Abstract
Objective:
To systematically search the literature and to summarize current evidence pertaining to the epidemiology of SCI in the MENA region incidence, gender, age, type of the injury and etiology of the injury.
Methods:
Embase, PubMed, Scopus, Web of Science and EBSCOhost were systematically searched from their dates of inception till July 2017 for English and non-English language articles. Also, regional databases were searched. Data were extracted from eligible articles and pooled under the random effect model using R. References of the included articles were also screened for potentially relevant studies.
Results:
We identified 29 articles from seven countries in the MENA region (Turkey, Iran, Saudi Arabia, Egypt, Jordan, Kuwait and Qatar). The mean age of the cases at time of injury was 31.32 (95% CI: 28.74-33.91). The random pooled annual incidence of TSCI per million was 23.24 (95% CI: 5.64-49.21). Pooled proportion of male gender was 77% (95% CI 73-80%) of the cases. Complete paraplegia was the most common type of injury. Thoracic level injury predominated. Also, the most commonly affected age group was 20-29 then 30-39. Motor vehicle accidents were found to be the leading cause of injury, then falls, gunshot, violence and sports. Further meta-regression analysis showed no association between age and etiology of the injury.
Conclusion:
This review shows lack of evidence about SCI in most countries of the MENA region. More epidemiological studies are needed.
Key Words: Spinal cord injury, Epidemiology, Incidence, Middle-East, North-Africa, Etiology, SCI
Introduction
Spinal cord injury (SCI) is one of the most devastating events in which lesions to the spinal cord cause motor impairments, sensory deficit, or autonomic nervous system dysfunction [1]. The incidence of traumatic spinal cord injury (TSCI) in the developing countries was 25.5/million/year [2]. People with SCI are 2 to 5 times to die prematurely than people without SCI, depending on the health-care system capacity [3]. Moreover, SCI is associated with various economic, psychological and social impacts. For example, in 2008, the total cost of SCI in Australia was estimated to AUS$ 2 billion with life-time cost of AUS$ 5 million per case of paraplegia and AUS$ 9.5 million per case of tetraplegia [4]. With the limited resources in low-income countries, healthcare cost is one of the main barriers affecting the quality of life of people with SCI [5]. Furthermore, clinical symptoms of depression were seen in 20-30% of people with SCI [6]. Because there is no cure for SCI, primary and secondary prevention strategies are vital [7]. Epidemiological evidence will help to plan and implement future preventive measures. Although more than 436 million live in the Middle-East and North-Africa (MENA) region, epidemiological patterns of SCI in the region are not well characterized [8]. This review aims to summarize current evidence pertaining to SCI in the MENA region regarding the incidence, age, gender, etiology and type of injury.
Materials and Methods
Guidelines
We followed the Meta-analysis of observational studies in epidemiology (MOOSE) Statement in reporting this meta-analysis [9].
Search Strategy
One of the authors (Elshahidi) designed and conducted the search process. The search process was performed using a comprehensive list of keywords (list of keywords and details from each database search can be found in the ‘supplementary materials: Search Strategy’). No language nor publication period restrictions were applied.
Data sources
An electronic search on Embase, PubMed, Scopus, Web of Science and EBSCOhost databases was conducted from their dates of inception till July 2017. In addition, other regional databases including the Index Medicus for the Eastern Mediterranean Region (IMEMR) and African Index Medicus were searched. Also, references of included articles were handsearched for relevant records. Also, some previously published systematic reviews were searched for relevant articles. Criteria for selecting studies.Two authors independently screened retrieved records in two steps: title and abstract screening then full-text reviewing. They applied the inclusion and exclusion criteria to select relevant articles (Table 1). Our definition of the Middle-East and North-Africa (MENA) region is based on The World Bank definition (See ‘supplementary materials: Search Strategy’ for list of the included countries) [10]. Any conflict was resolved by discussion.
Table 1.
Summary of inclusion and exclusion criteria
| Criteria | Inclusion | Exclusion |
|---|---|---|
| study | Any study published in any year, language or setting about SCI in the MENA region | Reviews, editorial, basic science studies, animal studies, case studies or studies out of the MENA region |
| Design | Cross sectional, Retrospective, Prospective | drug trials |
| Observation | Epidemiological characteristics of spinal cord injury; incidence, age, type of injury, etiology of injury | Specific etiological focus, unrelated specific topics (depression, sleep disorder, pain, pressure ulcer, morbidity or other secondary complications), mixed data without independent report of SCI data, spine injuries. |
Data extraction
Two authors independently extracted data using a data collection form prepared by the team. The extracted data included: study reference, sample size, country, duration of the study, male/female ratio, incidence, age, type of the study, type of the injury and etiology of the injury. Any disagreement was resolved by discussion.
Data analysis
SCI epidemiological characteristics were presented as percentages that were pooled with 95% confidence interval (CI) using the ‘meta’ package, R 3.4.0 [11]. We used Cochran-Q test to identify heterogeneity, and I-square test was used to quantify its extent. When significant heterogeneity was found (p<0.1), the random-effect model was used [12]. A subgroup group analysis by country was applied. Moreover, a meta-regression model was used to assess the association between etiology of injury and male gender and age.
