Clinical and Organizational Management of Spinal Cord Injury in a Metropolitan Setting: Experience from Almaty, Kazakhstan

Clinical and Organizational Management of Spinal Cord Injury in a Metropolitan Setting: Experience from Almaty, Kazakhstan | Authorea try { document.documentElement.classList.add('js'); } catch (e) { } var _gaq = _gaq || []; _gaq.push(['_setAccount', 'G-8VDV14Y67G']); _gaq.push(['_trackPageview']); (function() { var ga = document.createElement('script'); ga.type = 'text/javascript'; ga.async = true; ga.src = ('https:' == document.location.protocol ? 'https://ssl' : 'http://www') + '.google-analytics.com/ga.js'; var s = document.getElementsByTagName('script')[0]; s.parentNode.insertBefore(ga, s); })(); Skip to main content Preprints Collections Wiley Open Research IET Open Research Ecological Society of Japan All Collections About About Authorea FAQs Contact Us Quick Search anywhere Search for preprint articles, keywords, etc. Search Search ADVANCED SEARCH SCROLL This is a preprint and has not been peer reviewed. Data may be preliminary. 29 January 2026 V1 Latest version Share on Clinical and Organizational Management of Spinal Cord Injury in a Metropolitan Setting: Experience from Almaty, Kazakhstan Authors : Marat Aliyev , Nurlan Jainakbayev , Yermek Dyussembekov , Marat Almatov 0000-0003-0865-0254 , Bakhyt Aglakov , and Nursultan Abilkhanov 0009-0003-0570-8278 [email protected] Authors Info & Affiliations https://doi.org/10.22541/au.176968639.94861400/v1 127 views 64 downloads Contents Abstract References Information & Authors Metrics & Citations View Options References Figures Tables Media Share Abstract Objectives: Spinal cord injury (SCI) is still one of the main reasons of disability and death in world. In large urban cities, especially megapolis, epidemiology and outcomes of SCI have own specific features and create serious load for neurosurgical service. Purpose of this study was to analyze clinical, epidemiological and organizational aspects of SCI treatment in Almaty, Kazakhstan, and to define possible ways for improvement of neurosurgical care. Materials and Methods: Retrospective population-based study was performed using data of medical information systems for period 2013–2023. We analyzed causes of trauma, clinical characteristics, neurological status according to ASIA/IMSOP scale, duration of hospitalization, complications and outcomes. Indicators of disease burden such as DALY, YLL and YLD were calculated. Also, structured questionnaire survey among neurosurgeons was conducted to evaluate existing clinical protocols, availability of resources and organizational problems. Results:Average annual incidence of SCI was 43.7 per 100,000 population, mostly among patients of working age. Main causes of trauma were fall from height (about 50%) and road traffic accidents (near 33%). Severe neurological impairment (ASIA A and B) was revealed in significant number of cases, often combined with associated injuries. Mean length of hospital stay was 13.4 days, total mortality rate reached 5.7%. Total DALY for period 2018–2022 was 22,388.5 years, including 5,936.5 years of YLL and 16,402.0 years of YLD. Expert survey showed absence of unified protocols, insufficient multidisciplinary approach and limited resource support. Conclusions:SCI in conditions of big city represents serious medical, social and economic problem. Centralization of neurosurgical care, implementation of standardized treatment protocols, development of multidisciplinary rehabilitation and strengthening of preventive measures can lead to better outcomes and reduction of disability. Obtained data may be useful for optimization of SCI management in Kazakhstan and other similar urban regions. Title: Clinical and Organizational Management of Spinal Cord Injury in a Metropolitan Setting: Experience from Almaty, Kazakhstan Dear Editor, On behalf of my co-authors, I am pleased to submit our manuscript entitled “Clinical and Organizational Management of Spinal Cord Injury in a Metropolitan Setting: Experience from Almaty, Kazakhstan” for consideration for publication in International Journal of Health Planning and Management. Statement of Authorship All authors contributed substantially to the work, as follows: • Marat Aliyev: Conceptualization, Data curation, Methodology, Reviewing and Editing, Software, Supervision. • Nurlan Jainakbayev: Data curation, Visualization • Yermek Dyussembekov: Visualization, Investigation, Reviewing and Editing, Supervision. • Marat Almatov: Visualization, Validation. • Bakhyt Aglakov: Software, Validation. • Nursultan Abilkhanov: Writing - Original draft preparation, Validation, Writing, All authors have read and approved the final version of the manuscript and agree to be accountable for all aspects of the work. Sincerely, Nursultan Abilkhanov 0009-0003-0570-8278, [email protected] , M.D., City clinical hospital no 7, Department of neurosurgery, Almaty, Kazakhstan; Clinical and Organizational Management of Spinal Cord Injury in a Metropolitan Setting: Experience from Almaty, Kazakhstan Objectives: Spinal cord injury (SCI) is still one of the main reasons of disability and death in world. In large urban cities, especially megapolis, epidemiology and outcomes of SCI have own specific features and create serious load for neurosurgical service. Purpose of this study was to analyze clinical, epidemiological and organizational aspects of SCI treatment in Almaty, Kazakhstan, and to define possible ways for improvement of neurosurgical care. Materials and Methods: Retrospective population-based study was performed using data of medical information systems for period 2013–2023. We analyzed causes of trauma, clinical characteristics, neurological status according to ASIA/IMSOP scale, duration of hospitalization, complications and outcomes. Indicators of disease burden such as DALY, YLL and YLD were calculated. Also, structured questionnaire survey among neurosurgeons was conducted to evaluate existing clinical protocols, availability of resources and organizational problems. Results:Average annual incidence of SCI was 43.7 per 100,000 population, mostly among patients of working age. Main causes of trauma were fall from height (about 50%) and road traffic accidents (near 33%). Severe neurological impairment (ASIA A and B) was revealed in significant number of cases, often combined with associated injuries. Mean length of hospital stay was 13.4 days, total mortality rate reached 5.7%. Total DALY for period 2018–2022 was 22,388.5 years, including 5,936.5 years of YLL and 16,402.0 years of