Successful adaptation of twinning concept for global neurosurgery collaborations-a validation study

INTRODUCTION

Globally, many regions have an urgent, unmet need of neurosurgical care. A multi-step neurosurgical twinning technique, International Neurosurgical Twinning Modeled for Africa (INTIMA), was proved to be successful during a previous mission to Neurosurgical Unit, Enugu, Nigeria. The Swedish African Neurosurgical Collaboration (SANC) performed a developmental mission together with the local neurosurgical unit in The Gambia, adopting the INTIMA model.

METHODS

A multidisciplinary team visited for a 2-week collaborative mission at the Neurosurgical Department of the Edward Francis Small Teaching Hospital in Banjul, The Gambia. The mission followed the data of neurosurgical operations during and after the mission as well as about the operations 3 months prior to and after the mission was collected.

RESULTS

During the mission, a total of 22 operations was carried out, the most common being degenerative spinal conditions (n = 9). In the 3 months following the mission, 43 operations were performed compared to 24 during the 3 months leading up to the mission. The complexity of the performed procedures increased after the mission. An operating microscope (Möller-Wedel) was donated and installed and the neurosurgeons on site underwent training in microneurosurgery. The surgical nurses, nurses at the postoperative ward, and the physiotherapists underwent training. A biomedical engineer serviced multiple appliances and devices improving the patient care on site while training local technicians.

CONCLUSION

This study validated the use of the INTIMA model previously described in a mission by Swedish African Neurosurgical Collaboration (SANC). The model is sustainable and produces notable results. The core strength of the model is in the multidisciplinary team securing all the aspects and steps of the neurosurgical care. Installation of an operating microscope opened for further microsurgical possibilities, improving the neurosurgical care in The Gambia.

History and Current State of Neurosurgery in the Gambia

BACKGROUND

Despite global efforts to improve surgical care access, many low- and middle-income countries, especially in neurosurgery, face significant shortages. The Gambia exemplifies this, with only 1 fully qualified neurosurgeon serving its population of 2.5 million people. This scarcity results in higher morbidity and mortality.

OBJECTIVE

We aim to document the history and current state of neurosurgery in the Gambia to raise awareness and promote neurosurgery development.

METHODS

The study reviews the Gambia's health care system, infrastructure, neurosurgical history, workforce, disease burden, and progress, with information derived from reference sources as well as author experience and interviews with key partners in Gambian health care.

RESULTS

Neurosurgery in the Gambia began in the 1970s, facing constraints due to competing health care demands. Significant progress occurred much later in the early 2010s, marked by the initiation of Banjul Neuro Missions and the establishment of a dedicated neurosurgery unit. We report significant progress with neurosurgical interventions in the past few years showcasing the unit's dedication to advancing neurosurgical care in the Gambia. However, challenges persist, including a lack of trained neurosurgeons, equipment shortages such as ventilators and diagnostic imaging. Financial barriers for patients, particularly related to the costs of computer tomography scans, pose significant hurdles, impacting the timely diagnosis and intervention for neurological conditions.

CONCLUSIONS

Neurosurgery in the Gambia is progressing, but challenges like equipment scarcity hinder further progress. We emphasize the need for addressing cost barriers, improving infrastructure, and fostering research. Engaging the government and international collaborations are vital for sustained development in Gambian neurosurgery.

hglobal-Index: A Novel Author-Level Measure of the Diffusion of Scientific Ideas Among High-, Low-, and Middle-Income Countries

OBJECTIVE

To describe an intuitive and useful method for measuring the global impact of a medical scholar's research ideas by examining cross-border citations (CBCs) of peer-reviewed neurosurgical publications.

METHODS

Publication and citation data for a random sample of the top 50 most academically productive neurosurgeons were obtained from Scopus Application Programming Interface. We characterized an author-level global impact index analogous to the widely used h-index, the hglobal-index, defined as the number of published peer-reviewed manuscripts with at least the same number of CBCs. To uncover socioeconomic insights, we explored the hglobal-index for high-, middle-, and low-income countries.

RESULTS

The median (interquartile range) number of publications and CBCs were 144 (62-255) and 2704 (959-5325), respectively. The median (interquartile range) h-index and hglobal-index were 42 (23-61) and 32 (17-38), respectively. Compared with neurosurgeons in the random sample, the 3 global neurosurgeons had the highest hglobal-indices in low-income countries at 17, 13, and 9, despite below-average h-index scores of 33, 38, and 19, respectively.

CONCLUSION

This intuitive update to the h-index uses CBCs to measure the global impact of scientific research. The hglobal-index may provide insight into global diffusion of medical ideas, which can be used for social science research, author self-assessment, and academic promotion.

Opportunities and Considerations for the Incorporation of Artificial Intelligence into Global Neurosurgery: A Generative Pretrained Transformer Chatbot-Based Approach

OBJECTIVE

Global neurosurgery is a public health focus in neurosurgery that seeks to ensure safe, timely, and affordable neurosurgical care to all individuals worldwide. Although investigators have begun to explore the promise of artificial intelligence (AI) for neurosurgery, its applicability to global neurosurgery has been largely hypothetical. We characterize opportunities and considerations for the incorporation of AI into global neurosurgery by synthesizing key themes yielded from a series of generative pretrained transformers (GPTs), discuss important limitations of GPTs and cautions when using AI in neurosurgery, and develop a framework for the equitable incorporation of AI into global neurosurgery.

METHODS

ChatGPT, Bing Chat/Copilot, You, Perplexity.ai, and Google Bard were queried with the prompt "How can AI be incorporated into global neurosurgery?" A layered ChatGPT-based thematic analysis was performed. The authors synthesized the results into opportunities and considerations for the incorporation of AI in global neurosurgery. A Pareto analysis was conducted to determine common themes.

RESULTS

Eight opportunities and 14 important considerations were synthesized. Six opportunities related to patient care, 1 to education, and another to public health planning. Four of the important considerations were deemed specific to global neurosurgery. The Pareto analysis included all 8 opportunities and 5 considerations.

CONCLUSIONS

AI may be incorporated into global neurosurgery in a variety of capacities requiring numerous considerations. The framework presented in this manuscript may facilitate the incorporation of AI into global neurosurgery initiatives while balancing contextual factors and the reality of limited resources.