Quality assessment
A modified version of The Newcastle-Ottawa Scale (NOS) for assessing the quality of non-randomized studies in meta-analyses was used to assess quality of the included studies [13]. Each study could attain a maximum of four points. Studies with ≥ 3 points were considered of good quality. Those with ≤ 2 points were considered of poor quality. The scale rated the papers according to: 1) inclusion and exclusion criteria were clearly stated 2) data came from a secure source (register, administrative database or prospectively collected) 3) detailed reporting of analyses results (95% CI or standard error).
Results
Study selectionOur comprehensive search retrieved 21 557 references. After abstract and full-text reviewing, 29 articles met our inclusion criteria. The included studies were conducted in seven MENA countries (Figure 1). A summary of the included studies was provided in Tables 2, 3 and 4 [14-42]. The number of cases ranged from 1694 [30] to 4 [35].
Fig. 1.
A flow chart of the search process, performed in July, 2017.
Table 2.
Characteristics of the included studies.
| Study ID (Reference) | Duration of the study | Country | Sample size | Mean age(SD) | Male (%) | M/F ratio | Incidence (per million) | Prevalence | Type of the study |
|---|---|---|---|---|---|---|---|---|---|
| Al-Jadid et al., [14] | January 2005-October 2008 | Saudi Arabia | 495 | 34.3 (±0.68) | 404 (81.6%) | 4.44 | - | - | Retrospective review of admission records |
| Al-Jadid et al., [15] | August 1982-November 2010 | Saudi Arabia | 466 | 29.75 (±0.73) | 398 (85.4%) | 5.85 | - | - | Retrospective review of hospital records |
| Rahimi-Movaghar et al., [16] | June 2007-June 2008 | Iran | 496 | - | 342 (68.95%) | 2.22 | 72.45 | 4.4 (per 10 000) | Population-based |
| Al-Habib et al., [17] | May 2001-May 2009 | Saudi Arabia | 23 | 13.7 (±4.5) | 17 (74%) | 2.83 | - | - | Retrospective study |
| Tasoglu et al., [18] | June 2013- May 2014 | Turkey | 262 | 38.3 (± 17.6) | 183 (69.8%) | 2.32 | 8–21 | - | Retrospective |
| Derakhshanrad et al., [19] | September 2011- March 2015 | Iran | 1137 | 29.1 (±11.2) | 901 (79.2%) | 3.82 | - | 2.36 (per 10 000) | Cross-sectional study |
| Gur et al., [20] | 1990-1999 | Turkey | 539 | 30.62 (± 13.21) | 416 (77.17%) | 3.38 | 12.06 | - | Retrospective review of hospital records |
| Erhan et al., [21] | January 1992 - December 2002. | Turkey | 106 | 12.67 (± 4.3) | 70 (66%) | 1.94 | - | - | Retrospective study |
| Erdoǧan et al., [22] | January 2007 - December 2011 | Turkey | 409 | 46.82 (±19.05) | 253 (61.9%) | 1.62 | - | - | Descriptive study |
| Mahmoud et al., [23] | 2009 - 2014 | Saudi Arabia | 418 | 31.4 | 244 (78.2%) | 3.59 | - | - | Retrospective cohort study |
| Karamehmetoglul et al., [24] | January 1992 - 31 December 1992 | Turkey | 152 | 32.5 | 114 (75%) | 3.00 | 21 | - | Retrospective study in all hospitals of Istanbul |
| Alfrayh et al., [25] | August 1982 - November 1983 | Saudi Arabia | 260 | - | 130 (50%) | 1.00 | - | - | Hospital-based study |
| El Tallawy et al., [26] | July 2009 - January 2012 | Egypt | 6 | 40 (±16) | 5 (83.33%) | 5.00 | - | 18 (per 100 000) | Cross-sectional study |
| Movaghar et al., [27] | January 2003- January 2008 | Iran | - | 31 (±7) | - | - | - | 4.4 (per 10 000) | Cross-sectional study |
| Atci et al., [28] | 2010-2013 | Turkey | 91 | 41.3 | 64 (70.4%) | 2.37 | - | - | Retrospective review of the emergency department records |
| Karamehmetoglul et al., [29] | January 1994- December 1994 | Turkey | 75 | 31.3 | 64 (85.33%) | 5.82 | 16.9 | - | Retrospective study |
| Dincer et al., [30] | 1974-1985 | Turkey | 1694 | 26.8 | 1282 (75.68%) | 3.11 | - | - | Retrospective study |
| Karacan et al., [31] | January 1992 - December 1992 | Turkey | 581 | 35.5 (±15.1) | 415 (71.42%) | 2.50 | 12.7 | - | Retrospective study |
| Alshahri at al., [32] | January 2003 - December 2008 | Saudi Arabia | 307 | 29.5 | 271 (88%) | 7.53 | - | - | Retrospective study |
| Cosar et al., [33] | 1996 - 2008 | Turkey | 127 | 37.8 (±13.651) | 86 (67.7%) | 2.10 | - | - | Retrospective study |
| Taghippor et al., [34] | 2002-2003 | Iran | 85 | 35 (±12) | 68 (80%) | 4.00 | - | - | Prospective hospital based data collection study |
| Rahimi-Movaghar et al., [35] | September 2007- January 2008 | Iran | 4 | 31(±7) | 2 (50%) | 1.00 | 44 | 4.4 (per 10 000) | Population-based survey study |
| Chabok et al., [36] | 2005-2006 | Iran | 44 | 38.2 | - | - | - | - | Retrospective review of hospital database |
| Otom et al., [37] | January 1988- December 1993 | Jordan | 151 | 30 | 129 (85.4%) | 5.86 | 18 | - | Retrospective chart review |
| Raibulet et al., [38] | 1991-1999 | Kuwait | 90 | 20.6 | 79 (8.7%) | 7.18 | 7.8 | - | Retrospective chart review |
| Alshahri SS et al., [39] | January 2012- December2015 | Saudi Arabia | 216 | 28.94 | 187 (86.5%) | 6.45 | - | - | Retrospective chart review |
| Alhoseini et al., [40] | March 2010-July 2011 | Iran | 138 | 33.2 (±14.3) | 117 (84.8%) | 5.57 | 10.5 | - | Retrospective hospital based chart review |
| Fakharian et al., [41] | 1995-1999 | Iran | 39 | 39 (±18) | 31 (79.4%) | 3.88 | 30 | - | Prospective hospital study |
| Quinones et al., [42] | 1987-1996 | Qatar | 75 | 32 | 67 (89.24%) | 8.38 | 12.5 | - | Retrospective hospital study |
Table 3.