YLD. Expert survey showed absence of unified protocols, insufficient multidisciplinary approach and limited resource support. Conclusions:SCI in conditions of big city represents serious medical, social and economic problem. Centralization of neurosurgical care, implementation of standardized treatment protocols, development of multidisciplinary rehabilitation and strengthening of preventive measures can lead to better outcomes and reduction of disability. Obtained data may be useful for optimization of SCI management in Kazakhstan and other similar urban regions. Highlights Spinal cord injury remains a major urban medical and socioeconomic burden Traumatic spinal injuries predominantly affect the economically active population High DALY values reflect long-term disability rather than acute mortality Systemic organizational deficits adversely affect neurosurgical outcomes Keywords: Spinal cord injury, Neurosurgery, DALY, Epidemiology, Centralized care, Kazakhstan, ASIA scale, Urban trauma Acknowledgements The authors express their appreciation to practicing neurosurgeons who participated in the expert survey and provided valuable insights into current organizational challenges. The authors also acknowledge the administrative and clinical departments of neurosurgical institutions in Almaty for their assistance in data collection. This research was conducted without external financial support. Introduction Traumatic spinal cord injury (SCI) remains one of the most significant challenges in modern medicine and public health. Although the absolute number of affected patients is relatively limited, the consequences of SCI are severe and long-lasting. Patients frequently develop profound neurological deficits, persistent disability, dysfunction of pelvic organs, as well as respiratory and cardiovascular complications. These outcomes substantially impair quality of life and impose a considerable burden on families, healthcare systems, and society as a whole [1-7]. The global incidence of SCI ranges from 12 to 58 cases per million population per year, while prevalence varies from 236 to 1009 cases per million inhabitants [2]. Annually, between 200,000 and 500,000 new SCI cases are reported worldwide. Spinal cord injury ranks among the leading causes of mortality in young populations and represents one of the principal reasons for long-term disability [3,7-10]. In countries such as the United States, the United Kingdom, and Canada, the number of individuals living with SCI reaches several hundred thousand. The mean age at the time of injury ranges from 33 to 46 years, and males are affected significantly more often than females [6,7]. The most common causes of SCI are road traffic accidents and falls from height. Less frequent mechanisms include violence, sports-related injuries, and iatrogenic causes. The pronounced gender imbalance is largely explained by differences in exposure to injury mechanisms, with men more frequently involved in high-energy trauma such as traffic accidents and falls, whereas women are more often affected by lower-energy mechanisms [1-3]. The average age of injured patients is approximately 45 years; however, men are most commonly injured between 20 and 30 years of age, while the proportion of elderly patients with SCI is steadily increasing, reflecting the global aging of the population [9,18]. Analysis of injury patterns indicates that the cervical spine is involved most frequently, accounting for up to 50% of cases. Concomitant injuries are observed in 60-70% of patients, particularly following road traffic accidents. Traumatic brain injury accompanies SCI in 26-74% of cases and significantly increases the risk of adverse outcomes [1-3]. The most common complications include respiratory failure, pulmonary infections, pressure ulcers, and thromboembolic events. Mortality rates may reach up to 50% within the first year after injury, with a substantial proportion of patients dying before hospital admission [12-14]. The consequences of SCI extend far beyond the medical domain. The majority of patients experience long-term loss of working capacity and are assigned severe disability status, resulting in substantial economic costs for governments and insurance systems, as well as profound psychological and social burden for families and caregivers [12-13]. In the United States, the cost of acute-phase treatment for a single SCI patient may reach USD 145,000. Timely and specialized medical care has been shown to significantly reduce both direct healthcare expenditures and indirect societal costs [12,18,19]. The organization of timely and effective specialized care for patients with SCI remains a major challenge for healthcare systems worldwide. Suboptimal outcomes are often attributed to the absence of structured care pathways, insufficient coordination, and lack of standardized algorithms covering all stages of patient management [6]. Early specialized surgical intervention is considered a key determinant of favorable outcomes, necessitating the development of appropriate infrastructure and multidisciplinary teams [7.8]. The World Health Organization emphasizes that many adverse outcomes associated with spinal cord injury are related not only to the severity of neurological damage itself, but also to inadequate medical care, limited access to rehabilitation services, and existing social and policy barriers [8]. Core strategies aimed at improving survival and long-term outcomes include early diagnosis, prompt emergency care, access to specialized resources, rational rehabilitation programs, creation of a supportive environment, and continuous professional training of healthcare providers. For effective SCI care in metropolitan settings, several fundamental principles have been identified, including centralization through specialized units, multidisciplinary hospital structures, adequate resource allocation, personnel training, sustainable financing, and optimized patient flow. Currently, two main organizational models are distinguished: decentralized and centralized systems of care (Table 1). The decentralized model involves distribution of SCI patients across multiple general hospitals with limited annual case volumes and relatively low surgical activity. In contrast, the centralized model concentrates patients in specialized centers equipped with round-the-clock availability of highly qualified specialists, advanced diagnostic and surgical technologies, and sufficient financial support [17]. Centralized care has been shown to improve staff expertise, reduce time to definitive treatment, and