Traumatic Spinal Injury: Global Epidemiology and Worldwide Volume

Original Article
Traumatic Spinal Injury: Global Epidemiology and Worldwide Volume

Ramesh Kumar1, Jaims Lim2, Rania A. Mekary3,4, Abbas Rattani5,6, Michael C. Dewan5,7, Salman Y. Sharif 8,
Enrique Osorio-Fonseca9, Kee B. Park5
- BACKGROUND: Traumatic spinal injury (TSI) results compared with high-income countries (13.69 per 100,000
from injury to bony, ligamentous, and/or neurologic struc- persons). Road traffic accidents, followed by falls, were
tures of the spinal column and can cause significant the most common mechanism of TSI worldwide. Overall,
morbidity and mortality. The global burden of TSI is poorly 48.8% of patients with TSI required surgery.
understood, so we performed a systematic review and - CONCLUSIONS: TSI is a major source of morbidity and
meta-analysis to estimate the global volume of TSI.
mortality throughout the world. Largely preventable
- METHODS: We performed a systematic review through mechanisms, including road traffic accidents and falls, are
PubMed, Embase, and Cochrane Databases on TSI studies the main causes of TSI globally. Further investigation is
reported from 2000 to 2016. Collected data were used to needed to delineate local and regional TSI incidences and
perform a meta-analysis to estimate the annual incidence causes, especially in low- and middle-income countries.
of TSI across World Health Organization regions and World
Bank income groups using random-effect models. Incor-
porating global population figures, the annual worldwide
volume of TSI was estimated.
INTRODUCTION
- RESULTS: A total of 102 studies were included in the
systematic review and 19 studies in the meta-analysis. The
overall global incidence of TSI was 10.5 cases per 100,000
persons, resulting in an estimated 768,473 [95% confidence
interval, 597,213e939,732] new cases of TSI annually
T raumatic spinal injury (TSI) includes a multitude of in-
juries to the spinal cord, nerve roots, osseous structures,
and discoligamentous components of the spinal column.1
Injuries may be secondary to blunt or penetrating trauma and
result from both high-energy and low-energy mechanisms.2,3
worldwide. The incidence of TSI was higher in low- and Damage to the spinal column can lead to mechanical insta-
middle-income countries (8.72 per 100,000 persons) bility, pain, and impaired mobility, and damage to neurologic
Key words WPR: Western Pacific region

- Epidemiology WHO: World Health Organization
- Global
- Incidence From the 1Department of Neurosurgery, University of Colorado School of Medicine, Aurora,
- Traumatic spinal cord injury Colorado; 2School of Medicine, Vanderbilt University, Nashville, Tennessee; 3Department of
- Traumatic spinal injury Pharmaceutical Business and Administrative Sciences, School of Pharmacy, MCPHS
- Volume University, Boston, Massachusetts; 4Department of Neurosurgery, Harvard Medical School,
Cushing Neurosurgical Outcomes Center, Brigham and Women’s Hospital, Boston,
Abbreviations and Acronyms Massachusetts; 5Department of Global Health and Social Medicine, Harvard Medical School,
AFR: Africa Global Neurosurgery Initiative, Program in Global Surgery and Social Change, Boston,
AMR-L: Latin American region Massachusetts; 6School of Medicine, Meharry Medical College, Nashville, Tennessee;
7
AMR-US/CAN: United States and Canada Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville,
CI: Confidence interval Tennessee, USA; 8Department of Neurosurgery, Liaquat National Hospital & Medical
EMR: Eastern Mediterranean region College, Karachi, Pakistan; and 9Department of Neurological Surgery, Universidad el Bosque,
EUR: Europe Bogotá, Colombia
HIC: High-income country To whom correspondence should be addressed: Jaims Lim, B.S.
LIC: Low-income country [E-mail: jaims.lim@vanderbilt.edu]
LMICs: Low- and middle-income countries Citation: World Neurosurg. (2018) 113:e345-e363.
M/F: Male/female https://doi.org/10.1016/j.wneu.2018.02.033
MIC: Middle-income country
Journal homepage: www.WORLDNEUROSURGERY.org
SCI: Spinal cord injury
SD: Standard deviation Available online: www.sciencedirect.com
SEAR: South-East Asia region 1878-8750/$ - see front matter ª 2018 Elsevier Inc. All rights reserved.
TSI: Traumatic spinal injury
WORLD NEUROSURGERY 113: e345-e363, MAY 2018 www.WORLDNEUROSURGERY.org e345
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ORIGINAL ARTICLE
RAMESH KUMAR ET AL. GLOBAL EPIDEMIOLOGY OF TRAUMATIC SPINAL INJURY
structures commonly results in partial or complete paralysis.1,4,5 From abstract to full article, a random subset of titles was
Spinal cord injury (SCI) holds a more limited definition and reviewed by 2 authors (R.K. and J.L.) to ensure concordance in a
specifically pertains to injuries sustained to the spinal cord selection of articles. Any differences in the decision to include or
leading to neurologic deficits often measured using a clinical exclude an article were resolved by a tertiary review from 2 other
score such as the ASIA (American Spinal Injury Association) authors (M.D. and A.R.). Studies were excluded at this stage in the
score.6 Regardless of injury type, TSI has the potential to cause review for the following reasons: 1) high-income country (HIC)
severe disability or death. studies based on single institutions; 2) studies with a non-
Little is known regarding the worldwide volume of TSI. The generalizable cohort; 3) studies with poor and/or impertinent data
incidence of a particular subset of TSI, traumatic SCI, is better reporting; and (4) studies that precluded more current data from
understood. Estimated SCI incidences range from 8 to 246 cases the same cohort/population. Studies were considered to have poor
per million people per year.7-9 Although this is important infor- and/or impertinent data reporting when basic epidemiologic data
mation, the incidence of SCI represents only a fraction of the such as incidence, mechanism of injury, or anatomic location of
worldwide burden of TSI. The magnitude of effect of TSI as a injury were not reported. Review of the full article included the
global health issue remains obscure. weighting of each article with a score on a 6-point scale. The scale
The dearth of available data, especially from low- and middle- ranged from a lowest assigned score of 0 (small single-institution
income countries (LMICs), remains an obstacle to the assess- studies) to a highest of 5 (large population-based studies)
ment of the global burden of TSI. This lack of knowledge stands as (Appendix 1,Section B).12 To counter the potential publication
a major impediment to the development of national and inter- bias from HICs, a lower threshold for inclusion of studies from
national agendas focused on injury prevention, training of a LMICs was maintained. A PRISMA diagram was constructed to
capable medical workforce, and the creation of effective medical highlight reasons for inclusion or exclusion of an article at each
care delivery systems. The size of the neurosurgical workforce, step of the review process (Figure 1).
responsible in large part for the care of TSI, is woefully inadequate
in many parts of the world.10 Often, as is the irony with many Data Reporting
public health problems, the resources to treat disease and injury Descriptive data were reported as the proportion of a cohort or the
are limited where they are needed most. Yet, in the case of TSI, mean and/or median of multiple reported proportions. Mortality
even the most basic epidemiologic information is absent, was described as case-fatality rates. Standard deviations, inter-
precluding targeted resource allocation. In this study, we quartile ranges, and confidence intervals were reported where
performed a systematic review and meta-analysis of the TSI appropriate.
literature to estimate the global volume of this heterogeneous To coalesce data from countries in similar regions and socio-
group of injuries. economic statuses, we classified countries by income levels and
World Health Organization (WHO) regions. WHO member states
METHODS were divided into 6 separate regions as follows: Africa (AFR), the
Americas (AMR), the South-East Asia region (SEAR), Europe
Systematic Review (EUR), Eastern Mediterranean region (EMR), and the Western
A systematic review was conducted according to the guidelines set Pacific region (WPR).13 To better discern between the social and
forth by the PRISMA (Preferred Reporting Items for Systematic economic differences that may influence disease between North
Review and Meta-Analyses) statement.11 This review consisted of a America and Central and South America, we divided these
comprehensive search of literature published between January 1, regions for the purpose of this study: United States and Canada
2000 and October 17, 2016 querying PubMed, Embase, and the (AMR-US/CAN) and Latin America (AMR-L). We then classified
Cochrane Database of Systematic Reviews. A full list of search countries as HICs, middle-income countries (MICs), or low-
terms can be found in Appendix 1,Section A. income countries (LICs) based on the World Bank Country and
Two authors (R.K. and J.L.) jointly reviewed all titles, abstracts, Lending Groups classification system.14
and articles. The initial list of articles was narrowed to pertinent
titles by the following exclusion criteria: 1) no available abstract; 2) Meta-Analysis
nonhuman subjects; 3) study publication before 2000. The cutoff All studies in which an incidence of TSI could be extracted or
year of 2000 was selected to favor more timely and relevant calculated were included in the meta-analysis. Data were analyzed
studies. The titles were then screened and excluded if they were 1) with the Comprehensive Meta-Analysis version 3 (Biostat Inc.,
diagnostic, intervention, or outcomes focused; 2) comparative Englewood, New Jersey, USA) and Stata14 software. Overall inci-
studies (i.e., randomized control trials, cohort, and case-control dence estimates and 95% confidence intervals (CIs) were obtained
studies); 3) or focused on associations with the disease of inter- using the random-effects model according to the method of
est. Abstracts were then reviewed and excluded if they were 1) not DerSimonian and Laird,15 which accounted for variation between
in English or 2) not pertinent to the epidemiology of TSI. Abstracts and within studies for all income levels and WHO regions.
selected for further review focused either on the epidemiology Because no low-income studies met the inclusion criteria for the
(incidence, prevalence, volume, and burden) or the descriptive meta-analysis, LICs and MICs were grouped together as a com-
history of TSI. Thus, large population-based studies as well a mon incidence (i.e., LMICs). For the WHO regions with fewer
smaller cohort studies were included for further review. The full than 2 studies included in the meta-analysis, a weighted average of
article was then reviewed to assess the merit of a study for all countries in that region based on the World Bank income
inclusion. classification incidence values were used to calculate WHO
e346 www.SCIENCEDIRECT.com WORLD NEUROSURGERY, https://doi.org/10.1016/j.wneu.2018.02.033
ORIGINAL ARTICLE
Figure 1. PRISMA flowchart showing the exclusion and selection process of the 102 articles included in the final
review. HIC, high-income country.
regional incidence values. The global incidence of TSI was then review (Figure 1). Bibliography review of the selected articles
reported as a range using values calculated from a summation of was then performed and yielded 14 additional abstracts
the incidence of individual WHO regions as well as the global for review, none of which was included in the final selection.
incidence value surmised from the meta-analysis. Thus, 102 articles were included in the final selection
Forest plots were created to visualize individual and pooled (Table 1).2,3,16-49,51,55,57,60-63,67,70-73,80-114
estimates. The Cochran Q test (P < 0.10) was used to evaluate Articles represented 32 separate countries and all WHO regions.
heterogeneity among studies. Thereafter, I2 was used to measure Seven studies were from AFR, 17 from AMR-US/CAN, 4 from
the proportion of between-study heterogeneity. Subgroup analyses AMR-L, 11 from SEAR, 32 from EUR, 10 from EMR, and 21 from
by categorical covariates (WHO regions; country income levels) WPR. Most source articles included in this review were from HICs
were performed to assess potential sources of heterogeneity. To (n ¼ 50), whereas several were from MICs (n ¼ 46), and only a few
further explore sources of heterogeneity, meta-regression on study from LICs (n ¼ 6). Thirty-seven studies were population based,
quality was performed for studies included in the meta-analysis, most of which were from HICs (81%). No population-based
for each WHO region (when possible), and for each income studies were found from LICs. Seventy-three studies covered
level category. Publication bias was assessed by funnel plots, only SCI, whereas 29 studied TSI as a whole. The range of patients
Egger linear regression test, and Begg correlation test. A P value < within each study varied widely from 4 to 82,720, with a median of
0.05 was considered significant unless otherwise indicated. The 409 patients (Table 1).
statistical analysis was conducted by a statistician who is expert in A total of 19 articles were included in the meta-analysis
meta-analysis (R.A.M.). (Figure 2). This total included 1 from AFR, 3 from AMR-US/
CAN, 2 from EMR, 12 from EUR, 1 from WPR, and none from
RESULTS AMR-L and SEAR. Thirteen studies were from HICs and 6 were
from MICs. No incidence data were available in the LIC studies.
Literature Yield Five of the studies included in the meta-analysis focused on TSI in
The initial literature search yielded 5733 articles, of which 5493 general and 14 focused specifically on SCI. Heterogeneity between
were from PubMed, 233 from Embase, and 7 from Cochrane studies was high with an I2 value of 99.9% and a P heterogeneity of
Database of Systematic Reviews. After 5277 titles were excluded, < 0.01. Meta-regression analysis of the Logit event rate on study
456 abstracts remained, of which 165 were selected for full article quality showed a slope of 0.57 (P ¼ 0.07 in the random-effects
e348
RAMESH KUMAR ET AL.