Characteristics of the included studies.
| Study ID (Reference) | Scale(Franke l/ASIA) | Scale A (%) | Scale B (%) | Scale C (%) | Scale D (%) | Scale E (%) | Complete paraplegia (%) | Complete tetra plegia (%) | Incomplete paraplegia (%) | Incomplete tetraplegia (%) | Cervical | Thoracic | Lumbar/sac ral |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Al-Jadid et al., [14] | - | - | - | - | - | - | - | - | - | - | - | - | - |
| Al-Jadid et al., [15] | - | - | - | - | - | - | - | - | - | - | 146 (31.33%) | 225 (48.28%) | 95 (20.4%) |
| Rahimi-Movaghar et al., [16] | - | - | - | - | - | - | 278 (56.04%) | 99 (19.9%) | 73 (14.71%) | 39 (7.86%) | - | - | - |
| Al-Habib et al., [17] | - | - | - | - | - | - | - | - | - | - | 9 (39%) | 11 (47.8%) | 109 (43.5%) |
| Tasoglu et al., [18] | ASIA | 93 (35.5%) | 43 (16%) | 56 (21.4%) | 69 (26.3%) | 1 (0.04%) | 76 (29%) | 16 (6.1%) | 117 (44.7%) | 53 (20.2%) | 69 (26.3%) | 121 (46.2%) | 72 (27.5%) |
| Derakhshanrad et al., [19] | ASIA | 608 (53.5%) | 203 (18.7%) | 200 (17.6%) | 109 (9.6%) | 7 (0.6%) | 496 (43.6%) | 115 (10.1)% | 308 (27.1%) | 218 (19.2%) | 358 (31.5%) | 658 (57.9%) | 121 (10.6%) |
| Gur et al., [20] | - | - | - | - | - | 243(45.08%) | 75 (13.91%) | 148 (27.48%) | 74 (13.72%) | cervical:137 (25.41%), thoracic:198 | |||
| Erhan et al., [21] | ASIA | 56 (55%) | 45 (45%) | - | - | - | - | 50 (47.2%) | 37 (34.9%) | 13 (12.3%) | |||
| Erdoǧan et al., [22] | ASIA | 65 (15.9%) | 344 (84.1%) | - | - | - | - | ||||||
| Mahmoud et al., [23] | ASIA | 261 (83.7%) | 25 (8.01%) | 26 (8.33%) | - | 239 (76.6%) | 73 (23.4%) | - | - | - | - | - | |
| Karamehmetoglul et al., [24] | - | - | - | - | - | - | 102 (67%) | 50 (33%) | - | - | 50 (33%) | - | 102 (67%) |
| Alfrayh et al., [25] | - | - | - | - | - | - | - | - | - | - | - | - | - |
| El Tallawy et al., [26] | ASIA | 1 (16.7%) | - | 1 (16.7%) | 4 (66.7%) | - | - | - | - | - | 3 (50%) | 1 (16.7%) | 2 (33.3%) |
| Movaghar et al., [27] | - | - | - | - | - | - | - | - | - | - | - | - | - |
| Atci et al., [28] | - | - | - | - | - | - | - | - | - | - | 12(13.1%) | 56 (61.53%) | 23 (25.27%) |
| Karamehmetoglul et al., [29] | - | - | - | - | - | - | 44 (58.7%) | 31 (41.3%) | - | - | - | - | - |
| Dincer et al., [30] | - | - | - | - | - | - | 1442 (85.12%) | 82 (4.84%) | 116 (6.85%) | 54 (3.19%) | - | - | - |
| Karacan et al., [31] | - | - | - | - | - | - | 394 (67.8%) | 187 (32.18%) | - | - | 184 (31.7%) | 156 (26.6%) | 162 (27.8%) |
| Alshahri at al., [32] | - | - | - | - | - | - | 90 (29%) | 66 (22%) | 56 (18%) | 95 (31%) | - | - | - |
| Cosar et al., [33] | - | 94 (74%) | 18 (14.3%) | 8 (6.2%) | 7 (5.5%) | - | Tetra: 36 (28.3%) | Para: 76 (59.8%) | - | - | - | ||
| Taghippor et al., [34] | Frankel | 28 (32.94%) | 51 (60%) | - | - | - | - | - | - | - | - | ||
| Rahimi-Movaghar et al., [35] | - | - | - | - | - | - | - | - | - | - | - | - | - |
| Chabok et al., [36] | - | - | - | - | - | - | 4 (9.1%) | 11 (25%) | 29 (65.9%) | - | - | - | |
| Otom et al., [37] | Frankel | 81 (53.6%) | 15 (10%) | 34 (22.5%) | 21 (13.9%) | - | - | - | - | - | 48 (31.8%) | 103 (68.2%) | |
| Raibulet et al., [38] | Frankel | 26 (29%) | 21 (22.7%) | 34 (38.3%) | 9 (9.9%) | - | - | - | - | - | - | - | - |
| Alshahri SS et al., [39] | - | - | - | - | - | - | 80 (37.03%) | 36 (16.66%) | 53 (24.53%) | 47 (21.75%) | - | - | - |
| Alhoseini et al., [40] | ASIA | 119 (86.2%) | 5 (3.6%) | 3 (2.2%) | 11 (8%) | - | Tetra: 25 (18.1%) | Para: 113 (81.9%) | - | - | - | ||
| Fakharian et al., [41] | - | - | - | - | - | - | - | - | - | - | - | - | - |
| Quinones et al., [42] | - | - | - | - | - | - | 21 (28%) | 23 (30.7%) | 11 (14.7%) | 20 (26.6%) | 43 (57.3%) | 32 (42.66%) | |
Table 4.