increase the likelihood of favorable outcomes. A key principle of this model is timeliness, with surgical intervention ideally performed within the first 6-72 hours after injury [68]. Delayed treatment is often associated with the absence of clear transportation criteria, insufficient staff training, and lack of established multidisciplinary teams. Treatment adequacy depends on high-quality diagnostics and the integration of neurosurgical and orthopedic principles, while sufficient resource availability ensures access to modern conservative and surgical treatment modalities [5,9-11]. In summary, spinal cord injury represents a complex medical, social, and economic problem. The high rates of disability, severe neurological impairment, and substantial societal burden underscore the urgent need to develop effective strategies for prevention, early diagnosis, optimized treatment, and comprehensive rehabilitation of patients with spinal cord injuries. Table 1. Comparative characteristics of decentralized and centralized models of care for patients with spinal cord injury Infrastructure Multiple neurosurgical units within general hospitals with a low annual volume of SCI admissions and limited surgical activity Concentration of SCI patients in 2-3 specialized units within large multidisciplinary hospitals operating on a 24/7 basis Patient allocation approach Territorial principle: provision of care in the geographically nearest medical facility Syndrome-based triage at the prehospital level by emergency medical teams, with mandatory access to ground transportation Medical staff Insufficient level of training and limited practical experience in selecting evidence-based diagnostic and therapeutic strategies Highly qualified specialists capable of delivering a wide range of advanced diagnostic, surgical, and therapeutic interventions Equipment Limited availability of specialized equipment and surgical instruments Availability of high-technology diagnostic and surgical equipment Scope of services Restricted range of services, predominantly emergency-oriented Comprehensive range of medical services covering all stages of care Financing principle Regional budget funding Centralized funding, including high-technology medical care programs Materials and Methods This study was aimed at developing a set of clinical and organizational measures to improve treatment outcomes in patients with spinal cord injury (SCI) in a metropolitan setting(Table 2). At the first stage, an analysis of international and national literature was conducted focusing on traumatic spinal cord injuries, their global epidemiology, medical and socio-economic burden, and existing models for organizing specialized care for patients with SCI. Literature search and selection were performed using the following keywords: spinal cord injury, traumatic spinal cord injury, organization of care, clinical practice, medical and economic efficiency. The systematic review included original studies published by domestic and international researchers. In addition, a content analysis of regulatory and legal documents of the Republic of Kazakhstan governing the organization of specialized medical care for patients with SCI was performed.[15,16] At the second stage, a comprehensive clinical and statistical analysis of patients with SCI was carried out, comprising three main components. The first component assessed the epidemiology of SCI, including prevalence rates per 100,000 population in the city of Almaty, with consideration of age- and sex-specific patterns. Causes of injury and seasonal variations were also analyzed.[14,15-25] The second component focused on clinical and neurological characteristics, including evaluation of clinical symptoms and severity of injury according to the ASIA/IMSOP classification. Associations between injury severity and mechanisms of trauma were examined. The third component evaluated treatment outcomes, including hospitalization rates, comorbidities, and in-hospital mortality. Data sources included the Information System “Electronic Inpatient Registry,” the “Hospitalization Bureau” Information System, and the “Electronic Registry of Dispensary Patients” for the period from 2013 to 2023, as well as reports from medical organizations and data from the Bureau of National Statistics of the Agency for Strategic Planning and Reforms of the Republic of Kazakhstan. The study sites included the Central City Clinical Hospital, City Clinical Hospital No. 7, City Clinical Hospital No. 4, and the Emergency Care Hospital in Almaty. Descriptive statistics and correlation analyses were performed using the BioStat statistical software package. Survey of medical specialists To assess the incidence of SCI, injury patterns, current treatment approaches, and availability of medical equipment, a structured survey of healthcare professionals was conducted. The survey included 15 physicians from the above-mentioned medical institutions[9]. Inclusion criteria for respondents were specialty relevance, a minimum of 10 years of professional experience, and at least five years of involvement in the management of patients with SCI. The survey was conducted on a voluntary basis using an online format, with 1-2 days allocated for completion. The questionnaire covered diagnostic and therapeutic methods, pharmacological treatment, patient routing, regulatory frameworks, and expert opinions regarding the feasibility of transitioning from a decentralized to a centralized model of care[15-18]. The survey instrument was pilot-tested in a focus group of three participants and subsequently refined. Prior to data analysis, questionnaires were verified and open-ended responses were coded[9]. Data analysis was performed using Microsoft Excel and included descriptive statistics, factor analysis, cluster analysis, and regression analysis. The χ² test and Fisher’s F-test were applied to assess the significance of intergroup differences, with statistical significance set at p < 0.05. Associations between variables were examined using contingency tables and Pearson’s χ² coefficient. Based on the clinical and statistical analysis and the expert survey, proposals were formulated to update the national clinical protocol “Spinal Cord Injury and Its Consequences” (Protocol No. 18, Expert Council of the Republican State Enterprise on the Right of Economic Management, November 30, 2015). The updated protocol focuses on an optimized algorithm for providing specialized care to patients with cervical spine injuries.