Table 1. Article Overview
World Health Traumatic
Organization Income Population Spinal Injury Study Gender Ratio Study Study Study
www.SCIENCEDIRECT.com
Reference Year Country Region Level at Risk (N) Cases (n) Period (Male/Female) Design Scale Quality
Karacan et al.16 2000 Turkey EUR Middle 45,784,957 581 1992 2.5 Cross-sectional Population based 3
17
Kokoska et al. 2000 USA AMR-US/CAN High 25,500 408 1994e1999 1.44 Retrospective Other 2
18
Surkin et al. 2000 USA AMR-US/CAN High 395 1992e1994 4.1 Prospective Population based 3
Van Asbeck et al.19 2000 Netherlands EUR High 15,100,000 126 1994 3.3 Retrospective Population based 3
20
Ali Raja et al. 2001 Pakistan EMR Middle 2654 1995e1999 2.6 Retrospective Hospital based 2
Burke et al.21 2001 USA AMR-US/CAN High 161 1993e1998 3 Retrospective Other 2
22
Zhao et al. 2001 China WPR Middle 246,812 1995 7 Cross-sectional Population based 3
23
Brolin 2002 Sweden EUR High 1,450,000 4168 1987e1999 1.29 Retrospective Other 4
Augutis24 2003 Sweden EUR High 92 1985e1996 1.04 Retrospective Population based 3
Dryden et al.25 2003 Canada AMR-US/CAN High 1644 450 1997e2000 2.52 Retrospective Other 2
26
Pickett et al. 2003 Canada AMR-US/CAN High 2385 1994e1999 2.17 Retrospective Other 2
WORLD NEUROSURGERY, https://doi.org/10.1016/j.wneu.2018.02.033
Jackson et al.27 2004 USA AMR-US/CAN High 30,532 1973e2003 4.3 Retrospective Other 2
28
Nwadinigwe et al. 2004 Nigeria AFR Middle 104 1996e2001 5.5 Retrospective Hospital based 1
Dahlberg et al.29 2005 Finland EUR High 546,000 152 1999 3.2 Cross-sectional Population based 3
Gur et al.30 2005 Turkey EUR Middle 539 1990e1999 3.4 Retrospective Hospital based 2
31
Lakhey et al. 2005 Nepal SEAR Low 233 1997e2001 2.64 Retrospective Hospital based 1
GLOBAL EPIDEMIOLOGY OF TRAUMATIC SPINAL INJURY

O’Connor32 2005 Australia WPR High 2959 1986e1997 Cross-sectional Population based 3
33
O’Connor and Murray 2006 Ireland EUR High 46 2000 6.7 Prospective Hospital based 2
Pickett et al.34 2006 Canada AMR-US/CAN High 924,257 151 1997e2001 3 Retrospective Hospital based 2
Roohi et al.35 2006 Malaysia SEAR Middle 78 1998 3.76 Retrospective Hospital based 0
36
Vitale et al. 2006 USA AMR-US/CAN High 14,000,000 2909 1997e2000 2.54 Retrospective Population based 3
Agarwal et al.37 2007 India SEAR Middle 181 2003e2004 3.6 Retrospective Hospital based 1
38
Bajracharya et al. 2007 Nepal SEAR Low 896 1996e2006 3.2 Retrospective Hospital based 1
Roche et al.39 2007 Ireland EUR High 465,000 285 1.58 Retrospective Hospital based 2
40
Shrestha et al. 2007 Nepal SEAR Low 149 2001e2004 4 Retrospective Hospital based 1
41
Upendra et al. 2007 India SEAR Middle 440 1990e2000 4.58 Retrospective Hospital based 1
Ahoniemi et a.42 2008 Finland EUR High 1647 1976e2005 4.8 Retrospective Hospital based 2
ORIGINAL ARTICLE
43
Kato et al. 2008 Japan WPR High 15,640 127 2003e2005 Retrospective Hospital based 2
44
Rathore et al. 2008 Pakistan EMR Middle 83 2006 4.5 Prospective Hospital based 0
Yang et al.45 2008 Taiwan WPR High 21,984,415 54,484 2000e2003 0.99 Retrospective Population based 4
WORLD NEUROSURGERY 113: e345-e363, MAY 2018
RAMESH KUMAR ET AL.