Characteristics of the included studies.
| Study ID (Reference) | Motor accident | Falls | Gunshot | Sport-related | violence | Others | 0-9 | 10 to 19 | 20-29 | 30-39 | 40-49 | 50-59 | 60-69 | ≥70 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Al-Jadid et al., [14] | - | - | - | - | - | - | 55 (11.11%) | 198 (40%) | 98 (19.8%) | 60 (12.12%) | 31 (6.26%) | 42 (8.5%) | 11 (2.22%) | |
| Al-Jadid et al., [15] | 377 (80.9%) | 51 (10.94%) | 30 (6.45) | 3 (0.64%) | 5 (1.07%) | 0-15: 32 (6.9%), 16-30: 270 (58%), 31-45:100 (21.4%), ≥45: 64 (13.7%) | ||||||||
| Rahimi-Movaghar et al., [16] | - | - | - | - | - | - | 3 (0.6%) | 33 (6.65%) | 133 (26.81%) | 118 (23.79%) | 104 (20.96%) | ≥50: 105 (21.17%) | ||
| Al-Habib et al., [17] | 13 (56.5%) | 8 (35%) | 2 (8.6%) | - | - | - | - | - | - | - | - | - | - | |
| Tasoglu et al., [18] | 79 (30.2%) | 90 (34.4%) | 17 (6.46%) | 5 (1.9%) | 20 (7.6%) | 51 (19.44%) | 0-15: 17 (6%), 16-30: 86 (32.5%), 31-45:68 (25.9%), 46-60: 56 (21%), 61-75: 32 (13.1%). ≥76: 4 (1.5%) | |||||||
| Derakhshanrad et al., [19] | 703 (61.8)% | 279 (24.5%) | - | 32 (2.8%) | 43 (3.8%) | 80 (7.1%) | - | 76 (6.7%) | 646 (56.8% | 316 (27.8%) | 86 (7.6%) | 13 (1.1%) | - | - |
| Gur et al., [20] | 200 (37.1%) | 172 (32%) | 115 (21.33%) | - | 11(2.04%) | 41 (7.6%) | 0-14:32 (5.9%), 15-29:261 (48.42%), 30-44:158 (29.3%),45-59:64 (11.87%),≥60:24 (4.45%) | |||||||
| Erhan et al., [21] | 43 (40.6%) | 36 (34%) | 10 (9.4%) | 11 (10.4%) | - | 6 (5.7%) | - | - | - | - | - | - | - | - |
| Erdoǧan et al., [22] | 68 (16.6%) | 292 (71.4%) | - | 14 (3.4%) | - | 35 (8.6%) | - | - | - | - | - | - | - | - |
| Mahmoud et al., [23] | - | - | - | - | - | - | - | - | - | - | - | - | - | - |
| Karamehmetoglul et al., [24] | 62 (41%) | 65 (43%) | 8 (5%) | - | 3 (2%) | 11 (7% ) | 4 (2.63%) | 16 (10.5%) | 54 (35.5%) | 35 (23.02%) | 20 (13.15%) | 12 (7.89%) | 8 (5.26%) | 3 (1.97%) |
| Alfrayh et al., [25] | - | - | - | - | - | - | - | - | - | - | - | - | - | - |
| El Tallawy et al., [26] | - | - | - | - | - | - | - | - | - | - | - | - | - | - |
| Movaghar et al., [27] | - | - | - | - | - | - | - | - | - | - | - | - | - | - |
| Atci et al., [28] | 34 (37.36%) | 54 (59.3%) | - | 2 (2.2%) | 1 (1.1%) | - | - | 6 (6.6%) | 18 (19.8%) | 21 (23.08%) | 23 (25.27%) | 12 (13.19%) | 4 (4.4%) | 7 (7.7%) |
| Karamehmetoglul et al., [29] | 19 (25.3%) | 28 (37.3%) | 22 (29.3%) | - | 1 (1.3%) | - | 2 (2.6%) | 5 (6.7%) | 29 (38.7%) | 17 (22.7%) | 15 (20%) | 5 (6.7%) | 2 (2.7%) | - |
| Dincer et al., [30] | 600 (35.41%) | 500 (29.51%) | 372 (21.95%) | - | 34 (2%) | 188 (11.1%) | 58 (3.42%) | 394 (23.26%) | 548 (32.35%) | 360 (21.25%) | 196 (11.57%) | 110 (6.49%) | 28 (1.65%) | - |
| Karacan et al., [31] | 286 (48.8%) | 212 (36.5%) | 11 (1.9%) | 7 (1.2%) | 19 (3.3%) | - | 9 (1.5%) | 57 (9.8%) | 180 (30.9%) | 127 (21.9%) | 87 (15%) | 67 (11.8%) | 40 (6.9%) | 10 (1.8%) |
| Alshahri at al., [32] | 262 (85%) | 28 (9%) | 14 (5%) | 3 (1%) | - | - | (14–15 =8 (3%)), (16–30=196 (64%)),(31–45=72 (23%)),(46–60=23 (7%)) ,(61–75=8 (3%)) | |||||||
