Prehospital care pathways and delayed access to specialized care after traumatic spinal cord injury in a low-resource setting: an analytical cohort study of 366 patients from Côte d’Ivoire

Objective: In low- and middle-income countries (LMICs), the prognosis of traumatic spinal cord injury (TSCI) depends on injury severity but also on the prehospital chain and the referral pathway upstream of the referral center. The authors described this care pathway and access delays, identified the determinants of delayed access, and explored their association with in-hospital outcome. Methods: This analytical observational study included 366 patients admitted for TSCI at Bouaké University Hospital (retrospective phase 2017–2021, prospective phase 2025–June 2026), after a database audit. The determinants of delayed access (time to reception > 48 hours) and of non-medicalized transport were modeled by multivariable logistic regression following a predefined causal framework; the association between care pathway and in-hospital mortality was estimated after adjustment for severity (ASIA grade) and age. Reporting followed STROBE. Results: Nearly three-quarters of patients (263/366; 71.9%) were referred, transiting through 93 originating facilities; 208 (56.8%) were conveyed by non-medicalized transport and 56 (15.3%) were insured. The median time to reception was 2 days (IQR 1–3), with a long right tail (11.7% at 7 days or more; maximum 72 days). Non-medicalized transport (aOR 2.09; 95% CI 1.29–3.37) and residence outside the region (1.76; 1.02–3.03) were independently associated with a delay exceeding 48 hours. Neurological severity remained the dominant determinant of mortality (ASIA A: aOR 11.0; 5.50–22.0; AUC 0.81). Delayed access was associated with lower in-hospital mortality (aOR 0.27; 0.13–0.55); this inverse association is interpreted as depletion of susceptibles, mortality being early (median time to death 5 days; 62.5% of deaths within the first week) and the injury composition of arrivals remaining stable across delay strata. Conclusions: Prehospital delays in TSCI at Bouaké are driven mainly by non-medicalized transport and geographic remoteness. Because mortality is early, a likely substantial proportion of deaths occurs before access to the referral center, making the hospital cohort an incomplete representation of the true burden. Strengthening medical transport and structuring the referral pathway—modifiable organizational levers—are public-health priorities.