Divanogluo and Levi46 2009 Sweden/Greece EUR High 87/49 2006 7.1/3.3 Prospective Population based 3
Obalum et al.47 2009 Nigeria AFR Middle 468 1992e2006 2.34 Retrospective Hospital based 1
48
Puisto et al. 2009 Finland EUR High 1,100,000 749 1997e2006 1.04 Retrospective Population based 5
49
Rahimi-Movaghar et al. 2009 Iran EMR Middle 9006 4 2007e2008 1 Cross-sectional Population based 3
Santos et al.50 2009 Brazil AMR-L Middle 2,148,835 217 1997e2006 7.35 Prospective Population based 5
51
Wang et al. 2009 USA AMR-US/CAN High 20,276 2530 1994e2002 1.3 Retrospective Population based 4
Ye et al.52
2009 China WPR Middle 57 1993e2006 3.4 Retrospective Hospital based 2

2
Costacurta et al. 2010 Brazil AMR-L Middle 54 2002e2008 Retrospective Hospital based 1
53
Hagen et al. 2010 Norway EUR High 336 1952e2001 4.7 Retrospective Population based 3
Heidari et al.54 2010 Iran EMR Middle 16,321 619 1999e2004 2.17 Cross-sectional Other 2
55
Pirouzmand et al. 2010 Canada AMR-US/CAN High 12,192 1986e2006 1.94 Retrospective Hospital based 1
Rahimi- Movaghar et al.56 2010 Iran EMR Middle 496 2008 2.2 Retrospective Population based 3
Yousefzadeh57 2010 Iran EMR Middle 245 2005e2006 2.55 Retrospective Hospital based 1
58
Feng et al. 2011 China WPR Middle 239 1998e2009 4.2 Retrospective Hospital based 1
Li et al.59 2011 China WPR Middle 264 2002 3 Retrospective Other 2
Moradi-Lakeh et al.60 2011 Iran EMR Middle 16,000 619 2006e2007 2.17 Retrospective Population based 4
61
New et al. 2011 Australia WPR High 1364 2002e2006 2.52 Retrospective Other 3
Ning et al.62 2011 China WPR Middle 869 2004e2008 5.63 Retrospective Other 2
Tugcu et al. 63
2011 Turkey EUR Middle 2000e2007 Retrospective Hospital based 1
Chhabra and Arora64 2012 India SEAR Middle 1138 2002e2010 5.9 Retrospective Hospital based 1
Knútsdóttir et al.65

2012 Iceland EUR High 268,500 207 1975e2009 2.63 Retrospective Population based 3
66
Lenehan et al. 2012 Canada AMR-US/CAN High 4,200,000 930 1995e2004 4 Prospective Population based 3
Liu et al.67 2012 China WPR Middle 82,720 2001e2007 2.33 Retrospective Other 2
www.WORLDNEUROSURGERY.org
68
Pérez et al. 2012 Spain EUR High 10,274 2000e2009 2.8 Retrospective Population based 3
Sabre et al.69 2012 Estonia EUR High 1,340,000 595 1997e2007 5.5 Retrospective Population based 3
70
Wang et al. 2012 China WPR Middle 3142 2001e2010 1.9 Retrospective Hospital based 2
Erdogan et al.71 2013 Turkey EUR Middle 409 2007e2011 1.6 Retrospective Hospital based 1
Hua et al.72 2013 China WPR Middle 561 2001e2010 4.1 Retrospective Hospital based 1
73
Ibrahim et al. 2013 Malaysia SEAR Middle 449 167 2006e2009 3.3 Cross-sectional Hospital based 1
Sabre et al.74 2013 Estonia EUR High 545,533 71 1997e2001 3.4 Retrospective Population based 3
Sabre et al.74 2013 Norway EUR High 1,361,242 244 1997e2001 6 Retrospective Population based 3
ORIGINAL ARTICLE
75
Wang et al. 2013 China WPR Middle 761 2007e2010 3.4 Retrospective Hospital based 1
Fredø et al.76 2014 Norway EUR High 4,920,000 3248 2009e2012 2.2 Retrospective Population based 4
e349
AFR, Africa region; AMR-L, Latin American region; AMR-US/CAN, United States and Canada; EMR, Eastern Mediterranean region; EUR, Europe; SEAR, South-East Asia region; WPR, Western Pacific region. Continues
e350
RAMESH KUMAR ET AL.

Table 1. Continued
World Health Traumatic
Organization Income Population Spinal Injury Study Gender Ratio Study Study Study
Reference Year Country Region Level at Risk (N) Cases (n) Period (Male/Female) Design Scale Quality
www.SCIENCEDIRECT.com
Güzelküçük et al.77 2014 Turkey EUR Middle 37 2010e2013 Retrospective Hospital based 0
78
Kamravan et a. 2014 Iran EMR Middle 261 206 2009e2012 3 Cross-sectional Hospital based 0
Katoh et al.79
2014 Japan WPR High 776,790 91 2011e2012 2.6 Retrospective Population based 3
Korhonen et al.80 2014 Finland EUR High 5,400,000 372 1970e2011 Retrospective Population based 4
Koskinen et al.81 2014 Finland EUR High 3,065,946 77 2012 2.1 Prospective Population based 3
82
Lalwani et al. 2014 India SEAR Middle 341 2008e2011 5.4 Retrospective Hospital based 1
83
Moorin ete al. 2014 Australia WPR High 335 2003e2008 2.94 Retrospective Population based 3
Nijendijk et al.84 2014 Netherlands EUR High 185 2010 2.85 Retrospective Other 2
Selvarajah et al.85 2014 United States AMR-US/CAN High 6132 2007e2010 1.2 Retrospective Other 2
Sharif-Alhoseini et al.86 2014 Iran EMR Middle 867 138 2010e2011 5.57 Retrospective Hospital based 2
Shrestha et al.87 2014 Nepal SEAR Low 381 2008e2011 2.77 Retrospective Hospital based 1
WORLD NEUROSURGERY, https://doi.org/10.1016/j.wneu.2018.02.033
88
Smith et al. 2014 Ireland EUR High 4,581,269 58 2001e2010 Retrospective Hospital based 2
Wang et al.89 2014 China WPR Middle 642 2001e2010 0.63 Retrospective Hospital based 2
Bellucci et al.90 2015 Brazil AMR-L Middle 348 2012 5.56 Cross-sectional Hospital based 1
Biluts et al.91 2015 Ethiopia AFR Low 385 2008e2012 5.76 Retrospective Hospital based 1
92
Chamberlain et al. 2015 Switzerland EUR High 932 2005e2012 2.9 Retrospective Population based 3
93
Güzelküçük et al. 2015 Turkey EUR Middle 805 242 2009e2013 4.15 Retrospective Hospital based 1

