Treatment challenges related to traumatic spinal cord injury in lower-middle-income countries

Objectives: This review aims to synthesize evidence on pre-hospital and intrahospital treatment delays, associated barriers, and clinical outcomes in adults with TSCI in LMICs. Materials and Methods: This systematic review was registered in International Prospective Register of Systematic Reviews (PROSPERO) (CRD420251072247) and conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2020. Literature searches were performed in PubMed, ScienceDirect, Cochrane Library (CENTRAL), and Google Scholar. We only included studies in English. Screening and data extraction were conducted independently by at least two reviewers using Rayyan.AI, with disagreements resolved by consensus. Risk of bias was assessed using Newcastle–Ottawa Scale. The review was conducted between June 2025 and August 2025. Results: Twenty-three studies were included in this review, comprising case-controls, cohort studies, and cross-sectional studies. The number of subjects ranged from 15 to 2065 patients, the mean age ranged from 33 to 54.4 years old, and studies were performed in LMICs across Africa, Southeast Asia, and South Asia. Pre-hospital delays were frequently linked to delayed referral, transport limitations, and financial constraints. Intrahospital delays to definitive surgery were commonly attributed to delayed emergency evaluation, limited intensive care unit/operative resources, delayed imaging, and cost barriers. Delays were associated with prolonged hospitalization and complications including pressure ulcers, pneumonia, urinary tract infection, and sepsis. Mortality ranged widely across studies. Results indicate that in LMICs, TSCI care is frequently limited by delays in surgery and rehabilitation, leading to prolonged hospitalization, preventable complications, and increased mortality. However, available evidence is largely fragmented and short-term, limiting comparability and preventing meta-analysis. This underscores the need for multicenter research and improvements in healthcare systems. Conclusion: Delays in TSCI management in LMICs occur across the continuum of care and are associated with preventable complications. Strengthening referral pathways, transport systems, surgical capacity, and rehabilitation access is essential to improve outcomes.