[18,19-24] To assess the effectiveness of the existing decentralized system and the proposed transition to a centralized model, both medical and socio-economic efficiency were evaluated. Medical efficiency was assessed using data from healthcare information systems and medical organizations in Almaty. Key indicators included reduction in disease severity, disability rates, length of hospital stay, and time to recovery of work capacity. Coefficients were applied according to the methodology of Imperial College London (2017)[21]. Economic efficiency was evaluated using data from the Bureau of National Statistics and medical organizations. The analysis assessed the financial burden of SCI on the healthcare system and society, as well as the economic impact of transitioning from a decentralized to a centralized model of care. Indicators included hospitalization rates, disability, and mortality. The economic burden of hospitalization was calculated as the product of the average cost of inpatient treatment and the number of hospital admissions. Economic losses due to disability were calculated using the formula: EL = CP × LD + (P + SB + MC) × DD where CP is the value of lost production due to disability, LD is the number of lost working days, P is disability pension payments, SB represents social benefits, MC denotes medical care costs, and DD is the duration of disability in days. Economic losses due to mortality were calculated using the formula: PLᵥₜ = nᵥₜ × Cₜ × (Lₜ − A), with total losses across all age groups calculated as: Mₜ = ΣPLᵥₜ. Overall economic efficiency was assessed using a cost-effectiveness approach, calculating average costs per case for each indicator. Mortality analysis enabled estimation of economic losses associated with premature death.[19] Based on the analysis of clinical data and expert opinions, recommendations were developed for organizing a centralized system of specialized care for patients with SCI. These recommendations aim to improve clinical outcomes, reduce mortality and disability rates, and optimize healthcare resource utilization. The study addresses all stated objectives, encompassing organizational aspects of care and evidence-based treatment recommendations to improve patient outcomes[18-22]. Table 2. Study Design and Research Framework 1 Peer-reviewed national and international literature Epidemiology, clinical outcomes, socio-economic burden of SCI; organizational models of care Analytical 2 Medical information systems of Almaty (2013-2023) Incidence, hospitalization, mortality, injury characteristics, treatment patterns in SCI Descriptive and analytical statistics 3 Structured survey of physicians (n = 13) Diagnostic, therapeutic, and organizational approaches in routine practice Sociological; Statistical 4 National clinical protocol on spinal cord injury Development of updated clinical management algorithms Analytical 5 Clinical data from decentralized and centralized care settings Medical effectiveness of different models of SCI care Comparative statistical analysis 6 Healthcare expenditure and social data Economic effectiveness of SCI care models Cost-effectiveness analysis 7 Integrated clinical and economic outcomes Comparison of treatment results for cervical SCI Criterion-based evaluation 8 Synthesized study findings Development of a centralized model of specialized SCI care Analytical 3.1. Clinical and Statistical Characteristics of Patients with Spinal Cord Injury in a Metropolitan Setting The effectiveness of specialized care for patients with spinal cord injury (SCI) is determined by clinical and statistical characteristics, including incidence, injury patterns and severity, causes of adverse outcomes, and results of surgical and conservative treatment. To assess the burden of SCI on the healthcare system of a metropolitan area and identify key causal factors, an epidemiological analysis and clinical characterization of patients were conducted.[21-22] The average annual incidence of SCI in Almaty was 43.7 cases per 100,000 population. Data from 2020-2021 were excluded due to a significant decline in trauma incidence during COVID-19 restrictions. A consistent sex pattern was observed: 49.9 per 100,000 among men and 38.4 per 100,000 among women (male-to-female ratio, 1.2:1). The mean age of patients was 46.7 ± 0.7 years, with no significant gender differences. The highest number of cases occurred in patients aged >61 years, predominantly women, whereas male incidence was more evenly distributed across age groups. Up to 80% of patients were of working age, highlighting the substantial socio-economic burden of SCI[7]. Falls from height were the leading cause of SCI (46.7%), with catastrophic trauma more common in younger patients, while low-height falls were prevalent in patients >41 years. The mean age for catastrophic trauma was 34.8 ± 2.4 years, and 46.3 ± 1.3 years for low-height falls. Traffic accidents accounted for approximately one-third of cases, primarily in men, with 82.1% of accidents caused by the injured individuals themselves[9]. Physical violence caused 19% among men. Diving, sports, and occupational injuries were more common in younger patients. SCI showed clear seasonal variation, peaking in winter and summer, with weekends and holidays being high-risk periods (weekday-to-weekend ratio, 1:1.8). Neurological status was assessed using the ASIA/IMSOP classification. Sensory disturbances, pain, lower paraplegia, and lower paraparesis comprised ~70% of cases. Most injuries were ASIA type E (65.5 ± 1.6%) and D (25.3 ± 1.8%), with severe injuries (types A and B) in 4.1% of patients. Younger patients were more likely to sustain severe injuries, confirming a correlation between injury severity and age. About half of all SCIs involved the lumbar spine, mostly types D and E, often due to falls. Thoracic injuries accounted for trauma and traffic accidents. Cervical injuries were less frequent but had a higher proportion of severe injuries and unfavorable outcomes. Mechanism of injury was significantly associated with severity: severe injuries (types A and B) exceeded 30% in traffic, diving, sports, and occupational injuries(Figure 1). Hospitalization rate was 81.7%. Complications occurred in 37.3% of patients, most commonly urinary tract infections, respiratory complications, and thromboembolic events. Complication rates increased with severe injuries (ASIA A-C) and cervical or thoracic trauma. The mean hospital stay was 13.4 ± 0.9 days, increasing with complications and severe neurological deficit. Surgery was performed in 81.6% of patients, with early interventions (within 6 hours) mainly for ASIA A and B injuries. Neurological improvement was observed in 31.4% of cases, particularly transitions from A→B, B→C, and C→D, most frequently in cervical and thoracic injuries. The annual mortality rate was 5.7%, with one-third of deaths occurring within the first 24 hours. Mortality was highest in cervical and thoracic injuries, severe injury types, polytrauma, and patients with complications[23-29]. In summary, SCIs in a metropolitan setting demonstrate stable incidence, clear age- and sex-related patterns, and significant socio-economic impact. The predominance of working-age patients, high frequency of falls and traffic accidents, combined injuries, and complications underscore the need for optimized intersectoral coordination and enhanced neurosurgical care to improve clinical outcomes. Figure 1. Distribution of patients with spinal cord injuries according to the AIS (American Spinal Injury Association) / IMSOP (International Medical Society of Paraplegia) classification. 