Jain et al.94 2015 United States AMR-US/CAN High 3393 1993e2012 Retrospective Population based 0
Joseph et al.95 2015 South Africa AFR Middle 3,860,000 147 2013 5.9 Prospective Population based 3
96
Löfvenmark et al. 2015 Botswana AFR Middle 2,000,000 52 2011e2013 2.5 Prospective Hospital based 1
Mathur et al.97 2015 India SEAR Middle 8178 2716 2000e2008 4.2 Prospective Hospital based 1
98
Mendoza-Lattes et al. 2015 United States AMR-US/CAN High 80,167,284 6191 1997e2009 1.5 Retrospective Population based 4
New et al.99 2015 Australia WPR High 1364 2002e2006 2.51 Retrospective Population based 3
Sabre et al.100 2015 Estonia EUR High 391 2005e2007 3.9 Retrospective Population based 3
101
Saunders et al. 2015 United States AMR-US/CAN High 490 1998e2012 2.86 Retrospective Population based 3
Selassie et al.102 2015 United States AMR-US/Can High 3365 1998e2012 2.9 Cross-sectional Population based 3
3
Sothmann et al. 2015 South Africa AFR Middle 2042 2003e2014 5.25 Retrospective Hospital based 1
ORIGINAL ARTICLE
Stephan et al.103 2015 Germany EUR High 57,310 4285 2002e2012 Retrospective Other 2
104
Thesleff et al. 2015 Finland EUR High 2041 1987e2010 2.6 Retrospective Population based 4
105
Ametefe et al. 2016 Ghana AFR Low 185 2012e2014 3.2 Retrospective Hospital based 1
Chen et al.106 2016 United States AMR-US/CAN High 30,881 1970e2014 4.2 Cross-sectional Population based 3
ORIGINAL ARTICLE
model and P < 0.01 in the fixed-effect model), suggesting that

higher-quality studies tended to have a higher incidence of TSI
1
3
3
1
1
2
1
2
and may be a potential source of the high level of heterogeneity.
This positive slope was consistent across studies conducted in
EUR (slope ¼ 0.83; P ¼ 0.15), LMIC (slope ¼ 2.16; P < 0.01), and
Population based
Hospital based
Hospital based
Hospital based
Hospital based
Hospital based
Hospital based
HIC (slope ¼ 0.38; P ¼ 0.10) although some associations were not
statistically significant (Appendix,Section C).
Other
Incidence, Demographics, and Type of Injury

AFR, Africa region; AMR-L, Latin American region; AMR-US/CAN, United States and Canada; EMR, Eastern Mediterranean region; EUR, Europe; SEAR, South-East Asia region; WPR, Western Pacific region.
The total global incidence for TSI was 10.5 cases per 100,000
Cross-sectional
persons (95% CI, 8.6e12.84 cases/100,000). This incidence

Retrospective
Retrospective
Retrospective
Retrospective
Retrospective
Retrospective
Retrospective
resulted in an estimated 768,473e790,695 cases of TSI worldwide

each year (Table 2). Incidence of TSI, based on WHO region,
ranged from 3.4 per 100,000 in EUR (95% CI, 1.8e6.6 cases/
100,000) to 13.7 per 100,000 in SEAR. When analyzed by income
classification according to the World Bank Country and Lending
Groups, the incidence of TSI was higher in LMICs (13.7 per
1.82
3.03
4.33
2.34
3.8
3.6
3.5
100,000 persons; 95% CI, 6.4e21.0 cases/100,000) compared

with HICs (8.7 per 100,000 persons; 95% CI 6.6e10.9 cases/
100,000) (Figure 3). Worldwide, 37.3% (standard deviation [SD]
28.3) of patients with TSI had an SCI. There was a large
2011e2015
2002e2012
1994e2013
2009e2013
2006e2013
2003e2011
2009e2014
2009e2013
difference between the proportion of patients with TSI with SCI

in HICs (25.27%; SD 26.8) compared with MICs (36.6%; SD
26.9) and especially LICs (70.4; SD 6.0).
Worldwide, the mean age of patients with TSI was 39.8 (SD
12.2). Patients tended to be the oldest in WPR and the youngest in
1137
1543
1340
554
464
354
232
AMR-US/CAN. However, when average age was analyzed by in-

come classification, LICs showed the youngest average age at time
of injury (Figure 4). Males were more commonly affected by TSI,
with an average male/female (M/F) ratio of 3.37 worldwide
8,272,469
5,144,625
through all WHO regions and income levels. The highest M/F
ratio found was 7.35 in a report of cervical spine injury in
Brazil.50 Conversely, only 2 reports found women to be more
commonly affected than men, both of which were from
WPR.45,89 Overall, the M/F ratio of TSI was higher in LMICs
Middle
Middle
Middle
Middle
Middle
Middle
High
High
than in HICs (Figure 5).

TSI most commonly involved the cervical spine (46.02%; SD
19.2), whereas the lumbosacral spine was the least commonly
involved (24.8%; SD 17.7). The proportion of cervical spine
injuries ranged from 39% to 53% in most regions; however, the
AMR-L
WPR
WPR
WPR
WPR
EMR
EUR
EUR
EMR had a substantially lower rate of cervical spine injuries

(29.9%; SD 20.1) compared with other regions. The EMR and
AMR-L were the only regions in which thoracic injuries surpassed
the reported rate of cervical injuries on average (Figure 6). Road
traffic accidents (39.5%; SD 16.6) followed by falls (38.8%; SD
Scotland
Mexico
Austria
17.7) were the most common mechanisms for TSI worldwide.

China
China
China
China
Iran
Road traffic accidents accounted for 41.6% (SD 16.1) of TSI in

HICs as opposed to 40.7% (SD 18.4) and 27.2% (SD 22.6)
2016
2016
2016
2016
2016
2016
2016
2017
in MICs and LICs, respectively. Falls were the most common

mechanism of injury in LICs (54.7%; SD 19.6). Sports-related
injuries were relatively rare in MICs (2.1%; SD 2.8) and LICs
Rodríguez-Meza et al.111
(0.6%; SD 0.9) as opposed to HICs (8.6%; SD 5.8).

Derakhshaad et al.107
McCaughey et al.109
Majdan et al.108
Mortality and Surgical Incidence

Chen et al.114
112
Zhou et al.113
110
Reported mortality attributed to TSI ranged from 0% to 60%.

Yang et al.
Ning et al.
Mean mortality in HICs were 15.4%, as opposed to 3.8% in MICs.

Only 1 LIC study from Ethiopia reported a mortality of 1.8%.91
Furthermore, Augutis et al.24 reported a mortality of 60% within
ORIGINAL ARTICLE
Figure 2. Forest plot of the incidence per 100,000 size of the solid squares is proportional to the weight of
persons (95% confidence interval [CI]) of traumatic the study. Weights are from random-effects analysis
spinal injury by World Health Organization regions from using the method of DerSimonian and Laird.15 AFR,
19 studies. Solid squares represent the point estimate Africa; AMR-US/CAN, United States and Canada; EMR,
of each study and the diamonds represent the pooled Eastern Mediterranean region; ES, effect size; EUR,
estimate of the incidence for each subgroup. The width Europe; WPR, Western Pacific region.
of the diamond denotes 95% confidence intervals. The
1 year of injury in children who had SCI. This was the only study the more likely to have surgical intervention than patients in HICs
reporting a mortality >50%, which the study attributed to its (42.5% [26.7]).
pediatric-only cohort, inclusion of prehospital deaths, and high An asymmetry to the right of the pooled TSI incidence in the
proportion of traffic accidents. The proportion of patients un- funnel plot suggested the presence of publication bias with studies
dergoing surgical intervention ranged from 36.4% to 59.1% in the reporting a higher incidence being potentially missing
different WHO regions. Data for surgical intervention was again (Appendix,Section C). However, the Begg rank correlation
available from only 1 LIC study, in which 18.2% of patients un- test (P ¼ 0.20) indicated no publication bias but the Egger
derwent surgery. On average, patients in MICs (54.9% [16.4]) were linear regression test indicated a statistically significant bias
ORIGINAL ARTICLE
Table 2. Incidence and Annual Volume of Traumatic Spinal Injury by World Health Organization Region
Number of Persons
World Health Incidence 95% CIeLower 95% CIeUpper Affected Per
Organization Region (Per 100,000) Limit Limit* Population Annum (95% CI)
Africa 13.6* — — 990,267,592 134,676y