A Mixed-Methods Assessment of the Feasibility of Conducting Neurosurgical Clinical Research in Uganda

BACKGROUND

Clinical research is necessary to evaluate neurosurgical interventions, yet clinical trials are conducted less frequently in low- and middle-income countries. Because specific barriers, facilitating factors, and strategies for neurosurgical clinical research in Uganda have not been previously identified, this study evaluated neurosurgical providers' perspectives on clinical research and documentation patterns of neurosurgical variables at Mulago National Referral Hospital.

METHODS

Retrospective review of 166 neurosurgical patient charts assessed the frequency of documentation of key variables. Twenty-two providers working in neurosurgery participated in 6 focus group discussions with qualitative analysis utilizing the framework method.

RESULTS

Chart review showed that primary diagnosis (99.4%), pupil light response (97.6%), and computed tomography scan results (93.3%) were documented for most patients. Cranial nerve exam (61.5%), pupil size (69.9%), and time to neurosurgical intervention (45%) were documented less frequently. On average, Glasgow Coma Scale was documented for 86.6% of days hospitalized, while vital signs were documented for 12.3%. In most focus group discussions, participants identified follow-up, financing, recruitment, time, approval, and sociocultural factors as research barriers. Participants described how the current health workforce facilitates successful research. To improve research capacity, suggested strategies focused on research networks, data collection, leadership, participant recruitment, infrastructure, and implementation.

CONCLUSIONS

At Mulago National Referral Hospital, there was variability in the frequency of documentation of neurosurgical variables, which may impact data collection for future studies. While multiple barriers were identified, sociocultural, financing, and time barriers greatly impacted neurosurgical clinical research. Despite that, identified facilitating factors and strategies could be utilized to support neurosurgical research capacity growth.

The Impact of Colonialism on Surgical Training Structures in Africa Part 1: Contextualizing the Past, Present, and Future

Since the first African country attained independence from colonial rule, surgical training on the continent has evolved along 3 principal models. The first is a colonial, local master-apprentice model, the second is a purely local training model, and the third is a collegiate intercountry model. The 3 models exist currently and there are varied perceptions of their relative merits in training competent neurosurgeons. We reviewed the historical development of training and in an accompanying study, seek to describe the complex array of surgical training pathways and explore the neocolonial underpinnings of how these various models of training impact today the development of surgical capacity in Africa. In addition, we sought to better understand how some training systems may contribute to the widely recognized "brain drain" of surgeons from the African continent to high income countries in Europe and North America. To date, there are no published studies evaluating the impact of surgical training systems on skilled workforce emigration out of Africa. This review aims to discover potentially addressable sources of improving healthcare and training equity in this region.

Global Neurosurgery at the 76th World Health Assembly (2023): First Neurosurgery-Driven Resolution Calls for Micronutrient Fortification to Prevent Spina Bifida

Since 2018, a neurosurgery delegation has been actively engaged and consistently present at the World Health Assembly. Recognizing the growing impact of neurosurgical diseases, the neurosurgery delegation participated in the 76th World Health Assembly in May 2023, advocating for timely, safe, and affordable global neurosurgical care. The delegation focused on forging new collaborations, strengthening the World Health Organization-World Federation of Neurosurgical Societies official relations, and actively supporting resolutions that impact the neurosurgical patients. However, there is a long advocacy journey ahead to address unmet neurosurgical needs. Patient-centered advocacy is an inherent task of our profession and the essence of the Global Neurosurgery Bogota Declaration of 2016. The highlight of the 76th World Health Assembly was the adoption of the first neurosurgery-driven resolution calling for micronutrient fortification to prevent spina bifida and other micronutrient deficiencies. For the last 4 years, the Global Alliance for Prevention of Spina Bifida, a group spearheaded by neurosurgeons, advocated for spina bifida prevention. This Alliance collaborated with many stakeholders, notably, the Colombian government to promote the resolution: "Accelerating efforts for preventing micronutrient deficiencies and their consequences, including spina bifida and other neural tube defects, through safe and effective food fortification." This is a proud milestone for the neurosurgical profession. There are many strategies available for neurosurgeons, when working together with elected leaders, other stakeholders, and allied professionals, to implement initiatives that can prevent future cases of spina bifida and other neurological disorders and reduce the burden of neurosurgical disease.

The Impact of Colonialism on Surgical Training Structures In Africa Part 2: Surveying Current and Past Trainees

BACKGROUND

As a result of gradual independence from colonial rule over the course of the past century, Africa has developed and evolved 3 primary surgical training structures: an extracontinental colonial model, an intracontinental college-based model, and several smaller national or local models. There is consistent evidence of international brain drain of surgical trainees and an unequal continental distribution of surgeons; however there has not, to date, been an evaluation of the impact colonialism on the evolution of surgical training on the continent. This study aims to identify the etiologies and consequences of this segmentation of surgical training in Africa.

METHODS

This is a cross-sectional survey of the experience and perspectives of surgical training by current African trainees and graduates.

RESULTS

A surgeon's region of residence was found to have a statistically significant positive association with that of a surgeon's training structure (P <0.001). A surgeon's professional college or structure of residency has a significantly positive association with desire to complete subspecialty training (P = 0.008). College and structure of residency also are statistically significantly associated with successful completion of subspecialty training (P < 0.001).

CONCLUSIONS

These findings provide evidence to support the concept that the segmentation of surgical training structures in Africa, which is the direct result of prior colonization, has affected the distribution of trainees and specialists across the continent and the globe. This maldistribution of African surgical trainees directly impacts patient care, as the surgeon-patient ratios in many African countries are insufficient. These inequities should be acknowledged addressed and rectified to ensure that patients in Africa receive timely and appropriate surgical care.