| Cosar et al., [33] | 70 (55.1%) | 43 (33.9%) | 10 (7.9%) | 4 (3%) | - | - | - | - | - | - | - | - | - | - |
| Taghippor et al., [34] | 34 (40%) | 32 (37.64%) | - | - | 2 (2.35%) | 1 (1.17%) | 2 (2.35%) | 10 (11.76%) | 31 (36.47%) | 18 (21.17%) | 8 (8.4%) | 11 (12.94%) | 60+: 5 (5.8%) | |
| Rahimi-Movaghar et al., [35] | 3 (75%) | 1 (25%) | - | - | - | - | - | - | - | - | - | - | - | - |
| Chabok et al., [36] | - | - | - | - | - | - | - | - | - | - | - | - | - | - |
| Otom et al., [37] | 67 (44.4%) | 32 (21.2%) | 39 (25.8%) | 4 (2.6%) | 3 (2%) | 6 (4%) | 0-19: 37 (24.5%) | 54 (35.8%) | 24 (15.9%) | More than 40: 36 (23.8%) | ||||
| Raibulet et al., [38] | 57 (63.3%) | 22 (24.7%) | - | - | 2 (2.2%) | 8 (8.9%) | - | - | - | - | - | - | - | - |
| Alshahri SS et al., [39] | 196 (90.8%) | 7 (3.2%) | - | - | 13 (6%) | - | - | 14-25:118 (55%), 26-35:53 (24.5%), 36-45:16 (7.4%), 46-55:16 (7.4%), 56-65:8 (3.7%), 66+:5 (2.3%) | ||||||
| Alhoseini et al., [40] | 56 (40.57%) | 63 (45.65%) | - | - | - | 19 (1376%) | - | - | - | - | - | - | - | - |
| Fakharian et al., [41] | - | - | - | - | - | - | Less 20: 3 (7.7%), 20-50: 27 (69.2%), more 50: 9 (23.07%) | |||||||
| Quinones et al., [42] | 54 (72%) | 10 (13.3%) | - | - | - | 11 (14.7%) | - | - | - | - | - | - | - | - |
Mean Age
The mean age ranged from 41.3 in Turkey [28] to 20.6 in Kuwait [38]. The random pooled estimate of mean age was 31.32 (95% CI: 28.74-33.91) (Figure 2).
Fig. 2.
Random pooled mean age.
Male gender
27 studies showed high proportion of males than females. The other two studies showed equal proportion of males to females [25, 35]. The random pooled estimate of male proportion across the included studies was 77% (95% CI: 73-80%) (Figure 3).
Fig. 3.
A forest plot showing the pooled estimate of male gender.
Incidence
The incidence of SCI ranged from 7.8/million/year in Kuwait [38] to 72.45/million/year in Iran [16]. The pooled estimate of the annual incidence of SCI across studies was 23.24 per million (Figure 4).
Fig. 4.
A forest plot showing the pooled estimate of the SCI incidence/million/year
Completeness of the injuryThe random pooled estimate for complete paraplegia was 44% (95% CI: 37-53%) (Figure 5). Whereas, complete tetraplegia pooled estimate was 20% (95% CI: 15-27%) (Figure 5).
Fig. 5.
A forest plot showing the pooled estimate of the type of injury
Incompleteness of the injury.
Incomplete paraplegia injury showed a random pooled estimate of 20% (95% CI: 13-30%) (Figure 5). And, incomplete tetraplegia injury has a random pooled estimate of 15% (95% CI: 9-24%) (Figure 5).
Level of the injury
Injury at the cervical level was found to have a random pooled estimate of 31% (95% CI: 27-36%) (Figure 6) whereas, the random pooled estimate for thoracic-level injury was 42% (95% CI: 32-53%) (Figure 6) and, the random pooled estimate for lumbar/sacral level injury was 29% (95% CI: 19-42%) (Figure 6).
Fig. 6.
A forest plot showing the pooled estimate of the level of the injury.