Americas-United States and Canada 5.1 1.4 19.0 357,270,594 18,220 (5,002e67,881)
Americas-Latin America 12.6* — — 630,250,409 79,412y
Eastern Mediterranean 5.2 1.0 26.3 648,060,427 33,699 (6480e170,440)
Europe region 3.4 1.8 6.6 914,533,173 31,094 (16,462e60,359)
South-East Asia 13.7* — — 1,928,530,522 264,209y
Western Pacific 12.4* — — 1,849,874,735 229,385y
Low- to middle-income countries 13.69 6.39 20.98 6,160,085,274 843,316 (393,629e1,292,385)
High-income countries 8.72 6.56 10.88 1,163,727,841 101,477 (76,341e126,614)
Worldwide 10.5 8.16 12.84 7,318,787,452 768,473 (597,213e939,732)
Incidence values for regions with <2 studies included in the meta-analysis were calculated using a weighted average of the income classification incidence of the countries comprising that
region. The worldwide number of persons affected per annum reflects a range obtained by calculating the product of the lower and upper limits of the 95% CI and the respective population
divided by 100,000.
CI, confidence interval.
*Number of persons affected per annum based on the described incidence and population.
yReliable CI estimates not reported given the manner of aggregation of crude incidence rates across income levels.
(P < 0.01). The trim-and-fill method was used to recalculate the and their families, because they commonly lead to death or
pooled incidence by imputing 10 studies to the right of the effect profound disability. In more remote parts of the world, the
estimate. The analysis suggested that the imputed incidence only diagnosis and treatment of TSI may be inadequate because of a
slightly increased compared with the original pooled estimate. lack of diagnostic equipment and health care personnel trained
in the management of TSI.117 The delay in diagnosis and proper
management of TSI can be costly, resulting in neurologic injury,
TSI Versus SCI
chronic pain, or deformity.118
Studies focusing on TSI specifically, as opposed to SCI and TSI
combined, were analyzed separately to identify potential epide-
miologic differences. There were no significant differences in
incidence, age at time of injury, mechanism of injury, or gender Current Knowledge on the Global Epidemiology of TSI
ratio between TSI and TSI/SCI. Analyses did show differences in This study was the first attempt to estimate the worldwide inci-
the mortality and percentage of patients receiving surgery after dence of TSI stratified by WHO region (Figure 7). However, before
injury. TSI reports showed a mortality of 6.3, half the rate observed this study, several investigators assessed the global incidence of
in the TSI/SCI analyses. Furthermore, 36.6% of patients received SCI. In 2007, Fitzharris et al.7 estimated the global incidence of
surgery after a TSI injury, as opposed to 48.8% of patients with SCI, based on 31 separate studies, to be 23 cases per 1,000,000
TSI/SCI. persons, the highest rates of which were in SEAR and WPR.
Furlan et al.8 reviewed 64 articles published between 1950 and
2012 and found a wide range of reported SCI incidence, from 8
DISCUSSION to 246 cases per million persons. Most of these studies were
To the best of our knowledge, this report represents the first from North America and EUR, and none from AFR. Based on
attempt to define the volume of TSI worldwide. It encompassed both actual and extrapolated data, Lee et al.9 estimated the
102 studies from 32 different countries spread out among all the highest incidence of SCI in North America and the lowest in
WHO regions. Furthermore, studies from every income stratifi- Australia. Furthermore, they estimated a total annual number of
cation of the World Bank Country and Lending Groups Classifi- SCI cases to range from 133,000 to 226,000 worldwide.9 Chiu
cation system were included in this review. et al.119 compared the epidemiology of SCI between developed
Neurologic trauma remains a significant cause of death and and developing nations and found that people with SCI in
disability worldwide.115,116 These injuries often have preventable developing countries had higher mortality. The mechanism of
causes such as falls, road traffic accidents, and violence.116 For SCI injury also differed significantly between the 2 groups, because
alone, it has been estimated that up to 226,000 people are affected road traffic accidents were the leading cause of injury in
worldwide each year.9 Less is known on the burden of TSI as a developed countries, whereas falls accounted for most injuries
whole. Such injuries have significant ramifications for patients in developing nations. Rahimi et al. looked specifically at the
ORIGINAL ARTICLE
Figure 3. Forest plot of the incidence per 100 (95% denotes 95% confidence intervals. The size of the solid
confidence interval [CI]) of traumatic spinal injury by 2 squares is proportional to the weight of the study.
income levels from 19 cross-sectional studies. Solid Weights are from random-effects analysis using the
squares represent the point estimate of each study and method of DerSimonian and Laird.15 The first group
the diamonds represent the pooled estimate of the represents the high-income level; the second group
incidence for each subgroup. The width of the diamond represents the low/middle level. ES, effect size.
incidence of SCI in developing countries and found a rate of 25.5 Some studies have examined the incidence of TSI on a regional
cases per million persons per year.50 or national basis. Yang et al.45 investigated the incidence of
Although SCI represents a major portion of the burden of TSI, hospitalized TSI in Taiwan over several years. These
these studies certainly underestimate the magnitude of burden investigators found an average annual incidence of 61.61 cases
that TSI plays on a global level. Treatment of TSI by trained sur- per 100,000 persons. This estimated national incidence of all
geons often leads to improvement or preservation of neurologic TSI in Taiwan is significantly higher than the global incidence
function in all income stratifications, including LMICs such as of SCI reported by Lee et al.9 (2.3 cases per 100,000 persons).
Ethiopia.120 The study by Yang et al. was relatively stronger because all data
Furthermore, surgical care can prevent limited mobility, were collected from a national health insurance database, and
postural deformities, and chronic pain secondary to unstable thus, the only cases of TSI that were likely to be missed were
fractures, which often impede individuals’ abilities to return to patients who did not present for hospitalized care. This high
work or care for their families. Such conditions can result in severe incidence may represent a more accurate estimation of the
economic, social, and medical consequences for persons with TSI. volume of TSI than other studies that lack data from a
ORIGINAL ARTICLE
reporting on SCI and not TSI in general, our incidence calcula-

tions are biased toward the incidence of SCI. Comparing the in-
A cidences reported in this study with the incidences of SCI reported
WPR 46.21 by Lee et al.,9 the global and regional incidences of TSI are
SEAR 36.40 expectedly higher than that of SCI. However, the magnitude of
EUR 44.05 difference in volume of TSI and SCI is less than that reported
EMR 34.80
from a large national study on TSI by Yang et al.9,45 Third,
many cases of TSI, especially mild injuries, may go undiagnosed
AMR-US/CAN 29.33
in LMICS because the availability and access to the necessary
AMR-L 30.23
diagnostic capabilities is limited. This report excluded all osteo-
AFR 34.88 porotic fractures, which can occur in the presence or absence of
Total 39.83 trauma. It is estimated that in 2000, there were >1.4 million
0.00 10.00 20.00 30.00 40.00 50.00 60.00 70.00 osteoporotic vertebral fractures worldwide.122 This statistic adds
significantly to the volume of spinal injuries seen worldwide,
B although their cause is not always traumatic.
There are approximately 33,000 neurosurgeons worldwide, most
41.24
High
of whom reside in Asia, Europe, or North America.123,124 The
number of neurosurgeons may be higher because these estimates
Middle 38.83 are 7e15 years old and are based on differing criteria for neuro-
surgeons. The clustering of neurosurgeons and orthopedic sur-
Low 36.40
geons within certain countries around the world creates disparities
in the availability of neurosurgical care depending on a person’s
country or continent of residence. A stark contrast exists between
Total 39.83
regions such as North America, which has approximately 1
neurosurgeon for every 81,000 residents, and AFR, where there is
0 10 20 30 40 50 60
Figure 4. Mean age at time of injury is shown by World Health

Organization region (A) and income level (B). AFR, Africa; AMR-L, Latin
American region; AMR-US/CAN, United States and Canada; EMR, Eastern
Mediterranean region; EUR, Europe; SEAR, South-East Asia region; WPR,
Western Pacific region.
A
WPR 3.23
SEAR 3.94
EUR 3.26
EMR 2.96
nonporous catchment system. Yang et al. also looked at the rate of
AMR-US/CAN 2.74
SCI within the TSI population and found a range from 14.5% to
AMR-L 5.50
43.9% depending on age group, with younger individuals (age
0e19 years) more likely to have had a neurologic injury.45 AFR 4.35
TOTAL 3.37
0.00 1.00 2.00 3.00 4.00 5.00 6.00 7.00 8.00