Microsurgical thrombectomy: where the ancient art meets the new era

Mechanical thrombectomy (MT) is the leading treatment for acute large vessel occlusion (LVO). However, surgical thrombectomy (ST) may have a role in well selected LVO patients where MT failed to re-establish flow, the endovascular route is inaccessible, or where MT is a financially prohibitive or absent option (developing and poor countries). We compared the efficacy and efficiency between ST and MT, and described our operative experience and its potential application in the developing world. Clinical outcomes, procedural times, and efficacy of treatment were compared between the MT and ST of acute LVO between 2012 and 2022. Propensity score-matched analysis was also conducted to compare MT and ST. One-hundred nine patients fulfilled the study criteria (77 MTs vs 32 STs). Factors driving outcome were age (aOR: 0.95, 95%CI, 0.91-0.98), hemisphere side (aOR: 0.38, 95%CI, 0.15-0.96), and DWI-ASPECT (aOR: 1.39, 95%CI, 1.09-1.77) at presentation by the multivariate analysis. Times from door-start of procedure (P = 0.45) and start of procedure-recanalization (P = 0.13) were similar between treatment options. Propensity score-matched analysis found no significant difference for 2 treatment methods about time of door to recanalization (P = 0.155) and outcome (P = 0.221). The prognosticators of thrombectomy for acute LVO in patients with successful recanalization were age, affected hemisphere side, and DWI-ASPECT score. Our evidence shows that the efficacy of ST is similar to that of MT. There should be a place of ST for cases of mechanical failure or tandem cervical ICA and MCA occlusion. ST may be a temporizing LVO treatment option in healthcare systems where MT is inexistent or financially prohibitive to patients.

Pandemic impact on aneurysmal subarachnoid hemorrhage in Peru's high COVID-19 lethality setting: A public institutional experience

Background

The COVID-19 pandemic in 2020 profoundly impacted healthcare worldwide, and Peru was particularly affected, experiencing the highest COVID-19 case fatality rate globally.

Methods

We conducted a retrospective comparative study of patients presenting with aneurysmal subarachnoid hemorrhage (SAH) at a public Peruvian national referral center specializing in cerebrovascular diseases. Two study periods were considered, one during the first wave of the COVID-19 pandemic and a second identical period in 2019. Variables included patient demographics, comorbidities, COVID-19 infection status, clinical presentation, treatment approaches, and hospital outcomes.

Results

We analyzed 114 patients with aneurysmal SAH, 65 (57.0%) treated in 2019 and 49 (43.0%) in 2020. The mean time from emergency admission to the day of definitive treatment during 2019 and 2020 was 2.72 and 1.93 days, respectively. Likewise, the mean time from symptom onset to the date of definitive treatment was 6.71 and 7.70 days, respectively. We identified significant associations between complications such as sepsis, respiratory failure, acute kidney failure, and hospital mortality. The proportion of fatalities was significantly higher in 2020 compared to 2019 (36.7% vs. 15.4%, respectively). Interestingly, there was no statistically significant association between COVID-19 infection status and mortality during the 2020 period.

Conclusion

Patients with aneurysmal SAH treated during the pandemic had a higher proportion of sepsis, respiratory failure, acute kidney failure, and mortality compared to the pre-pandemic period. Reallocating healthcare resources to prioritize COVID-19 patients may have inadvertently neglected or delayed care for patients with other emergency conditions, such as aneurysmal SAH. This highlights the importance of maintaining adequate care for non-infectious emergencies during a pandemic.

Current State of Brazilian Neurosurgery: Evaluation of Burden of Care and Case Volume

BACKGROUND

Low- and middle-income countries (LMICs) bear a heavier burden of neurosurgical diseases than high-income countries. Brazil, a growing middle-income country, holds promise as a health care market. However, there exists a lack of information to characterize the state of neurosurgical practice and access to care in Brazil. This study aimed to characterize neurosurgical practice in Brazil and identify barriers to care.

METHODS

A collaborative survey was developed with Brazilian neurosurgeons and distributed by the Brazilian Society of Neurosurgery. The survey gathered demographic information, practice characteristics, case volume, referral patterns, income sources, and assessed barriers using a Likert scale. Descriptive statistics were employed for data analysis.

RESULTS

One-hundred and forty-nine neurosurgeons participated (response rate: 17.5%), representing various states in Brazil. Neurosurgeons practiced in more than 4 different hospital systems on average, with most consultations and procedures occurring in public hospitals. Common procedures included tumor surgeries, general neurosurgery, spine surgeries, trauma surgeries, and hydrocephalus management. Equipment shortage and systemic issues were identified as major barriers to care.

CONCLUSIONS

Neurosurgical practice in Brazil exhibits diverse age distribution, widespread distribution across states, and involvement in both public and private hospitals. Survey insights shed light on neurosurgical workload and neurosurgical practice characterization. Lack of equipment and inadequate postoperative resources pose significant barriers to care. The findings highlight the need for investments in equipment, critical care facilities, and improved health care system coordination to enhance access to neurosurgical care in Brazil.

Neurosurgical Education in Tanzania: The Dar es Salaam Global Neurosurgery Course

BACKGROUND

Postgraduate neurosurgical training is essential to develop a neurosurgical workforce with the skills and knowledge to address patient needs for neurosurgical care. In Tanzania, the number of neurosurgeons and neurosurgical services offered have expanded in the past 40 years. Training opportunities within the country, however, are not sufficient to meet the needs of residents, specialists, and nurses in neurosurgery, forcing many to train outside the country incurring associated costs and burdens. We report on the Dar es Salaam Global Neurosurgery Course, which aims to provide local training to neurosurgical health care providers in Tanzania and surrounding countries.

METHODS

We report the experience of the Global Neurosurgery Course held in March 2023 in Dar es Salaam, Tanzania. We describe the funding, planning, organization, and teaching methods along with participant and faculty feedback.

RESULTS

The course trained 121 participants with 63 faculty-42 from Tanzania and 21 international faculty. Training methods included lectures, hands-on surgical teaching, webinars, case discussions, surgical simulation, virtual reality, and bedside teaching. Although there were challenges with equipment and Internet connectivity, participant feedback was positive, with overall improvement in knowledge reported in all topics taught during the course.

CONCLUSIONS

International collaboration can be successful in delivering topic-specific training that aims to address the everyday needs of surgeons in their local setting. Suggestions for future courses include increasing training on allied topics to neurosurgery and neurosurgical subspecialty topics, reflecting the growth in neurosurgical capacity and services offered in Tanzania.