3.2. Results of the Formalized Survey of Specialists on Diagnostic and Therapeutic Practices for Spinal Cord Injury To evaluate real-world clinical practices in the diagnosis and management of spinal cord injury (SCI), a formalized survey of physicians directly involved in the care of SCI patients was conducted[3]. The survey aimed to identify existing organizational, diagnostic, and therapeutic practices, as well as problem areas affecting the effectiveness of treatment. Fifteen specialists from four medical institutions in the metropolitan area participated. The majority were neurosurgeons, reflecting the profile of centers providing specialized SCI care[3,4-16]. The average professional experience exceeded 10 years, ensuring the reliability and representativeness of the data for assessing current clinical practice. Most respondents reported using clinical and neurological assessment based on the international ASIA/IMSOP classification during the initial evaluation of SCI patients. However, the completeness and consistency of ASIA/IMSOP assessment varied considerably among institutions. Only a subset of specialists documented neurological status systematically at admission, throughout treatment, and at discharge. In some cases, ASIA/IMSOP evaluation was episodic or limited to a formal injury category without detailed motor-sensory analysis.[8] Respondents emphasized that ASIA/IMSOP scoring is critical for objectively assessing neurological deficits, predicting outcomes, and evaluating treatment effectiveness. Nonetheless, a lack of standardized medical documentation and unified protocols for longitudinal monitoring reduced data comparability and complicated outcome analysis.[12] All specialists highlighted mandatory spinal computed tomography (CT) at admission for suspected SCI. Magnetic resonance imaging (MRI) was considered essential for assessing spinal cord, ligamentous, and soft-tissue integrity. However, access to urgent MRI remains limited and largely depends on institutional logistics and patient admission time.[6,7] Survey responses indicated that early spinal decompression and stabilization are standard approaches when indicated. Yet, timing of surgical intervention varied significantly due to logistical challenges, operating room congestion, limited availability of specialized implants, and insufficient trained surgical teams. Several specialists noted that in a decentralized system, early surgery is not always feasible, potentially compromising functional outcomes. Considerable variability was observed in medication strategies. Opinions differed regarding the use of high-dose glucocorticoids in the acute phase, reflecting inconsistent interpretation of international guidelines. Most specialists, however, stressed the importance of comprehensive therapy aimed at preventing secondary SCI damage, correcting hemodynamic disturbances, and initiating early rehabilitation.[8,9,15,18] Specialists identified insufficient coordination between emergency, inpatient, and rehabilitation services. The absence of dedicated spinal centers and standardized patient pathways was highlighted as a major barrier limiting treatment effectiveness and recovery for SCI patients. The survey revealed that despite the availability of modern diagnostic and therapeutic approaches, including ASIA/IMSOP assessment, practical implementation is inconsistent. Variability in diagnostic procedures, surgical timing, and care organization underscores the need to update clinical protocols and implement a more centralized model of SCI management. 3.3. Development of Recommendations for Updating the Clinical Protocol “Spinal Cord Injury and Its Consequences” Analysis of the existing clinical protocol “Spinal Cord Injury and Its Consequences,” approved in Kazakhstan in 2015, revealed that over the past decade the document has not been revised, despite significant changes in the organization of healthcare, advances in neurosurgical technologies, and the accumulation of evidence-based data on the treatment of SCI patients. During this period, approaches to surgical timing and scope, pharmacotherapy, anticoagulant prophylaxis, the diagnostic role of magnetic resonance imaging (MRI), and rehabilitation strategies have substantially evolved.[18,19] Based on a review of international clinical guidelines and findings from the present study, the need to update key concepts and definitions used in the clinical protocol was justified. Clarification of terminology aims to standardize diagnostics, improve reproducibility of clinical decisions, and allow comparability of treatment outcomes. Acute SCI is defined as a sudden traumatic event resulting in anatomical disruption of spinal cord tissue, accompanied by motor, sensory, or autonomic deficits. Complete and incomplete injuries are recommended to be clearly differentiated based on preservation of sensory and motor function in sacral segments S4-S5 according to the ASIA/IMSOP classification[6]. Special attention was given to clinical syndromes and levels of spinal cord injury[1-10]. Central cord syndrome is defined as a form of incomplete injury predominantly affecting the cervical spinal cord, with greater neurological deficits in the upper extremities. Tetraplegia and paraplegia are classified according to the level of injury, which is crucial for prognosis and rehabilitation planning. Penetrating and blunt SCIs are considered distinct pathogenic forms requiring specific diagnostic and therapeutic approaches. The protocol update proposes maintaining both the Frankel classification and the ASIA scale, with clear delineation of their clinical use. ASIA is recommended as the primary tool for objective neurological assessment, monitoring progression, and predicting functional outcomes. Additionally, the inclusion of functional independence scales, such as FIM and SCIM, is justified to quantitatively assess the degree of disability and effectiveness of rehabilitation interventions, allowing for more precise evaluation of clinically relevant changes and patient recovery quality.