Global and Regional Incidences of TSI
This report estimated the global incidence of TSI to be 10.5 cases B
per 100,000 persons. Given the worldwide population of >7
billion people according to the World Bank 2015 metadata,121 this High 3.01
incidence accounts for >700,000 new cases of TSI globally, each

year. This annual burden of TSI represents a significant, yet
Middle 3.71
poorly recognized, threat to global public health. The estimated
incidence of TSI varied widely between WHO regions, with a
low value of 3.4 per 100,000 persons in AMR-L and a high rate Low 3.60
of 13.7 per 100,000 persons in WPR. This wide variation may
reflect true regional differences in the incidence of TSI, but also
the quality of studies included in the meta-analysis. Total 3.37
There are several reasons why the incidence figures reported

here might underestimate the volume of TSI. First, the paucity of 0.00 1.00 2.00 3.00 4.00 5.00 6.00
large databases and national health systems capable of identifying Figure 5. Mean gender ratio based on World Health Organization region (A)
all cases of TSI means that many cases of TSI likely go unreported and income level (B). AFR, Africa; AMR-L, Latin American region;
and are not captured in the literature. This situation is likely more AMR-US/CAN, United States and Canada; EMR, Eastern Mediterranean
region; EUR, Europe; SEAR, South-East Asia region; WPR, Western Pacific
pronounced in LMICs with poor database infrastructure and region.
data reporting. Second, because the literature is biased toward
ORIGINAL ARTICLE
A
W 27.05
P 26.75
R 47.60
SE 35.03
A 26.06
R 40.19
E 23.89
U 32.68
R 39.59
E 29.37
M 46.12
R 29.85
A
M 24.21
24.06
R- 50.08
U…
A
M 9.45
51.50
R- 39.10
L
A 19.60
F 26.11
R 53.94
T
O 24.84
30.68
T 46.02
A…
0 10 20 30 40 50 60 70 80
Lumbosacral Thoracic Cervical
B
22.23
High 29.22
51.41
26.84
Middle 31.77
41.90
29.07
Low 30.19
39.25
24.84
Total 30.68
46.02
0 10 20 30 40 50 60 70
Lumbosacral Thoracic Cervical
Figure 6. Distribution of injury (lumbosacral, thoracic, or Canada; EMR, Eastern Mediterranean region; EUR,
cervical) based on World Health Organization region (A) Europe; SEAR, South-East Asia region; WPR, Western
and income level (B). AFR, Africa; AMR-L, Latin Pacific region.
American region; AMR-US/CAN, United States and
a single neurosurgeon for every 1,238,000 persons.123,124 Consid- accessibility of adequate and affordable neurosurgical care. Lack
ering the paucity of neurosurgeons on the African continent in of accessibility is further highlighted by Dewan et al.125 (in press),
light of an estimated 13.6 new cases of TSI for every 100,000 who found that >5 million patients worldwide annually have
persons in that region, many patients with TSI likely struggle with treatable neurosurgical conditions but do not receive surgical
ORIGINAL ARTICLE
Figure 7. Annual incidence of traumatic spinal injury is illustrated by World shown by World Health Organization region and income region on the right.
Health Organization region on the left. Burden of traumatic spinal injury is
interventions. The study also found that people in AFR and SEAR portion of HICs, because the average age of injury was >14 years
are particularly at higher risk because of a low proportion of higher in EUR compared with AMR-US/CAN.
neurosurgeons to neurosurgical disease.125 The lack of access to Road traffic accidents and falls were the leading causes of TSI
quality neurosurgical care in regions such as AFR, AMR-L, and worldwide (39.5%, SD 16.6% and 38.8%, SD 17.7%). Simi-
SEAR is worsened by the tendency for neurosurgeons to cluster larly, road traffic accidents followed by falls are the most common
within urban areas of LMICs, thus making it even more difficult types of unintentional injuries to cause death worldwide, yet the
for rural populations to access care in the instance of TSI. With an ratio between the 2 types of injury for overall mortality is greater
average of 48.8% (SD 22.0%) of patients with TSI undergoing than 2:1 in favor of road traffic accidents.127,128 Road traffic acci-
surgical intervention, the shortage of global medical personnel dents leading to TSI were more common in HICs (41.6%, SD 16.
capable of caring for TSI stands as a great impediment to the 1%) compared with MICs (40.7%, SD 18.4%) and LICs (27.2%,
adequate delivery of care. SD 22.6%). The higher rate of road traffic injuries leading to TSI
in HICs may reflect the fact that HICs have a significantly higher
Differences in TSI Demographics, Injury Types, and Mechanism of number of motor vehicles per capita.129 The significant amount of
Injury injuries from road traffic accidents in LMICs, despite a lower
This report confirmed that TSI affected men more commonly than number of motor vehicle per capita, is likely secondary to poor
women. We found little variation between M/F ratios and country road infrastructure and poor signage, as well as inadequate
income levels (3.7 in MICs vs. 3.0 in HICs). This universal predi- safety legislation and law enforcement in those countries.130
lection for TSI to affect males may be secondary to unique occu- Falls were common in both HICs and LMICs; however, many
pational hazards or riskier behavior that lends them vulnerable to falls in HICs tended to occur in the elderly, whereas falls in
trauma.126 LMICs were often work related. A good example of the
We found that the average age of TSI worldwide was 40 years. predominance of work-related falls is from hospital-based
Overall, we found that TSI victims tended to be slightly older in studies in Pakistan and Nepal, where many falls occurred while
HICs compared with LMICs. There was a dichotomy between the 2 people were working on rooftops, trees, or slopes.31,40,44,87 To
major regions (AMR-US/CAN and EUR) that make up a significant state that falls in the elderly population were uncommon in LMICs
ORIGINAL ARTICLE
would be misleading, because many LMIC studies reported a high underestimated in certain regions because of a lack of data,
rate of fall-induced injuries in the elderly,70,77 which partly reflects especially in LMICs. Concurrently, data largely derived from
the increasing life expectancies and aging populations seen hospital-based studies may lend to an estimation of disease inci-
worldwide. Violence as a cause for TSI was more than double in dence that is not representative of the country or region as a
MICs compared with LICs and HICs. This situation appears to be whole. The exclusion of non-English articles, because we were
caused by only a few countries, particularly South Africa,3 unable to read or translate the text, is another limitation of this
Mexico,111 Brazil,2 and Botswana,96 that report a high level of study.
violence-related injuries and may not clearly represent MICs as a In this study, we aimed only to estimate the global volume of
whole. TSI, not the global burden of disease, which incorporates the
Globally, just more than one third of patients with TSI have SCI. extent of morbidity and mortality conferred by a disease. Future
The proportion of SCI in patients with TSI varied greatly between studies incorporating disability-adjusted life years, years lived with
income levels, with a higher proportion of SCI in LMICs compared disability, and years of life lost are needed to quantify this
with HICs. This large difference in the rate of SCI is unlikely to be important health care metric.
explained by differences in mechanisms, because road traffic ac- This study represents an initial step to understanding the global
cidents and falls were the most common mechanisms of injury in epidemiology of TSI, yet more work is needed. Future in-
all income strata. However, the severity of injuries caused by these vestigations should focus on the creation of prospective multi-
mechanisms may be higher in LMICs because of poor safety institutional regional and national databases to better charac-
standards and regulations, thus leading to a higher proportion of terize local incidences and causes of TSI. Work must also be
SCI. A more plausible explanation is that patients in LMICs with undertaken to further delineate the burden of TSI.
TSI, but without neurologic deficit, may be less likely to seek care The neurosurgical community must work diligently to advocate
because of a lack of access to care and obstructive financial costs. for the prevention and treatment of TSI and other neurologic
Patients in HICs with a sole report of pain after a traumatic event disorders around the world. Public health policies focused on the
are more likely to seek care and subsequently be diagnosed with a effective prevention of TSI should be the utmost priority. Areas of
TSI. This phenomenon could certainly lead to an underestimation particular public health interest should pertain to increasing road
of the volume of TSI in LMICs. It may also partly explain the safety and preventing both workplace and domestic falls. To
higher rate of surgical intervention seen in LMICs compared with address the current and future burden of TSI, we must also focus
HICs. on the education and training of neurosurgical providers, espe-
cially in LMICs, and the development of more robust surgical
Limitations and Future Directions delivery systems around the globe.
This study sheds light on the global volume of TSI; however, it is
not without its limitations. First, because this study does not
incorporate primary data, its strength is intimately tied to the CONCLUSIONS
strength of the data presented in the literature. In this regard, TSI is a major source of morbidity and mortality throughout the
there is a significant bias in the literature to study SCI alone as world. It is estimated that 768,473e790,695 people have a TSI each
opposed to TSI. The available literature on global TSI is weakened year. The proportion of patients with TSI with SCI is higher in
by a limited number of studies from LMICs, extremely heteroge- LMICs compared with HICs. Partly preventable mechanisms,
neous data reporting, and a preponderance of hospital-based including road traffic accidents and falls, are the main causes of
cohort studies rather than population-based studies, and the TSI globally. Further investigation is needed to delineate local and
limited information reported by most of the selected studies in the regional incidences and causes of TSI throughout the world,
systematic review. WHO regions with especially low amounts of especially in LMICs. Public health initiatives should focus on the
available data included AMR-L and AFR. As a result, estimates of prevention of TSI with programs directed toward improving road
incidence from these regions are based on studies from only a few safety and decreasing the incidence of falls. For the neurosurgical
countries or extrapolated by other means. TSI can be viewed as community, these data support the ever-loudening call for scaling
both a local and a regional phenomenon, in which regional/global up of global neurosurgical capacity through increased neurosur-
epidemiologic trends are present, yet discrete epidemiologic gical education and training, and building stronger and more
variability exists on a local level. The literature and this study are comprehensive surgical delivery systems.
inadequate to detect variability on a local level and rather focus on
regional and global epidemiology. Second, the data presented
here are modeled estimates, not true incidences. This situation ACKNOWLEDGMENTS
introduces the possibility of inaccuracies in estimating of the We acknowledge the Vanderbilt Medical Scholars Program for
volume of disease. For example, the incidence of disease may be providing Abbas Rattani with support on this project.
2. Costacurta MLG, Taricco LD, Kobaiyashi ET, 3. Sothmann J, Stander J, Kruger N, Dunn R.
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ORIGINAL ARTICLE
APPENDIX OR Gabon*[tiab] OR Gambia*[tiab] OR Gaza*[tiab] OR Geor-