Transitioning care for adolescents with spina bifida in the US: challenges for management

Open spina bifida (OSB) is a common neural tube defect. Medical and surgical care involves addressing the baseline orthopedic, urologic, and neurological dysfunction as well as the changes or declines that may occur as the patient ages. Given the complexity of this disease, coordinated, multidisciplinary care involving specialists in neurosurgery, orthopedics, urology, rehabilitation and physical medicine, pediatrics, and psychology is necessary to establish and optimize baseline function. Traditionally in the US, pediatric multispecialty spina bifida clinics have provided the patient with a coordinated medical support system. Unfortunately, this coordinated, medical home has been difficult to establish during the transition from pediatric to adult care. Medical professionals must have a strong understanding of OSB to properly manage the disease and detect and prevent associated complications. In this manuscript, we (1) describe the changing needs and challenges of people living with OSB over a lifespan, (2) delineate current practices in the transition of care for people with OSB from childhood to adulthood, and (3) provide recommendations for best practices in navigating the transition process for clinicians who provide care for those afflicted with this most complex congenital abnormality of the nervous system compatible with long term survival.

Hussein Suleiman Abusalih (1930-2021): First Neurosurgeon and Former Minister of Health of Sudan

BACKGROUND

This historical account reviews the course and lasting impact of Dr. Hussein Suleiman Abusalih (October 5, 1930 to December 6, 2021) in neurosurgery.

METHODS

The conception of this project was sparked by the discovery of original scientific and bibliographical information about Dr. Abusalih, a prolific neurosurgeon and political figure in his home country of Sudan. This project aims to thoroughly describe the impact of Dr. Abusalih in his home country and in the field of neurosurgery.

RESULTS

From humble beginnings, Dr. Abusalih traveled extensively to pursue his passions in education and medicine. He received his neurosurgical training with Dr. Ahmed El-Banhawi of Ain Shams University. Afterward, he returned to Sudan to become the nation's first neurosurgeon and formed the first neurosurgical department in the country in addition to being appointed as the Minister of Health of Sudan. Partnering with several neuroscientists and fellow physicians, Dr. Abusalih was one of the founders of the Pan African Association of Neurological Sciences and worked extensively for various indigenous populations. As a prolific researcher and educator, Dr. Abusalih authored many presentations, publications, and various books, such as "Inside the Ministry of Health" and "Neurosurgery in the Seventies." Dr. Abusalih was a prominent figure in both medical and political fields.

CONCLUSIONS

Our article provides a look into the life and impact of Dr. Abusalih as a prominent political pioneer and the first neurosurgeon in Sudan.

Global neurosurgery: Reflections on myelomeningocele in the Zanzibar archipelago (Tanzania)

Objective

Our main goal was to describe the general characteristics and demographic data of myelomeningocele (MMC) patients at Mnazi Mmoja Surgical NED Institute (MMSNI) in Zanzibar and to assess the clinical characteristics and medium-term result-impact of the implemented health care measures.

Methods

This is a retrospective study on 41 MMC patients treated at the MMSNI in Zanzibar (Tanzania) from September 2016 to September 2018. Patient demographics, prenatal care, clinical and radiographic characteristics, surgical management and nursing care, and clinical outcomes were abstracted.

Results

The mean age of the patients was 6.1 ± 4.6 days, and 53.7% were males. A total of 51.2% came from Zanzibar, 39% to Pemba, and 9.8% from mainland Tanzania. Maternal ultrasound checkups revealed hydrocephalus in 18.7% of the cases. 85.4% of the newborns were operated on. Surgical wound infection was the most frequent complication (28.6%). A significantly higher risk of complications was observed in children from Pemba Island (p = 0.046) and those born by vaginal delivery (p = 0.694), particularly infections. During follow-up, 48.57% of the patients presented with infantile hydrocephalus and in the majority of them, a ventriculoperitoneal shunt was inserted.

Conclusions

Proper prenatal care with early diagnosis, together with the neurosurgical and nursing standard of care in a specialized institution, are all essential to increase the chances of successful treatment of newborns harboring MMC and is one of the main goals pursued in the MMSNI, as the only referral public health center with locally trained health personnel in Zanzibar archipelago.

The state of art of awake craniotomy in Latin American countries: a scoping review

BACKGROUND AND OBJECTIVE

Awake craniotomy (AC) is a valuable technique for surgical interventions in eloquent areas, but its adoption in low- and middle-income countries faces challenges like limited infrastructure, trained personnel shortage, and inadequate funding. This scoping review explores AC techniques in Latin American countries, focusing on patient characteristics, tumor location, symptomatology, and outcomes.

METHODS

A scoping review followed PRISMA guidelines, searching five databases in English, Spanish, and Portuguese. We included 28 studies with 258 patients (mean age: 43, range: 11-92). Patterns in AC use in Latin America were analyzed.

RESULTS

Most studies were from Brazil and Mexico (53.6%) and public institutions (70%). Low-grade gliomas were the most common lesions (55%), most of them located in the left hemisphere (52.3%) and frontal lobe (52.3%). Gross-total resection was achieved in 34.3% of cases. 62.9% used an Asleep-Awake-Asleep protocol, and 14.8% used Awake-Awake-Awake. The main complication was seizures (14.6%). Mean post-surgery discharge time was 68 h. Challenges included limited training, infrastructure, and instrumentation availability. Strategies discussed involve training in specialized centers, seeking sponsorships, applying for awards, and multidisciplinary collaborations with neuropsychology.

CONCLUSION

Improved accessibility to resources, infrastructure, and adequate instrumentation is crucial for wider AC availability in Latin America. Despite disparities, AC implementation with proper training and teamwork yields favorable outcomes in resource-limited centers. Efforts should focus on addressing challenges and promoting equitable access to this valuable surgical technique in the region.