[12-17] A key principle in patient management is a comprehensive, pathophysiologically grounded approach. Conservative management is indicated for stable injuries without significant neurological deficits, whereas surgical intervention is prioritized in unstable injuries, spinal cord compression, or progressive neurological deterioration. The protocol emphasizes the importance of early decompressive and decompressive-stabilizing surgeries, especially in patients with incomplete deficits[2-8,17]. Optimal timing for surgical decompression was identified based on literature and clinical data. The most favorable window is within 24 hours post-injury, during which spinal cord decompression promotes neuroprotection and more pronounced neurological recovery. Even in central cord syndrome, early decompression may reduce secondary injury and accelerate functional restoration, provided hemodynamic stabilization is adequate. The use of methylprednisolone sodium succinate was evaluated regarding efficacy and safety. Despite potential neuroprotective effects, evidence supports its use only within a strictly limited timeframe. A 24-hour high-dose infusion is recommended for adult patients within the first 8 hours post-injury, whereas later administration or prolonged infusion is not recommended due to lack of proven benefit and increased risk of complications.[8] Thromboprophylaxis was emphasized due to the high risk of deep vein thrombosis and pulmonary embolism in SCI patients. According to AANS/CNS recommendations, early initiation of anticoagulant prophylaxis with low-molecular-weight heparins or low fixed doses of unfractionated heparin combined with mechanical prevention is advised, balancing thromboembolic risk and hemorrhagic complications.[14] MRI was identified as a key tool for evaluating spinal cord and soft tissue integrity and as a prognostic factor for neurological and functional outcomes. When technically feasible, MRI is recommended in the acute period before and after surgical intervention.[6-8] Rehabilitation is considered a critical component of SCI management. Therapy should begin immediately after stabilization and proceed in stages with a multidisciplinary team. Early rehabilitation focuses on preventing secondary complications and preparing the patient for active recovery; inpatient care targets motor and functional skill restoration, while outpatient care maintains and enhances achieved results. Modern physical rehabilitation methods, functional electrical stimulation, botulinum therapy, and telemedicine are recommended to ensure continuity of care.[6-9] In summary, the results underscore the necessity of a comprehensive update of the clinical protocol “Spinal Cord Injury and Its Consequences,” integrating contemporary international recommendations, real-world clinical practice, and identified organizational challenges. Algorithmic and standardized diagnostic and therapeutic approaches are expected to improve the quality, timeliness, and effectiveness of care for SCI patients. 3.4. Analysis of Medical Effectiveness of Decentralized and Centralized Care Systems for Patients with Spinal Cord Injury in a Kazakh Megapolis Modern evidence-based clinical approaches focus not only on reducing mortality and prolonging life but also on minimizing non-fatal health losses. In the context of increasing trauma incidence and a growing proportion of working-age patients, evaluating the medical effectiveness of healthcare systems providing care for spinal cord injury (SCI) patients is particularly relevant.[15-18] Changes in the structure of healthcare challenges, driven by longer life expectancy alongside declining health quality due to injuries and chronic conditions, have led the World Health Organization (WHO) to implement the Disability-Adjusted Life Years (DALY) metric. This integrated indicator combines premature mortality and disability, reflecting overall health loss expressed in years of healthy life. The Years of Life Lost (YLL) component, representing life years lost due to premature death, demonstrated substantial values in SCI patients.[15] Over a five-year observation period, 191 deaths were recorded, equivalent to 5,936.5 years of life lost. Peak YLL values were observed in 2019 and 2022, correlating with an increased incidence of SCI. Temporary reductions in 2020-2021 were attributed to COVID-19-related restrictions, which reduced traffic accidents and falls from height. Structural analysis of YLL showed that road traffic accidents (RTAs) and falls from height contributed more than two-thirds of all lost life years. These causes also demonstrated the highest hospitalization rates and mortality. Notable YLL losses were associated with occupational injuries and acts of violence, indicating systemic gaps in occupational safety and trauma prevention.[7-14] Analysis of neurological status according to the ASIA/IMSOP classification revealed the highest YLL values among patients with complete spinal cord injuries (type A), reflecting the severity of clinical conditions. Significant life-year losses were also observed in patients with incomplete injuries (types B and C), largely due to the high prevalence of combined injuries in this group. By injury level, cervical spine trauma contributed most to YLL, reflecting both clinical severity and higher mortality rates.[8] Years Lived with Disability (YLD), reflecting life years lost due to disability, highlighted an even greater burden of SCI. Over the five-year period, the total YLD reached 16,402 years, with peaks in 2018, 2019, and 2022, corresponding to increased SCI incidence. A trend toward reduced average disability severity was observed, likely associated with the adoption of advanced surgical techniques, improved rehabilitation services, and changes in healthcare delivery models.[21-23] By cause of injury, falls from height and RTAs were associated with the highest YLD values, reflecting both frequency and severity, as well as prolonged duration of disability before remission or death. A strong correlation between disability severity and disease duration underscores the need for early and adequate treatment in this patient population.