Social Determinants of Health Impact Spinal Cord Injury Outcomes in Low- and Middle-Income Countries: A Meta-Epidemiological Study

BACKGROUND AND OBJECTIVES: Traumatic spinal cord injuries (SCI), which disproportionally occur in low- and middle-income countries (LMICs), pose a significant global health challenge. Despite the prevalence and severity of SCI in these settings, access to appropriate surgical care and barriers to treatment remain poorly understood on a global scale, with data from LMICs being particularly scarce and underreported. This study sought to examine the impact of social determinants of health (SDoH) on the pooled in-hospital and follow-up mortality, and neurological outcomes, after SCI in LMICs. METHODS: A systematic review was conducted in adherence to the Preferred Reporting in Systematic Review and Meta-Analysis-guidelines. Multivariable analysis was performed by multivariable linear regression, investigating the impact of the parameters of interest (patient demographics, country SDoH characteristics) on major patient outcomes (in-hospital/follow-up mortality, neurological dysfunction). RESULTS: Forty-five (N = 45) studies were included for analysis, representing 13 individual countries and 18 134 total patients. The aggregate pooled in-hospital mortality rate was 6.46% and 17.29% at follow-up. The in-hospital severe neurological dysfunction rate was 97.64% and 57.36% at follow-up. Patients with rural injury had a nearly 4 times greater rate of severe in-hospital neurological deficits than patients in urban areas. The Gini index, reflective of income inequality, was associated with a 23.8% increase in in-hospital mortality, a 20.1% decrease in neurological dysfunction at follow-up, and a 12.9% increase in mortality at follow-up. CONCLUSION: This study demonstrates the prevalence of injury and impact of SDoH on major patient outcomes after SCI in LMICs. Future initiatives may use these findings to design global solutions for more equitable care of patients with SCI.