A Longitudinal Investigation into the Trajectory of Functional Recovery After Traumatic Spinal Cord Injury in South East Nigeria: Predictors, Pathways, and Policy Implications

Functional recovery following traumatic spinal cord injury (SCI) in sub-Saharan Africa is shaped by a complex interplay of neurological, rehabilitative, psychosocial, and health systems factors that are fundamentally different from recovery pathways described in high-income country literature. This prospective longitudinal study characterises recovery trajectories and their determinants in adult traumatic SCI patients over 24 months at four tertiary hospitals in South East Nigeria, comprising UNTH Enugu, NAUTH Nnewi, FETHA Abakaliki, and ESUTH Enugu. ASIA Impairment Scale, Spinal Cord Independence Measure (SCIM III), EQ-5D-5L, and Patient Health Questionnaire-9 (PHQ-9) assessments will be conducted at admission, three, six, twelve, and 24 months. Group-based trajectory modelling will identify distinct recovery pathway subgroups. Mixed-effects logistic regression will determine neurological, demographic, and health system predictors of favourable trajectories. Causal inference analysis (g-computation) will estimate the effect of specific rehabilitation exposures on outcomes. Qualitative longitudinal interviews with 25 patients will provide phenomenological insight into the lived experience of recovery. The study hypothesises the existence of at least three distinct recovery trajectories and that early structured rehabilitation access and absence of pressure ulcer complications are the strongest predictors of optimal trajectory membership. Findings will generate a novel theoretical model of SCI recovery adapted to the South East Nigerian context and will be submitted to policy makers through Nigeria's Federal Ministry of Health disability health desk. Keywords: spinal cord injury, functional recovery, longitudinal study, trajectory modelling, South East Nigeria.