[22-28] Analysis of YLD by ASIA/IMSOP neurological status showed that patients with type E injuries contributed most to total YLD due to their numerical predominance. However, per-case losses were highest in patients with complete spinal cord injuries (type A). By spinal level, total YLD was highest for thoracic and lumbar injuries, while per-case losses were greatest for thoracic and cervical injuries.[8] The overall assessment of the global burden of disease, DALY (sum of YLL and YLD), indicated that over the five-year period, SCI accounted for 22,388.5 years of lost healthy life. A persistent upward trend in DALY reflects ongoing challenges in healthcare delivery and trauma prevention. Visualization of DALY dynamics demonstrates the substantial impact of SCI on public health and socio-economic development (table 3). Thus, the evaluation of medical effectiveness of the current SCI care system revealed significant health losses due to both premature mortality and disability. Use of YLL, YLD, and DALY metrics enables an objective assessment of the problem’s magnitude and provides a basis for informed policy decisions aimed at reducing mortality, disability, and preserving human and labor potential. Dynamic analysis of these indices also offers opportunities to assess the effectiveness of medical technologies, organizational models, and preventive interventions at the population level.[18-25] Table 3. Years of Life Lost (YLL) among patients with spinal cord injury across the study period (2018-2022). 2018 31 29.15 903.65 2019 48 34.68 1,664.64 2020 17 28.77 489.09 2021 28 29.03 812.84 2022 67 30.84 2,066.28 Total 191 — 5,936.50 3.5. Analysis of Medical and Economic Effectiveness of Decentralized and Centralized Systems of Care for Patients with Spinal Cord Injury in a Kazakh Megapolis (Almaty) Assessment of medical effectiveness in the care of patients with spinal cord injury (SCI) is inseparably linked to the analysis of the economic consequences of this condition. High rates of disability, prolonged treatment durations, the need for multi-stage rehabilitation, and substantial social losses create a significant economic burden for both the healthcare system and society. Consequently, evaluating the medical and economic effectiveness of different organizational care models is of particular importance.[15-17] In the context of a Kazakh megapolis, a decentralized care system has traditionally operated, where patients were admitted to various multidisciplinary hospitals without standardized referral pathways or uniform clinical protocols. This model was characterized by heterogeneity in diagnostic and therapeutic interventions, variability in hospital resources, and differences in specialist expertise, directly influencing clinical and economic outcomes. Analysis of cost structure under the decentralized system revealed that a substantial proportion of expenses were associated with prolonged hospitalization, repeated admissions, delayed surgical interventions, and management of complications. Average inpatient duration for patients with severe SCI was significantly higher, increasing direct medical costs. Furthermore, the high incidence of secondary complications, including pressure injuries, infections, and thromboembolic events, further increased the overall cost of care.[20-25] Indirect economic losses under the decentralized model were driven by a high proportion of permanent disability among working-age patients. Long-term loss of productivity, reduced labor output, and the need for social benefits contributed to a significant socio-economic burden. Analysis of YLD and DALY indicators confirmed that disability constitutes the main contributor to total health and economic losses.[18-23] Implementation of a centralized care model, based on the concentration of SCI patients in specialized centers, altered both medical and economic outcomes. Centralization enabled earlier diagnostics, timely surgical interventions, and standardized treatment approaches in accordance with contemporary clinical guidelines.[28,29] Medical effectiveness in the centralized system was reflected by reduced mortality, lower rates of severe complications, and improved functional outcomes. This was confirmed by reductions in YLL due to lower premature mortality and decreased average YLD due to reduced disability severity. The effect was particularly pronounced in patients with incomplete SCI according to ASIA/IMSOP classification, where timely specialized care promoted better neurological recovery[9]. Economic analysis indicated that, despite higher initial expenditures associated with advanced diagnostic and therapeutic technologies, the centralized system proved more cost-effective in the medium term. Reduced hospitalization duration, fewer readmissions, and decreased complication rates led to lower overall direct medical costs per patient. Additional economic benefits included decreased indirect losses through improved social and occupational reintegration. Comparative cost-effectiveness analysis demonstrated that the cost per prevented year of lost healthy life (per DALY) was lower under the centralized system than the decentralized model[7]. This indicates more rational resource utilization and greater return on investment in specialized care. Using the integrated DALY metric allowed for quantitative assessment of the economic feasibility of organizational reforms and confirmed the advantages of a centralized approach. Thus, the analysis demonstrated that a centralized care system for patients with SCI in a megapolis setting provides superior medical and economic effectiveness compared to a decentralized model[11-13]. These results support the further development of specialized centers, optimization of patient referral pathways, and implementation of unified clinical protocols aimed at reducing mortality, disability, and socio-economic losses[13]. Conclusion The results of this dissertation are aimed at forming an effective system for providing specialized medical care to patients with spinal cord injury (SCI) in a megapolis setting. The implementation of the proposed approaches allows for improving the quality and accessibility of healthcare, enhancing functional outcomes, reducing disability and mortality rates, and decreasing socio-economic losses for both society and the state. The dissertation presents a comprehensive analysis of clinical, organizational, and economic aspects of specialized medical care for patients with SCI. The study examined current epidemiological