The current landscape of intracranial aneurysms in Africa: management outcomes, challenges, and strategies-a narrative review

Intracranial aneurysms (IAs) pose complex and potentially life-threatening challenges in Africa, where limited resources, restricted access to specialised healthcare facilities, and disparities in healthcare provision amplify the difficulties of management. Timely diagnosis and treatment are pivotal in preventing complications, including subarachnoid haemorrhage. Treatment options encompass observation, surgical clipping, endovascular coiling, and flow diversion. Positive outcomes observed in IA management in Africa include high survival rates, favourable functional outcomes, successful treatment techniques, and the absence of complications in some cases. However, negative outcomes such as postoperative complications, reduced quality of life, perioperative mortality, and the risk of recurrence persist. Challenges in IA management encompass limited access to diagnostic tools, a scarcity of specialised healthcare professionals, and an unequal distribution of services. Addressing these challenges requires interventions focused on improving access to diagnostic tools, expanding the number of trained professionals, and establishing specialised IA treatment centres. Collaboration, research, and capacity-building efforts hold significant importance in improving patient outcomes and reducing disparities in IA management across Africa.

Needs, Roles, and Challenges of Young Latin American and Caribbean Neurosurgeons

BACKGROUND

Barriers to neurosurgery training and practice in Latin American and Caribbean countries (LACs) have been scarcely documented. The World Federation of Neurosurgical Societies Young Neurosurgeons Forum survey sought to identify young neurosurgeons' needs, roles, and challenges. We present the results focused on Latin America and the Caribbean.

METHODS

In this cross-sectional study, we analyzed the Young Neurosurgeons Forum survey responses from LACs, following online survey dissemination through personal contacts, social media, and neurosurgical societies' e-mailing lists between April and November 2018. Data analysis was performed using Jamovi version 2.0 and STATA version 16.

RESULTS

There were 91 respondents from LACs. Three (3.3%) respondents practiced in high-income countries, 77 (84.6%) in upper middle-income countries, 10 (11%) in lower middle-income countries, and 1 (1.1%) in an unclassified country. The majority (77, or 84.6%) of respondents were male, and 71 (90.2%) were younger than 40. Access to basic imaging modalities was high, with access to computed tomography scan universal among the survey respondents. However, only 25 (27.5%) of respondents reported having access to imaging guidance systems (navigation), and 73 (80.2%) reported having access to high-speed drills. A high GDP per capita was associated with increased availability of high-speed drills and more time dedicated to educational endeavors in neurosurgery, such as didactic teaching and topic presentation (P < 0.05).

CONCLUSIONS

This survey found that neurosurgery trainees and practitioners of Latin America and the Caribbean face many barriers to practice. These include inadequate state-of-the-art neurosurgical equipment, a lack of standardized training curricula, few research opportunities, and long working hours.

Glioblastoma management in low and middle-income countries; existing challenges and policy recommendations

Glioblastomas (GBM) are the most prevalent malignant CNS tumors globally, affecting about 3.19 per 100,000 people. The standard of care of GBM management includes surgical resection followed by radiotherapy and/or chemotherapy owing to the high recurrent rates. Despite the advances in neurosurgical practice and brain cancer research, low- and middle-income countries (LMICs) did not benefit greatly from these advances compared to high-income countries (HICs). First, the case ascertainment is low in LMICs, which contributes to a lower than actual disease burden and delayed presentation of the tumors with a worse prognosis. Second, GBM treatment is expensive; unregulated radiation and chemotherapy costs can expose the patients to financial hardships and lead to treatment discontinuation. Third, the lack of trained neurosurgical workforce in poor resource settings in LMICs further complicates the situation. Fourth, radiation therapy and chemotherapies are expensive and unavailable in many poor-resource settings in LMICs. Fifth, LMICs suffer from a weak infrastructure especially with low numbers of prepared ORs, laboratories, and advanced imaging techniques. In the present article, we highlight the major challenges of GBM management and further propose solutions for governments and health policy makers to improve GBM care in LMICs.

The impact of traumatic brain injury on economic productivity in the Caribbean

Introduction

Traumatic brain injury (TBI) is a significant cause of morbidity and mortality in the Caribbean as well as globally. Within the Caribbean, the prevalence of TBI is approximately 706 per 100,000 persons - one of the highest rates per capita in the world.

Research question

We aim to assess the economic productivity lost due to moderate to severe TBI in the Caribbean.

Material and methods

The annual cost of economic productivity lost in the Caribbean from TBI was calculated from four variables: (1) the number of people with moderate to severe TBI of working age (15-64 years), (2) the employment-to-population ratio, (3) the relative reduction in employment for people with TBI, and (4) per capita Gross Domestic Product (GDP). Sensitivity analyses were performed to evaluate whether the uncertainty of the TBI prevalence data result in substantive changes in the productivity losses.

Results

Globally, there was an estimated 55 million (95% UI 53, 400, 547 to 57, 626, 214) cases of TBI in 2016 of which 322,291 (95% UI 292,210 to 359,914) were in the Caribbean. Using GDP per capita, we calculated the annual cost of potential productivity losses for the Caribbean to be $1.2 billion.

Discussion and conclusion

TBI has a significant impact on economic productivity in the Caribbean. With upwards of $1.2 billion lost in economic productivity from TBI, there is an urgent need for appropriate prevention and management of this disease by upscaling neurosurgical capacity. Neurosurgical and policy interventions are necessary to ensure the success of these patients in order to maximize economic productivity.

The impact of limited access to electronic medical records on neurosurgical care within the CARICOM countries: A survey and scoping review

Introduction

Global access to electronic medical records (EMRs) continues to grow, however many countries including those within the Caribbean Community (CARICOM) lack access to this system. Minimal research investigating EMR use in this region exists.

Research question

How does limited EMR access impact neurosurgical care within the CARICOM?

Materials and methods

The Cochrane Library, EMBASE, Scopus, PubMed/MEDLINE databases, and grey literature were queried for studies addressing this issue within the CARICOM and low- and/or middle-income countries (LMICs). A comprehensive search for hospitals within the CARICOM was performed and responses to a survey inquiring about neurosurgery availability and EMR access within each facility were recorded.

Results

26 out of 87 surveys were returned leading to a response rate of 29.0%. Among the survey respondents, 57.7% stated neurosurgery was provided at their facility; however, only 38.4% admitted to using an EMR system. Paper charting was the primary means of record keeping for the majority of the facilities (61.5%). The most frequently reported barriers stalling EMR implementation were financial limitations (73.6%) and poor internet access (26.3%). A total of 14 articles were included in the scoping review. Results from these studies suggest that limited EMR access contributes to suboptimal neurosurgical outcomes within the CARICOM and LMICs.

