Neurological recovery following delayed surgical management of traumatic spinal cord injury in a resource-limited setting

Abstract Background Traumatic spinal cord injury (SCI) is a major cause of long-term disability worldwide. While early surgical decompression is increasingly recommended to optimize neurological recovery, timely intervention remains challenging in many low- and middle-income countries (LMICs) due to delayed referrals, limited specialist availability, and resource constraints. This study evaluated neurological outcomes following delayed surgical management of traumatic SCI in a resource-limited setting and identified factors associated with recovery. Methods This retrospective cohort study included 68 patients with traumatic SCI who underwent surgical intervention at Ayub Teaching Hospital, Abbottabad, Pakistan, between January 2019 and February 2022. Due to healthcare system constraints, all patients underwent surgery more than 10 days after injury. Patients with fractures below L2, those who died within 12–18 months of surgery, and those with incomplete records were excluded. Neurological recovery was assessed by change in Frankel grade between preoperative assessment and final follow-up. Associations with clinical variables were analyzed using Chi-square and Fisher’s exact tests. Results The cohort comprised 39 males and 29 females with a mean age of 35 years. Lumbar fractures were the most common injury pattern, and instrumentation combined with decompression was the most frequently performed procedure. Despite delayed intervention, neurological improvement was observed in 72.1% of patients, with no patient experiencing deterioration. Preoperative Frankel grade was strongly associated with postoperative recovery ( p < 0.001), and fracture level was also significant ( p = 0.042), with lumbar injuries showing the most favorable outcomes. Age, sex, fracture multiplicity, and surgical technique were not significantly associated with improvement. Conclusion Meaningful neurological recovery remains achievable following delayed surgical management of traumatic SCI in resource-constrained settings. Preoperative neurological status and fracture level were the strongest predictors of recovery. These findings provide important outcome data from an LMIC setting and may assist clinicians in counseling patients when early intervention is not feasible.