Etiology of the injury
The random pooled estimates for motor vehicle accidents (MVA), falls, gunshots, sports and violence were found to be 51% (95% CI: 42-60%), 29% (95% CI: 23-36%), 10% (95% CI: 6-15%), 2% (95% CI: 1-4%) and 3% (95% CI: 2-4%) respectively (Figure 7). In addition, the pooled estimate for etiology by country showed that MVA were the leading cause of injury and then falls, except in Turkey were falls were the leading etiology (Figure 8). Moreover, based on a meta-regression model to investigate possible association between male gender and mean age, male gender was found to have no association with any cause of the injury. However, mean age was found to have association between MVA (p<0.0004), falls (p<0.0001) and sports (p<0.041).
Fig. 7.
A forest plot showing the pooled estimate of the etiology of injury.
Fig. 8.
Etiology of the spinal cord injury by country.
Age groups
The random pooled estimates for the age groups 0-9, 10-19, 20-29, 30-39, 40-49, 50-59, 60-69 and ≥ 70 were found to be 2% (95% CI: 1-4%), 10% (95% CI: 6-15%), 35% (95% CI: 28-43%), 22% (95% CI: 20-25%), 14% (95% CI: 11-18%), 7% (95% CI: 4-11%), 4% (95% CI: 2-8%) and 3 % (95% CI: 1-5%) respectively (Figure 9).
Fig. 9.
A forest plot showing the pooled estimate of proportion of SCI cases by the age group.
Quality of the included studies
Sixteen studies were of good quality; six studies have score of 3, and ten studies have a score of 4. The remaining thirteen studies were of poor quality; having score ≤ 2. Most studies achieved low score in both the clear definition of inclusion and exclusion criteria and the qualifications of the person responsible for data collection. Also, many studies received low score in the category of security of the data repositories. Many studies either did not mention the form of the data source or did not mention the appropriateness of these data repositories.
Discussion
Spinal cord injury (SCI) negatively affect the patient’s physical, social and psychological well-beings. Besides its paramount economic costs, SCI places profound burden on healthcare systems. In addition to the importance of epidemiological evidence to help in implementing effective prevention strategies, it will help physicians in managing cases with SCI. Because of lack of resources and limited number of rehabilitation centers across the MENA region, this knowledge is crucial [43, 44].
Based on this comprehensive meta-analysis, the annual incidence of SCI in the MENA region was found to be 23.24/million. 77% of SCI cases were estimated to be males. Mean age of all cases was estimated to be 31.32. The most affected age group was those aging 20-29 then those aging 30-39. Thoracic spinal region was the most affected. Complete paraplegia was the most common type of injury. Furthermore, MVA and falls were the leading causes of SCI. However, it is difficult to compares countries upon causes of SCI because of lack of standardization in defining the etiology of SCI. For example, different studies have different definition of MVA. Some studies consider hitting pedestrians as MVA whereas other studies considered them as different category. The same issue was found in defining sports, whether it include diving.
In addition, there is lack of evidence about SCI in most countries. Only seven countries out of the twenty-one MENA countries have published reports about the epidemiology of SCI. This may restrict the generalizability of this meta-analysis results across the region.
Also, most studies used a retrospective chart review of their records. In most studies, it is unclear whether the records came from a register or paper records.
Finally, this review, up to our knowledge, is the most comprehensive systematic review of published studies about the epidemiological patterns of SCI in the Middle-East and North-Africa region.
Conclusion
This review summarized evidence pertaining to the pattern of traumatic spinal cord injuries in the MENA region. It will help in implementing preventive measures and will help in managing patients with SCI. It will help healthcare systems in the MENA region in properly allocating resources to improve the care of patients with SCI.
Limitation
Lack of full data reporting and the limited number of available articles restrict the generalizability of the analysis results. Also, there is discrepancy in defining etiology of SCI. So, the data of this meta-analysis should be interpreted carefully.
Recommendations
More studies in this field, especially from countries not included in this review, are needed. Large scale national studies are encouraged to ensure representativeness of the sample.
Moreover, using more standardized definitions in reporting SCI epidemiological studies will help to solve discrepancy in the literature [45, 46].
Conflict of Interest:
None declared.
References
- 1.Singh A, Tetreault L, Kalsi-Ryan S, Nouri A, Fehlings MG. Global prevalence and incidence of traumatic spinal cord injury. Clin Epidemiol. 2014;6:309–31. doi: 10.2147/CLEP.S68889. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.Rahimi-Movaghar V, Sayyah MK, Akbari H, Khorramirouz R, Rasouli MR, Moradi-Lakeh M, et al. Epidemiology of traumatic spinal cord injury in developing countries: a systematic review. Neuroepidemiology. 2013;41(2):65–85. doi: 10.1159/000350710. [DOI] [PubMed] [Google Scholar]
- 3.Lidal IB, Snekkevik H, Aamodt G, Hjeltnes N, Biering-Sorensen F, Stanghelle JK. Mortality after spinal cord injury in Norway. J Rehabil Med. 2007;39(2):145–51. doi: 10.2340/16501977-0017. [DOI] [PubMed] [Google Scholar]
- 4.Economics A. The economic cost of spinal cord injury and traumatic brain injury in Australia. Report by Access Economics for the Victorian Neurotrauma Initiative. Canberra: Access Economics; 2009. p. 31. [Google Scholar]
- 5.Kawu AA, Olawepo A, Salami AO, Kuranga SA, Abdulhameed S, Esenwah VC. A cost analysis of conservative management of spinal cord-injured patients in Nigeria. Spinal Cord. 2011;49(11):1134–7. doi: 10.1038/sc.2011.69. [DOI] [PubMed] [Google Scholar]
- 6.Post MW, van Leeuwen CM. Psychosocial issues in spinal cord injury: a review. Spinal Cord. 2012;50(5):382–9. doi: 10.1038/sc.2011.182. [DOI] [PubMed] [Google Scholar]
- 7.Sandin KJ, Klaas SJ. Assessment and evaluation of primary prevention in spinal cord injury. Top Spinal Cord Inj Rehabil. 2013;19(1):9–14. doi: 10.1310/sci1901-9. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 8.In: The World Bank Data. Middle East & North Africa | Data. [[Accessed: 26 Sep 2017]]. Available from: https://data.worldbank.org/region/middle-east-and-north-africa.