trends, identified key organizational challenges, evaluated the effectiveness of existing treatment models, and developed practical recommendations for improving the care system for patients with SCI. The first chapter provides a detailed review of national and international literature, highlighting the relevance of SCI as one of the leading causes of disability and mortality among working-age individuals. Globally, up to 500,000 new cases of SCI are registered annually, with disability rates reaching 60-100%. Spinal and spinal cord injuries account for 20-26% of all musculoskeletal trauma, with acute-phase mortality reaching 6.5 per 100,000 population. Special attention was given to analyzing causes of injury, injury patterns, complication rates, mortality, and organizational models for specialized care. Despite advances in medical technology, mortality and disability rates remain high, emphasizing the need for further improvements in the healthcare system. The second chapter describes the materials and methods used. A multidisciplinary approach was employed, including epidemiological, clinical-statistical, sociological, and economic analyses. Data sources included healthcare information systems in Almaty (2013-2023), official statistics, a formalized survey of neurosurgical specialists, hospital reports, regulatory documents, and scientific publications. Modern statistical and economic evaluation methods were applied, using DALY, YLL, and YLD indicators. The sociological component allowed for identifying key organizational challenges and prioritizing directions for the development of specialized neurosurgical care. The third chapter presents the results of the original research. A clinical-statistical characterization of SCI patients in a megapolis was performed. The average annual incidence of SCI in Almaty was 43.7 cases per 100,000 population, with up to 80% of patients being of working age. The main causes of injury were falls from height and road traffic accidents. Seasonal and weekly variations were noted, with peaks in winter and summer months, as well as on weekends and holidays. Clinically, the majority of patients presented with pain, sensory disturbances, lower paraplegia, and paresis. A high rate of combined injuries, significant complications, and an average hospital stay of 13.4 days confirmed the severity of the patient cohort. Neurological deficit regression was observed in 31.4% of cases, and mortality was 5.7%. The results of the formalized survey of specialists indicated insufficient relevance of the current clinical protocol, shortages in personnel and material resources, and the need for a multidisciplinary approach. Problems in patient routing, delayed diagnosis and initiation of specialized treatment, and unequal equipment levels across medical institutions were identified. Based on the data obtained, proposals for updating the clinical protocol were developed, focusing on the algorithmization of diagnostic and therapeutic procedures, expanding pharmacotherapy options, implementing a multidisciplinary approach, and developing rehabilitation technologies. The advisability of transitioning to a centralized model of specialized care for SCI patients was substantiated. The analysis of medical and economic effectiveness demonstrated that the centralized model provides superior clinical and economic outcomes compared to the decentralized system. Reduced hospitalization duration, lower disability and mortality rates, and decreased total economic losses were observed. Over the past five years, economic losses associated with SCI exceeded 12 billion tenge, including costs of inpatient care, disability, and premature death. It was shown that optimizing care organization and developing preventive programs can significantly reduce the socio-economic burden. The study allowed for the formulation of key conclusions reflecting the clinical-epidemiological characteristics of SCI, evaluation of organizational models, directions for updating clinical protocols, improvement of personnel and material resources, as well as preventive measures and reduction of economic losses. Practical recommendations based on the study results focus on updating national clinical protocols in accordance with international guidelines, optimizing patient routing, developing specialized centers, enhancing medical personnel qualifications, implementing a multidisciplinary approach, and using economic analysis and digital technologies to increase the efficiency of the care system. In conclusion, the results of this dissertation confirm that a comprehensive clinical, organizational, and economic approach to specialized medical care for patients with SCI is justified and promising. Its implementation can significantly improve medical and socio-economic outcomes in a modern megapolis setting. References 1. GBD 2019 Spinal Cord Injury Collaborators. Global, regional, and national burden of spinal cord injury, 1990–2019. Lancet Neurol. 2023; 22(11): 1076–1092. https://doi.org/10.1016/S1474-4422(23)00287-9. Crossref Google Scholar 2. World Health Organization. International Perspectives on Spinal Cord Injury. Geneva: WHO; 2013. Google Scholar 3. GBD 2021 Falls Collaborators. Global burden of falls in older adults, 1990–2021. Lancet Public Health. 2023; 8(4): e256–e272. https://doi.org/10.1016/S2468-2667(23)00062-0 Crossref Google Scholar 4. Fehlings MG, Tetreault LA, Wilson JR, et al. Timing of decompression in acute spinal cord injury: updated review. 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Keywords asia scale centralized care daly spinal cord injury urban trauma Authors Affiliations Marat Aliyev Kazakh-Russian Medical University View all articles by this author Nurlan Jainakbayev Kazakh-Russian Medical University View all articles by this author Yermek Dyussembekov City Clinical Hospital No 7 View all articles by this author Marat Almatov 0000-0003-0865-0254 Kazakh Medical University of Continuing Education View all articles by this author Bakhyt Aglakov City Clinical Hospital No 7 View all articles by this author Nursultan Abilkhanov 0009-0003-0570-8278 [email protected] City Clinical Hospital No 7 View all articles by this author Metrics & Citations Metrics Article Usage 127 views 64 downloads .FvxKWukQNSOunydq8rnd { width: 100px; } Citations Download citation Marat Aliyev, Nurlan Jainakbayev, Yermek Dyussembekov, et al. Clinical and Organizational Management of Spinal Cord Injury in a Metropolitan Setting: Experience from Almaty, Kazakhstan. 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