gia*[tiab] OR German*[tiab] OR Ghana*[tiab] OR Greece[tiab]
Section A: List of Terms Used for PubMed Systematic Review OR Grenada*[tiab] OR Grenadines[tiab] OR Guadeloupe[tiab]
((("epidemiology" [Subheading] OR "Epidemiology"[Mesh] OR OR Guatemala*[tiab] OR Guinea*[tiab] OR Guyan*[tiab] OR
epidemiology[tiab] OR epidemiological[tiab] OR population[tiab] Haiti*[tiab] OR Herzegovina*[tiab] OR Hondura*[tiab] OR
OR population-based[tiab] OR inciden*[tiab] OR prevalen*[tiab] Hungary[tiab] OR Iceland*[tiab] OR income[tiab] OR India
OR burden[tiab] OR DALY[tiab] OR “disability adjusted life [tiab] OR Indian*[tiab] OR Indonesia*[tiab] OR Iran*[tiab] OR
year*”[tiab] OR YLL[tiab] OR “years of life lost”[tiab] OR YLD Iraq*[tiab] OR Ireland[tiab] OR Israel*[tiab] OR Italian[tiab] OR
[tiab] OR “years lost to disability”[tiab] or “years lost due to Italy[tiab] OR Ivory Coast[tiab] OR Jamaica*[tiab] OR Japan*
disability”[tiab] OR ratio[tiab] OR QALY[tiab] OR “quality [tiab] OR Jordan*[tiab] OR Kazakh*[tiab] OR Kenya*[tiab] OR
adjusted life year*”[tiab])) Kiribati[tiab] OR Kitts[tiab] OR Korea*[tiab] OR Kosovar*[tiab]
AND OR Kosovo[tiab] OR Kuwait*[tiab] OR Kyrgyz*[tiab] OR Lao
“spinal injuries”[MESH] OR “spinal cord injuries”[MESH] OR [tiab] OR Laos*[tiab] OR Laotian*[tiab] OR latin america[tiab]
"spinal fractures"[MESH] OR “spinal fracture*”[tiab] OR “spinal OR Latvia[tiab] OR Lebanes*[tiab] OR Lebanon[tiab] OR leb-
fracture dislocation*”[tiab] OR “chance fracture*”[tiab] OR "trans- onese[tiab] OR Lesotho[tiab] OR less developed countr*[tiab]
verse process fracture*”[tiab] OR "spinous process fracture*"[tiab] OR less developed nation*[tiab] OR Liberia*[tiab] OR Libya*
OR “burst fracture*”[tiab] OR “vertebral fracture*”[tiab] OR “cervical [tiab] OR Liechtenstein[tiab] OR Lithuania[tiab] OR lmic[tiab]
fracture*”[tiab] OR “thoracic fracture*”[tiab] OR “lumbar fractur- OR lmics[tiab] OR low income countr*[tiab] OR low income
e*”[tiab] OR “facet fracture*”[tiab] OR “endplate fracture*”[tiab] OR nation*[tiab] OR Lucia[tiab] OR Luxembourg[tiab] OR
“spinal injury”[tiab] OR “spinal cord injury”[tiab] OR “spinal column Macedonia*[tiab] OR Madagascar*[tiab] OR Madeira Island
injury” OR “spinal injuries”[tiab] OR “spinal cord injuries”[tiab] OR [tiab] OR Malawi*[tiab] OR Malaysia*[tiab] OR Maldives[tiab]
“spinal column injuries” OR ((“spinal ligament”[tiab]) AND (trauma OR Mali[tiab] OR Malta[tiab] OR Marshall Island*[tiab] OR
[tiab] OR traumatic[tiab] OR injur*[tiab])) Martinique[tiab] OR Mauritania*[tiab] OR Mauriti*[tiab] OR
AND Mexican*[tiab] OR Mexico[tiab] OR Micronesia*[tiab] OR mid-
("Africa"[mesh] OR "Asia"[mesh] OR "Central Amer- dle income countr*[tiab] OR middle income nation*[tiab] OR
ica"[mesh] OR "Developing Countries"[mesh] OR "Geographical Moldova[tiab] OR Moldova*[tiab] OR Monaco[tiab] OR
Locations Category"[Mesh] OR "Internationality"[Mesh] OR Mongolia*[tiab] OR Montenegr*[tiab] OR Montserrat[tiab] OR
"Latin America"[mesh] OR "South America"[mesh] OR Morocc*[tiab] OR Mozambique[tiab] OR Myanmar[tiab] OR
“Dominican Republic”[tiab] OR “Principe”[tiab] OR “Puerto Namibia*[tiab] OR Nauru[tiab] OR Nepal*[tiab] OR Nevis[tiab]
Rico”[tiab] OR “Sao Tome”[tiab] OR “Saudi Arabia”[tiab] OR OR New Zealand[tiab] OR Nicaragua*[tiab] OR Niger*[tiab] OR
“Sierra Leone”[tiab] OR “Virgin Islands”[tiab] OR Afghanistan* Nigeria*[tiab] OR North[tiab] OR Norway[tiab] OR Oman*[tiab]
[tiab] OR Africa*[tiab] OR Albania*[tiab] OR Algeria*[tiab] OR OR Pacific[tiab] OR Pakistan*[tiab] OR Palau[tiab] OR Palestin*
America*[tiab] OR Andorra*[tiab] OR Angola*[tiab] OR [tiab] OR Panama*[tiab] OR Papua[tiab] OR Paraguay*[tiab] OR
Antarct*[tiab] OR Antigua*[tiab] OR Arab Emirate*[tiab] OR Peru*[tiab] OR Philippin*[tiab] OR Poland[tiab] OR poor
Argentin*[tiab] OR Armenia*[tiab] OR Aruba*[tiab] OR Asia* countr*[tiab] OR poor nation*[tiab] OR Portug*[tiab] OR Prin-
[tiab] OR Atlantic[tiab] OR Australia*[tiab] OR Austria*[tiab] cipe[tiab] OR Qatar*[tiab] OR Romania*[tiab] OR Russia*[tiab]
OR Azerbaijan*[tiab] OR Azores Islands[tiab] OR Baham*[tiab] OR Rwanda*[tiab] OR Saint Lucia[tiab] OR Saint Vincent[tiab]
OR Bahra*[tiab] OR Bangladesh*[tiab] OR Barbad*[tiab] OR OR Samoa*[tiab] OR San Marino[tiab] OR Sao Tome[tiab] OR
Barbuda*[tiab] OR Barthelemy[tiab] OR Barthélemy[tiab] OR Senegal*[tiab] OR Serbia*[tiab] OR Seychelles[tiab] OR Sierra
Belarus*[tiab] OR Belgi*[tiab] OR Belize[tiab] OR Bengali[tiab] Leone*[tiab] OR Singapore[tiab] OR Slovakia*[tiab] OR
OR Benin*[tiab] OR Bermuda*[tiab] OR Bhutan*[tiab] OR Bis- Slovenia*[tiab] OR Solomon[tiab] OR Solomon Island*[tiab] OR
sau[tiab] OR Bolivia*[tiab] OR Bosnia*[tiab] OR Botswana* Somalia*[tiab] OR South [tiab] OR Spain[tiab] OR Sri Lanka
[tiab] OR Brazil*[tiab] OR Brunei[tiab] OR Bulgaria*[tiab] OR [tiab] OR Sudan*[tiab] OR Suriname*[tiab] OR Swaziland*[tiab]
Burkina Faso[tiab] OR Burma[tiab] OR Burmese*[tiab] OR OR Swed*[tiab] OR Switzerland[tiab] OR Syria*[tiab] OR
Burundi*[tiab] OR Cabo Verd*[tiab] OR Caicos[tiab] OR Taiwan[tiab] OR Tajik*[tiab] OR Tanzania*[tiab] OR Thai*[tiab]
Cambodia*[tiab] OR Cameroon*[tiab] OR Canad*[tiab] OR OR third world countr*[tiab] OR third world nation*[tiab] OR
Cape Verd*[tiab] OR Cayman[tiab] OR Central[tiab] OR Chad* Timor Leste[tiab] OR Timor*[tiab] OR Tobago[tiab] OR Togo*
[tiab] OR Chile[tiab] OR China[tiab] OR Chinese[tiab] OR [tiab] OR Tonga*[tiab] OR Trinidad*[tiab] OR Tunisia*[tiab]
Colombia*[tiab] OR Comoros[tiab] OR Congo*[tiab] OR Costa OR Turkey[tiab] OR Turkish[tiab] OR Turkmen*[tiab] OR Turks
Rica*[tiab] OR Cote[tiab] OR Cote d’Ivoire[tiab] OR Croatia* [tiab] OR Tuvalu*[tiab] OR Uganda*[tiab] OR Ukrain*[tiab] OR
[tiab] OR Cuba[tiab] OR Cuban[tiab] OR Cyprus[tiab] OR Czech under developed countr*[tiab] OR under developed nation*[tiab]
Republic[tiab] OR Denmark[tiab] OR developing countr*[tiab] OR underdeveloped nation*[tiab] OR underdeveloped nation*
OR developing nation*[tiab] OR Djibouti[tiab] OR Dominica* [tiab] OR United Kingdom[tiab] OR United States[tiab] OR
[tiab] OR East[tiab] OR East Timor[tiab] OR Ecuador*[tiab] OR Uruguay[tiab] OR Uzbeki*[tiab] OR Vanuatu*[tiab] OR Vatican
Egypt*[tiab] OR El Salvador*[tiab] OR Eritrea*[tiab] OR [tiab] OR Venezuela*[tiab] OR Viet nam*[tiab] OR Vietnam*
Estonia*[tiab] OR Ethiopia*[tiab] OR Europ*[tiab] OR Fiji* [tiab] OR Vincent[tiab] OR West[tiab] OR West Bank[tiab] OR
[tiab] OR Finland[tiab] OR France[tiab] OR French Guiana[tiab] Yemen*[tiab] OR Zambia*[tiab] OR Zimbabw*[tiab])
ORIGINAL ARTICLE
NOT Section C: Meta-Regression by Study Quality