- 9.Stroup DF, Berlin JA, Morton SC, Olkin I, Williamson GD, Rennie D, et al. Meta-analysis of observational studies in epidemiology: a proposal for reporting Meta-analysis Of Observational Studies in Epidemiology (MOOSE) group. JAMA. 2000;283(15):2008–12. doi: 10.1001/jama.283.15.2008. [DOI] [PubMed] [Google Scholar]
- 10.In: World Bank Countries. Our Locations. [ [Accessed: 26 Sep 2017]]. Available from: http://www.worldbank.org/en/country.
- 11.Schwarzer G. Meta: an R package for meta-analysis. R news. 2007;7(3):40–5. [Google Scholar]
- 12.Higgins JP, Green S. Cochrane handbook for systematic reviews of interventions version 5.1. 0. The cochrane collaboration. 2011;5(0) [Google Scholar]
- 13.Wells G, Shea B, O’connell D, Peterson J, Welch V, Losos M, et al. The Newcastle-Ottawa Scale (NOS) for assessing the quality of nonrandomised studies in meta-analyses. Ottawa (ON): Ottawa Hospital Research Institute; 2009. Available in March. 2016. [Google Scholar]
- 14.Al-Jadid M, Robert AA. An analysis of the length of stay in traumatic and non-traumatic spinal cord injured patients A rehabilitation unit experience in Saudi Arabia. Saudi Med J. 2010;31(5):555–9. [PubMed] [Google Scholar]
- 15.Al-Jadid MS. A retrospective study on traumatic spinal cord injury in an inpatient rehabilitation unit in central Saudi Arabia. Saudi Med J. 2013;34(2):161–5. [PubMed] [Google Scholar]
- 16.Rahimi-Movaghar V, Moradi-Lakeh M, Rasouli MR, Vaccaro AR. Burden of spinal cord injury in Tehran, Iran. Spinal Cord. 2010;48(6):492–7. doi: 10.1038/sc.2009.158. [DOI] [PubMed] [Google Scholar]
- 17.Al-Habib A, Alaqeel A, Marwa I, Almohammadi M, Al Shalaan H, AlEissa S, et al. Causes and patterns of spine trauma in children and adolescents in Saudi Arabia: implications for injury prevention. Ann Saudi Med. 2014;34(1):31–7. doi: 10.5144/0256-4947.2014.31. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 18.Tasoglu O, Koyuncu E, Daylak R. Demographic and clinical characteristics of persons with spinal cord injury in Turkey: One-year experience of a primary referral rehabilitation center. J Spinal Cord Med. 2018;41(2):157–64. doi: 10.1080/10790268.2016.1224215. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 19.Derakhshanrad N, Yekaninejad MS, Vosoughi F, Sadeghi Fazel F, Saberi H. Epidemiological study of traumatic spinal cord injuries: experience from a specialized spine center in Iran. Spinal Cord. 2016;54(10):901–7. doi: 10.1038/sc.2016.10. [DOI] [PubMed] [Google Scholar]
- 20.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(1):57–62. doi: 10.1097/00004356-200503000-00008. [DOI] [PubMed] [Google Scholar]
- 21.Erhan B, Ulu MO, Gunduz B, Tanriverdi T. Pediatric spine and spinal cord injury in Istanbul: a retrospective analysis of 106 patients. Neurosurgery Quarterly. 2005;15(1):21–4. [Google Scholar]
- 22.Erdogan MO, Anlas Demir S, Kosargelir M, Colak S, Ozturk E. Local differences in the epidemiology of traumatic spinal injuries. Ulus Travma Acil Cerrahi Derg. 2013;19(1):49–52. doi: 10.5505/tjtes.2013.74501. [DOI] [PubMed] [Google Scholar]
- 23.Mahmoud H, Qannam H, Zbogar D, Mortenson B. Spinal cord injury rehabilitation in Riyadh, Saudi Arabia: time to rehabilitation admission, length of stay and functional independence. Spinal Cord. 2017;55(5):509–14. doi: 10.1038/sc.2016.165. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 24.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(8):469–71. doi: 10.1038/sc.1995.102. [DOI] [PubMed] [Google Scholar]
- 25.Alfrayh A, Al Naquib N. The pattern of central nervous disease in children in King Khalid University Hospital in Riyadh, Saudi Arabia. J Trop Pediatr. 1987;33(3):124–30. doi: 10.1093/tropej/33.3.124. [DOI] [PubMed] [Google Scholar]
- 26.El Tallawy HN, Farghly WM, Badry R, Rageh TA, Hakeem Metwally NA, Shehata GA, et al. Prevalence of spinal cord disorders in Al-Quseir City, Red Sea Governorate, Egypt. Neuroepidemiology. 2013;41(1):42–7. doi: 10.1159/000348320. [DOI] [PubMed] [Google Scholar]