Discussion and conclusion

This paper is the first to address the impact that limited EMR has on neurosurgical outcomes in the CARICOM. The lack of research addressing this issue also highlights the need for ongoing efforts to increase research output focused on EMR accessibility and neurosurgical outcomes in these countries.

Evaluating the potential impact of spinal anesthesia use in lumbar surgery on global healthcare cost and climate change

Introduction

Despite recent evidence demonstrating its safety and efficacy, spinal anesthesia remains a seldom-utilized anesthetic modality in lumbar surgical procedures. In addition, numerous clinical advantages, such as reduced cost, blood loss, operative time, and inpatient length of stay have been consistently demonstrated with spinal anesthesia over general anesthesia.

Research question

In this report we aim to examine the differences between spinal anesthesia and general anesthesia with regard to accessibility and climate impact and determine whether wider adoption of spinal anesthesia would have a meaningful impact on the global population. Materials and Methods: The climate impact of spinal fusions performed under spinal and general anesthesia were obtained from recent studies published in the literature. Cost of spinal fusions was obtained from an unpublished study performed at our institution. Volume of spinal fusions performed in several countries were ascertained from published reports. Data on cost and carbon emissions were extrapolated based on volume of spinal fusions in each of the nations.

Results

In the U.S., use of spinal anesthesia for lumbar fusions would have resulted in savings of 343 million dollars in 2015. A similar reduction in cost was seen with each country studied. Additionally, spinal anesthesia was associated with 12,352 ​kg carbon dioxide equivalents (CO₂e) while general anesthesia produced 942,872 ​kg CO₂e. Similar reduction in carbon emissions was seen with each country studied.

Discussion and conclusion

Spinal anesthesia is safe and effective for both simple and complex spine surgeries, it reduces carbon emissions, permits lower operative times, and decreases cost.

Characteristics of the clinical and global neurosurgical research publications from Africa: A scoping review

Introduction

Scientific research has a direct, profound impact on healthcare systems worldwide. While an upward trend can be observed in the number of produced papers in the neurosurgical specialty, disparities still exist between African neurosurgeons on one side and between African neurosurgeons and neurosurgeons from high income countries, on the other.

Research question

This study aims to analyze neurosurgical research produced in Africa to identify gaps in the literature and provide recommendations for aspiring African neurosurgeons for essential research areas.

Materials and methods

Four electronic databases (PubMed, Scopus, Web of Science, and Embase) were systematically searched for relevant articles on neurosurgery published by African authors. The three main inclusion criteria were: Articles published in the Neurosurgical field, articles published by African authors (whether first authors or co-authors) and articles published in Africa. Data extracted included the study design, scope, neurosurgical subspecialty, and the authors' nationalities.

Results

A total of 982 articles were included in the analysis. Of these articles, 889 (90.6%) were primary, 48 (4.9%) secondary, and 44 (4.5%) other types of research. Global Neurosurgery papers represent 7% of African neurosurgery research output. Most common primary studies included retrospective cohort (32.4%), case reports (28.3%), and prospective cohort (13.8%) studies. The most common secondary research articles were literature reviews (4.9%), letters to the editor (1.2%), and systematic reviews and meta-analyses (0.8%). Common research areas were neuro-oncology 242 (24.7%), spinal surgery 157 (16%), and cerebrovascular (14%). The most common nationalities of the first authors were Egyptian (32.4%), Moroccan (15%), and Nigerian (14.2%).

Discussion and conclusion

This study identifies increased African authorship in neurosurgical research in recent years. Nevertheless, many countries still lack representation in the neurosurgical research scene.Furthermore, a high percentage of the published papers is of low evidence. Therefore, we recommend that African neurosurgical researchers focus more on clinical trials and systematic reviews that directly translate to improving clinical practice. African neurosurgeons should also consider more collaboration between African authors.

The role of neurosurgery in advancing pediatric CNS tumor care worldwide

Introduction

There is substantial inequity in survival outcomes for pediatric brain tumor patients residing in high-income countries (HICs) compared to low- and middle-income countries (LMICs). To address disparities in pediatric cancer survival, the World Health Organization (WHO) established the Global Initiative for Childhood Cancer (GICC) to expand quality care for children with cancer.

Research question

To provide an overview of pediatric neurosurgical capacity and detail the burden of neurosurgical diseases impacting children.

Material and methods

A narrative review of the current context of global pediatric neurosurgical capacity as it relates to neurooncology and other diseases relevant to children.

Results

In this article, we provide an overview of pediatric neurosurgical capacity and detail the burden of neurosurgical diseases impacting children. We highlight concerted advocacy and legislative efforts aimed at addressing unmet neurosurgical needs in children. Finally, we discuss the potential implications of advocacy efforts on treating pediatric CNS tumors and outline strategies to improve global outcomes for children with brain tumors worldwide in the context of the WHO GICC.

Discussion and conclusion

With both global pediatric oncology and neurosurgical initiatives converging on the treatment of pediatric brain tumors, significant strides toward decreasing the burden of pediatric neurosurgical diseases will hopefully be made.

The NED foundation experience: A model of global neurosurgery

Introduction

The Neurosurgery Education and Development (NED) Foundation (NEDF) started the development of local neurosurgical practice in Zanzibar (Tanzania) in 2008. More than a decade later, multiple actions with humanitarian purposes have significantly improved neurosurgical practice and education for physicians and nurses.

Research question

To what extent could comprehensive interventions (beyond treating patients) be effective in developing global neurosurgery from the outset in low and middle-income countries?

Material and method

A retrospective review of a 14- year period (2008-2022) of NEDF activities highlighting landmarks, projects, and evolving collaborations in Zanzibar was carried out. We propose a particular model, the NEDF model, with interventions in the field of health cooperation that have simultaneously aimed to equip, treat, and educate in a stepwise manner.

Results

138 neurosurgical missions with 248 NED volunteers have been reported. In the NED Institute, between Nov 2014-Nov 2022, 29635 patients were seen in the outpatient clinics and 1985 surgical procedures were performed. During the course of NEDF's projects, we have identified three different levels of complexity (1, 2 and 3) that include the areas of equipment ("equip"), healthcare ("treat") and training ("educate"), facilitating an increase of autonomy throughout the process.