("Animals"[mesh] NOT "Humans"[mesh])
Funnel Plot of Standard Error by Logit event rate

Section B: Six-Point Weighting Scale for Fully Reviewed Articles 0.0
- 0: Small (<100 patients) single-institutionebased studies

0.1
- 1: Large (>100 patients) single-institutionebased studies

2: Multiple institution, non-populationebased and/or trauma
Standard Error
- 0.2
registryebased studies
- 3: Large population-based studies focused on spinal cord 0.3
injuryonly
0.4
- 4: Large population-based studies on traumatic spinal injury,
-20 -10 0 10 20
poor methodology
Logit event rate
- 5: Large population-based studies on traumatic spinal injury,
good methodology
Fixed-effect model (slope ¼ 1.28; P interaction < 0.01).

Random-effect model (slope ¼ 0.57; P interaction ¼ 0.07).

Traumatic Spinal Injury: Global Epidemiology and Worldwide Volume

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Traumatic Spinal Injury: Global Epidemiology and Worldwide Volume

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Original Article

Traumatic Spinal Injury: Global Epidemiology and Worldwide Volume

Key words WPR: Western Pacific region

WORLD NEUROSURGERY 113: e345-e363, MAY 2018 www.WORLDNEUROSURGERY.org e345

e346 www.SCIENCEDIRECT.com WORLD NEUROSURGERY, https://doi.org/10.1016/j.wneu.2018.02.033

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RAMESH KUMAR ET AL.

GLOBAL EPIDEMIOLOGY OF TRAUMATIC SPINAL INJURY

RAMESH KUMAR ET AL.

2009 China WPR Middle 57 1993e2006 3.4 Retrospective Hospital based 2

GLOBAL EPIDEMIOLOGY OF TRAUMATIC SPINAL INJURY

RAMESH KUMAR ET AL.

GLOBAL EPIDEMIOLOGY OF TRAUMATIC SPINAL INJURY

model and P < 0.01 in the ﬁxed-effect model), suggesting that

Incidence, Demographics, and Type of Injury

persons (95% CI, 8.6e12.84 cases/100,000). This incidence

resulted in an estimated 768,473e790,695 cases of TSI worldwide

100,000 persons; 95% CI, 6.4e21.0 cases/100,000) compared

difference between the proportion of patients with TSI with SCI

AMR-US/CAN. However, when average age was analyzed by in-

than in HICs (Figure 5).

EMR had a substantially lower rate of cervical spine injuries

17.7) were the most common mechanisms for TSI worldwide.

Road trafﬁc accidents accounted for 41.6% (SD 16.1) of TSI in

in MICs and LICs, respectively. Falls were the most common

(0.6%; SD 0.9) as opposed to HICs (8.6%; SD 5.8).

Mortality and Surgical Incidence

Reported mortality attributed to TSI ranged from 0% to 60%.

Mean mortality in HICs were 15.4%, as opposed to 3.8% in MICs.

WORLD NEUROSURGERY 113: e345-e363, MAY 2018 www.WORLDNEUROSURGERY.org e351

e352 www.SCIENCEDIRECT.com WORLD NEUROSURGERY, https://doi.org/10.1016/j.wneu.2018.02.033

Africa 13.6* — — 990,267,592 134,676y

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e354 www.SCIENCEDIRECT.com WORLD NEUROSURGERY, https://doi.org/10.1016/j.wneu.2018.02.033

reporting on SCI and not TSI in general, our incidence calcula-

Figure 4. Mean age at time of injury is shown by World Health

0.00 1.00 2.00 3.00 4.00 5.00 6.00 7.00 8.00

incidence accounts for >700,000 new cases of TSI globally, each

There are several reasons why the incidence ﬁgures reported

WORLD NEUROSURGERY 113: e345-e363, MAY 2018 www.WORLDNEUROSURGERY.org e355

Lumbosacral Thoracic Cervical

e356 www.SCIENCEDIRECT.com WORLD NEUROSURGERY, https://doi.org/10.1016/j.wneu.2018.02.033

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APPENDIX OR Gabon*[tiab] OR Gambia*[tiab] OR Gaza*[tiab] OR Geor-

e362 www.SCIENCEDIRECT.com WORLD NEUROSURGERY, https://doi.org/10.1016/j.wneu.2018.02.033

NOT Section C: Meta-Regression by Study Quality

Funnel Plot of Standard Error by Logit event rate

- 0: Small (<100 patients) single-institutionebased studies

- 1: Large (>100 patients) single-institutionebased studies

Fixed-effect model (slope ¼ 1.28; P interaction < 0.01).

WORLD NEUROSURGERY 113: e345-e363, MAY 2018 www.WORLDNEUROSURGERY.org e363

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APPENDIX OR Gabon[tiab] OR Gambia[tiab] OR Gaza*[tiab] OR Geor-