder management and digital ano-rectal stimulation for bowel management. The most frequent complications during admission were PU, UTI, and pain.

At 2nd follow-up [17]: follow-up rate was 71% (27 out of 38 persons attended follow-up, the remaining were contacted by phone), with higher attendance among those with complete injuries and

those with secondary complications. Age, gender, distance to the center, or education did not affect the follow-up rate. CIC and SPC remained the preferred methods of bladder management.

Despite high rates of PU and UTI, no deaths had occurred during the follow-up period resulting in 38 persons survived to be included in the current study.

Botswana, as well as a substantial part of Sub-Saharan Africa, is lacking reliable information on the long-term outcome and mortality after SCI [9, 10, 18]. After initial establishment of a

specialized SCI-center in Botswana, outcomes for persons with TSCI improved and mortality was decreased for up to two years post-injury [17]. Complications were still prevalent, however, at

a lower rate compared with before the SCI-center. Therefore, the aim of this study is to describe the long-term outcomes 10 years post-TSCI in Botswana after completing rehabilitation and

attending to the follow-up assessments.

To evaluate the procedures of interdisciplinary follow-up assessments at the SCI-center.

To describe the medical status, consequences, and complications 10 years post-SCI for persons with TSCI in Botswana.

To describe home situation, functional outcomes, quality of life, and prevalence of work/studies 10 years post-SCI.

To describe rate and causes of mortality for persons with TSCI after the 2nd yearly follow-up and whether causes of death were SCI-related.

This was a prospective follow-up study conducted at the national SCI-rehabilitation center in Botswana. The study population includes all persons admitted to PMH with acute TSCI between

February 1rst 2011 – January 31rst 2013 and who had survived up to two years post-SCI, i.e. the same cohort as in the three previous studies, with an addition of one person who did not

consent initially, but now gave verbal consent to participate, resulting in 39 participants who were included in the current study (Fig. 1).

Study I-III are previously published, study IV is the current study.

International standards for neurological classification of SCI [20]

CardiovascularMedical history regarding cardiac and circulatory problems. Questions added to the data set; pulmonary diseases, tumors, tropical diseases, diabetes, HIV/AIDS.

Quality of life (QoL): Includes three questions; ‘how satisfied are you’ with the following: ‘life as a whole’, ‘physical health’, and ‘psychological health, emotions and mood’. Ratings 0–10

completely dissatisfied–completely satisfied.

Data regarding mortality rate, time, place, and causes of deaths have mainly been retrieved from the relatives since most persons deceased in their homes and no data regarding mortality were

available. An autopsy is only conducted at the request of the family when a person dies in their home. Data for deceased participants have been retrieved from their latest follow-up

assessment.

IBM SPSS statistics 28.0.0.0 (Armonk, NY, USA) were used for analyzing data. Categorical variables are presented as absolute numbers and proportions, and continuous variables as mean and

standard deviation (SD), and median and interquartile range (IQR) [21]. Non-parametric tests were used for comparing groups because of the small sample, Mann–Whitney U-test for continuous

variables and Fisher’s exact test for categorical variables. P-value were set to P