Discussion and Conclusion

In the NEDF's model, the interventions required in each action area (ETE) are coherent for each level of development (1, 2 and 3). When applied simultaneously, they have a greater impact. We believe the model can be equally useful for the development of other medical and/or surgical specialties in other low-resource healthcare settings.

Development and evaluation of a 3d printed training model for endoscopic third ventriculostomy in low-income countries

Introduction

Pediatric hydrocephalus is highly prevalent and therefore a major neurosurgical problem in Africa. In addition to ventriculoperitoneal shunts, which have high cost and potential complications, endoscopic third ventriculostomy is becoming an increasingly popular technique especially in this part of the world. However, performing this procedure requires trained neurosurgeons with an optimal learning curve. For this reason, we have developed a 3D printed training model of hydrocephalus so that neurosurgeons without previous experience with endoscopic techniques can acquire these skills, especially in low-income countries, where specific techniques training as this, are relatively absent.

Research Question

Our research question was about the possibility to develop and produce a low-cost endoscopic training model and to evaluate the usefulness and the skills acquired after training with it.

Material and Methods

A neuroendoscopy simulation model was developed. A sample of last year medical students and junior neurosurgery residents without prior experience in neuroendoscopy were involved in the study. The model was evaluated by measuring several parameters, as procedure time, number of fenestration attempts, diameter of the fenestration, and number of contacts with critical structures.

Results

An improvement of the average score on the ETV-Training-Scale was noticed between the first and last attempt (11.6, compared to 27.5 points; p<0.0001). A statistically significant improvement in all parameters, was observed.

Discussion and Conclusion

This 3D printed simulator facilitates acquiring surgical skills with the neuroendoscope to treat hydrocephalus by performing an endoscopic third ventriculostomy. Furthermore, it has been shown to be useful to understand the intraventricular anatomical relationships.

Benefits and limitations of a groundbreaking approach to communication and education

Introduction

Social media have become ubiquitous and their role in medicine is quickly growing. They provide an open platform by which members share educational material, clinical experiences, and collaborate with educational equity.

Research question

To characterize the role of social media in neurosurgery, we analyzed metrics of the largest neurosurgical group (Neurosurgery Cocktail), collected relevant data about activities, impact and risks of this groundbreaking technology.

Material and methods

We extracted Facebook metrics from 60-day time sample, including users demographics and other platform-specific values such as active members and number of posts within 60 days. A quality assessment of the posted material (clinical case reports and second opinions) was obtained establishing four main quality-criteria: privacy violation; quality of imaging; clinical and follow up data.

Results

By December 2022, the group included 29.524 members (79.8% male), most (29%) between 35 and 44 years of age. Over 100 countries were represented. A total of 787 posts were published in 60 days with an average of 12.7 per day. In 173 clinical cases presented through the platform, some issue with privacy was recorded in 50.9%. The imaging was considered insufficient in 39.3%, clinical data in 53.8%; follow up data were missing in 60.7%.

Discussion and conclusion

The study provided a quantitative evaluation of impact, flaws and limitations of social medial for healthcare. Flaws were mostly data breach and insufficient quality of case reports. There are actions to correct these flaws that can be easily taken to provide a greater credibility and efficacy to the system.

Private healthcare initiatives in developing countries - Building sustainable neurosurgery in Indonesia and Pakistan

Introduction

Severe global shortages in neurosurgery, surgery, and healthcare in general have been documented, especially in low- and middle-income countries (LMICs).

Research question

In LMICs, how do we expand both neurosurgery and overall healthcare?

Material and methods

Two different approaches to improving neurosurgery are presented. Author EW convinced a private hospital chain that neurosurgical resources were important throughout Indonesia. Author TK established a consortium (Alliance Healthcare) to obtain financial support for healthcare in Peshawar, Pakistan.

Results

The expansion over 20 years in neurosurgery (throughout Indonesia) and in healthcare (for Peshawar and Khyber Pakhtunkhwa (KP) province, Pakistan) is impressive. In Indonesia, neurosurgery centers have expanded from one in Jakarta to over 40 throughout the islands of Indonesia. In Pakistan, two general hospitals, schools of medicine, nursing, and allied health professions, and an ambulance service have been established. Recently US$11 million has been awarded to Alliance Healthcare by the International Finance Corporation (the private sector arm of the World Bank Group) to further expand healthcare infrastructure in Peshawar and KP.

Discussion and conclusion

The enterprising techniques described here can be implemented in other LMIC settings. Three keys to success both programs utilized: (1) educating the community (population at large) of the need for surgery in particular to improve overall healthcare; (2) being entrepreneurial and persistent in seeking the community support and the professional and financial support needed to advance both neurosurgery and overall healthcare through the private sector; (3) creating sustainable training and support institutions and policies for young neurosurgeons.

Greek reflections on global neurosurgery

Introduction

Large populations in middle- and low-income countries in Africa, Asia, and Central and South Americas face a dramatic neurosurgical crisis. However, large social groups in high-income countries face similar limited access to neurosurgical services. Proper identification of such a problem, analysis of the underlying causes, and proposal of potential solutions may not only address the problem at a national level, but may also provide valuable reflections on the efficient management of global neurosurgical crisis.

Research question

To evaluate if special social groups face similar problems in Greece.

Material and methods

The structure of the Greek health system was examined. The national census along with the registry of practicing neurosurgeons of the Greek National Society, as well as the national health map were searched.

Results

A series of socio-economic factors, language barriers, cultural and religion differences, geographical barriers, the COVID-19 pandemic aftermath, along with the inherent malfunctioning of the Greek health system have led to this national neurosurgical crisis.

Discussion and conclusion

An extensive redrawing of the Greek health map, reorganization of the national health system, along with adaptation of all recent advances in telemedicine may alleviate the health burden in these populations. The results of this local reformation may be applied to a global level for managing the ongoing health crisis. Moreover, the development of a European taskforce by the European Association of Neurosurgical Societies (EANS) may well facilitate the development of realistic and efficacious global solutions, and contribute to the global effort for providing high-quality neurosurgical services worldwide.