- 27.Rahimi-Movaghar V, Moradi-Lakeh M, Rasouli MR, Vaccaro AR. Burden of spinal cord injury in Tehran, Iran. Spinal Cord. 2010;48(6):492–7. doi: 10.1038/sc.2009.158. [DOI] [PubMed] [Google Scholar]
- 28.brahim Atci I. Retrospective Analysis of 91 Patients with Spinal Trauma Who Examined at Emergency Department. Journal of Clinical and Analytical Medicine. 2014;7(111):80–4. [Google Scholar]
- 29.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(8):531–3. doi: 10.1038/sj.sc.3100404. [DOI] [PubMed] [Google Scholar]
- 30.Dincer F, Oflazer A, Beyazova M, Celiker R, Basgoze O, Altioklar K. Traumatic spinal cord injuries in Turkey. Paraplegia. 1992;30(9):641–6. doi: 10.1038/sc.1992.127. [DOI] [PubMed] [Google Scholar]
- 31.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(11):697–701. doi: 10.1038/sj.sc.3101064. [DOI] [PubMed] [Google Scholar]
- 32.Alshahri SS, Cripps RA, Lee BB, Al-Jadid MS. Traumatic spinal cord injury in Saudi Arabia: an epidemiological estimate from Riyadh. Spinal Cord. 2012;50(12):882–4. doi: 10.1038/sc.2012.65. [DOI] [PubMed] [Google Scholar]
- 33.Cosar SN, Yemisci OU, Oztop P, Cetin N, Sarifakioglu B, Yalbuzdag SA, et al. Demographic characteristics after traumatic and non-traumatic spinal cord injury: a retrospective comparison study. Spinal Cord. 2010;48(12):862–6. doi: 10.1038/sc.2010.49. [DOI] [PubMed] [Google Scholar]
- 34.Taghippor M, Sherafat Kazemzadeh E. Column and Spinal Cord Injuries in Shiraz Nemazi Hospital, an Epidemiological Study. Armaghane danesh. 2006;10(4):55–62. [Google Scholar]
- 35.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(4):428–31. doi: 10.1080/10790268.2009.11754572. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 36.Yousefzadeh Chabok S, Safaee M, Alizadeh A, Ahmadi Dafchahi M, Taghinnejadi O, Koochakinejad L. Epidemiology of traumatic spinal injury: a descriptive study. Acta Med Iran. 2010;48(5):308–11. [PubMed] [Google Scholar]
- 37.Otom AS, Doughan AM, Kawar JS, Hattar EZ. Traumatic spinal cord injuries in Jordan--an epidemiological study. Spinal Cord. 1997;35(4):253–5. doi: 10.1038/sj.sc.3100402. [DOI] [PubMed] [Google Scholar]
- 38.Raibulet T, Fakhri S, Khamees M, Eyadeh A. Spinal cord injury patients in the physical medicine and rehabilitation hospital, Kuwait: a nine-year retrospective study. Kuwait Med J. 2001;33:211–5. [Google Scholar]
- 39.Alshahri S. Traumatic Spinal Cord Injury in King Fahd Medical City: An Epidemiological Study. World Academy of Science, Engineering and Technology, International Journal of Medical and Health Sciences. 2017;4(1) [Google Scholar]
- 40.Sharif-Alhoseini M, Rahimi-Movaghar V. Hospital-based incidence of traumatic spinal cord injury in tehran, iran. Iran J Public Health. 2014;43(3):331–41. [PMC free article] [PubMed] [Google Scholar]
- 41.Fakharian E, Tabesh H, Masoud S. An epidemiologic study on spinal injuries in Kashan. Journal of Guilan University of Medical Sciences. 2004;13(49):80–5. [Google Scholar]
- 42.Quinones PM, Nassal M, AlBader K, Al Muraikhi A, Al Kahlout S. Traumatic spinal cord injury in Qatar: an epidemiological study. Middle East J Emergency Med. 2002;2(1):35–40. [Google Scholar]
- 43.Haig AJ, Im J, Adewole A, Nelson VS, Krabak B. The practice of physical medicine and rehabilitation in subSaharan Africa and Antarctica: A white paper or a black mark? PM&R. 2009;1(5):421–6. doi: 10.1016/j.pmrj.2008.12.012. [DOI] [PubMed] [Google Scholar]
- 44.Burns AS, O'Connell C. The challenge of spinal cord injury care in the developing world. J Spinal Cord Med. 2012;35(1):3–8. doi: 10.1179/2045772311Y.0000000043. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 45.DeVivo 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(9):535–40. doi: 10.1038/sj.sc.3101958. [DOI] [PubMed] [Google Scholar]
- 46.Biering-Sorensen F, Noonan VK. Standardization of Data for Clinical Use and Research in Spinal Cord Injury. Brain Sci. 2016;6(3) doi: 10.3390/brainsci6030029. [DOI] [PMC free article] [PubMed] [Google Scholar]