I have read ‘Neglected traumatic spinal cord injuries: causes, consequences and outcomes in an Indian setting’ by Chhabra and Arora1 with interest. They have highlighted a problem regarding the management of traumatic spinal cord injury (TSCI) in India, which I believe holds true for most of the developing regions of the world. Spinal cord injury (SCI) management and rehabilitation in most of the low resourced regions of the world is inadequate. There are concerns about the pre-hospital management,2, 3 lack of advanced imaging studies,4 inadequate access to specialized surgical care, high cost of spinal surgery5 and lack of comprehensive SCI rehabilitation.2

Neglected SCIs are encountered in Pakistan as well, although they have not been reported in the medical literature. I would like to present two unusual cases of neglected-TSCI from Pakistan, which were seen during my visit to the mountainous terrain of Balakot in June 2008 as part of the community-based rehabilitation program for the TSCI survivors of 2005 earthquake.

The first patient was a young paraplegic female with T12 SCI-ASIA B, who was managed conservatively and discharged after 3 months indoor treatment. In her quest to find a cure for her paraplegia she went to a quack who claimed to get her spinal cord repaired by inserting magnetic rods in her back. She underwent this weird procedure where multiple small metallic needles (2–3 cm) and an ∼6 cm large rod were placed subcutaneosuly in her back over the spine under local anesthesia. There were healed scars and many of the needles were palpable. The patient did not allow her bare back to be photographed, but I was able to document the X-ray (Figure 1). Although her neurological status had remained unchanged after 2 months of undergoing this procedure, she was still hopeful that these magnetic rods will cure her SCI, helping her to regain independent ambulation.

Figure 1
figure 1

X-rays showing multiple small metallic needles places over the lumbosacral spine.

Full size image

The second patient was an 18-year-old boy who had sustained SCI T6 ASIA-A after fall from a tree few months back. His parents did not have the finances to take him to the city for definite SCI management. Three weeks before our visit, he was operated in a makeshift theater in a tent by an unknown surgeon who had come from a far off place to help the people of this area by offering free surgical operations, as per the description of the parents. The surgeon left after performing around one dozen surgeries in 3 days. There were no radiological investigations or operation notes available with the patient. On examination he was a young lying prone in the bed with large open wounds, exposed implants and sutures visible in the dorsal spine area (Figure 2). Patient was counseled regarding the nature of the disease and the need to go to the orthopedic unit in Abbottabad (120 km away). He was lost to follow up.

Figure 2
figure 2

Open wounds, exposed inplants and sutures in a young paraplegic who was opearted in questionable circumstances.

Full size image

These cases highlight many important aspects about management of TSCI in a developing country in the 21st century.

  • Patients are interested in a complete cure of their disability and are always exploring options that give a hope/claim for cure. They are more concerned about their future ability to walk instead of focusing on achieving functional independence.2

  • In areas where health-care systems are not well established, quacks try to fill in the vacuums by offering non-scientific and even harmful remedies for cure and management.

  • The treatment cost of SCI is high and it is important that surveillance programs should be established in the country to identify the non-affording patients to offer early definitive management.

  • In the absence of strong regulations for charity medical work anybody can set up a medical camp and do surgical procedures in tents under questionable conditions.

I hope that the article by Chhabra and Arora will help in increasing the awareness about neglected TSCI in the developing regions, resulting in early and better access to definitive management and rehabilitation of TSCI.