The current state of global contribution to open access publishing in neurosurgery: A bibliometric analysis

•The top three countries made up 56.7% of the total open-access (OA) contributions.•Low and lower-middle-income countries are less than 8% of the total OA publications.•There is a disparity in academic voice in the neurosurgical literature.•Disparities potentially affect neurosurgery practice and knowledge dissemination.

The utility and post-operative evolution of head circumference in nonsyndromic single-suture craniosynostosis: a prospective study in Vietnamese children

PURPOSE

Head circumference (HC) is an important clinical tool for following head growth in children with craniosynostosis (CS). The purpose of this study is to quantify the usefulness of HC along continuum of CS care, from diagnosis to pre- and post-operative (pre-op, post-op) follow-up in Vietnamese children.

METHODS

A prospective cohort of 54 nonsyndromic single-suture CS patients undergoing open surgery from January 2015 to January 2020 was collected at Children's Hospital 2, Vietnam. HC z-score on admission was compared with World Health Organization (WHO) standards to evaluate for utility in initial diagnosis. Pre-op and post-op HC were compared to demonstrate the evolution of head growth following reconstruction.

RESULTS

Nonsyndromic single-suture CS was more predominant in males (79.6%) than in females (20.4%). The mean HC z-score was - 0.38 [Formula: see text] 1.29 similar to normal WHO standards regardless of which sutural involvement. The HC z-score increased above + 1 standard deviation (SD) significantly at 3 months of follow-up (p < 0.001); however, the trajectory gradually decreased after the first year of surgery. One patient (1.8%, 1/54) demonstrated restenosis and delayed intracranial hypertension (DIH) 4 years after reconstruction.

CONCLUSIONS

The HC in nonsyndromic single-suture CS children presents similarly to the values of healthy children. Additionally, HC reliably increased after reconstruction and gradually normalized over subsequent years. This indicator is consistent in Southeast Asian populations and should be used to follow all patients to assess the normal progression of post-op head growth and as a useful indicator of suspected recurrent synostosis.

Bibliometric Analysis of the Neurosurgery Publication Productivity of Southeast Asia in 2011-2020

BACKGROUND

There is a large disparity between the quality of neurosurgical research in developed and developing nations, including the Association of Southeast Asian Nations (ASEAN). Bibliometric analysis is an appropriate method for evaluating the quality of research in a geographic region. We analyzed the neurosurgery reports published by the ASEAN countries to highlight regional productivity in neurosurgery research.

METHODS

We performed a bibliometric analysis of neurosurgery reports from the ASEAN countries between 2011 and 2020. We described the publication number, study type, and field of study of the publication articles. In addition, we assessed the correlations between the neurosurgery research productivity of these countries and the neurosurgeon ratio, medical doctor ratio, per capita gross domestic product, and health expenditure per capita.

RESULTS

We identified 1939 neurosurgeons in the ASEAN region; 570 articles were published by neurosurgeons in the region between 2011 and 2020. Singaporean neurosurgeons were the most productive, with 177 articles, accounting for 31% of the total ASEAN neurosurgeon publications in the study period. However, there has been a rapid recent increase in the number of articles. Case reports and tumors were the dominant type and field of the articles, respectively. There was no significant correlation between the neurosurgical research productivity of the ASEAN countries and the neurosurgeon ratio, medical doctor ratio, per capita gross domestic product, and health expenditure per capita.

CONCLUSIONS

By analyzing the neurosurgery publications from ASEAN countries over the previous decade, we highlight the status of neurosurgical research in these countries.

The Greatest Healthcare Disparity: Addressing Inequities in the Treatment of Childhood Central Nervous System Tumors in Low- and Middle-Income Countries

The antithesis between childhood cancer survival rates in low- and middle-income countries (LMIC) and high-income countries (HIC) represents one of healthcare's most significant disparities. In HICs, the 5-year survival rate for children with cancer, including most brain tumors, exceeds 80%. Unfortunately, children in LMICs experience far worse outcomes with 5-year survival rates as low as 20%. To address inequities in the treatment of childhood cancer and disease burden globally, the World Health Organization (WHO) launched the Global Initiative for Childhood Cancer. Within this initiative, pediatric low-grade glioma (LGG) represents a unique opportunity for the neurosurgical community to directly contribute to a paradigm shift in the survival outcomes of children in LMICs, as many of these tumors can be managed with surgical resection alone. In this chapter, we discuss the burden of pediatric LGG and outline actions the neurosurgical community might consider to improve survival for children with LGG in LMICs.

Expanding access to microneurosurgery in low-resource settings: Feasibility of a low-cost exoscope in transforaminal lumbar interbody fusion

Objectives

Less than a quarter of the world population has access to microneurosurgical care within a range of 2 h. We introduce a simplified exoscopic visualization system for low-resource settings.

Materials and Methods

We purchased a 48 megapixels microscope camera with a c-mount lens and a ring light at a total cost of US$ 125. Sixteen patients with lumbar degenerative disk disease were divided into an exoscope group and a microscope group. In each group, we performed four open and four minimally invasive transforaminal lumbar interbody fusions (TLIF). We conducted a questionnaire-based assessment of the user experience.

Results

The exoscope achieved similar outcomes with comparable blood loss and operating time as the microscope. It provided similar image quality and magnification. Yet, it lacked stereoscopic perception and the adjustability of the camera position was cumbersome. Most users strongly agreed the exoscope would significantly improve surgical teaching. Over 75% reported that they would recommend the exoscope to colleagues and all users saw its great potential for low-resource environments.

Conclusion

Our low-budget exoscope is safe and feasible for TLIF and purchasable at a fraction of the cost of conventional microscopes. It may thus help expand access to neurosurgical care and training worldwide.

International Neurosurgery: The Role for Collaboration

The global death toll from lack of access to basic surgical care is three times as much as for tuberculosis, HIV and malaria combined. Patients dying of curable neurosurgical conditions solely because of inadequacy or absence of neurosurgical infrastructure is an issue deserving immediate attention and action. Global neurosurgery is an important step forward in this regard, under which different models of collaboration between HICs and LMICs aim to increase both the number of neurosurgeons as well the quality of neurosurgical care available in these countries through arranging surgical camps, providing neurosurgical training and education, and restructuring the health system in these countries in order to create an environment conducive to the provision of the highest form of neurosurgical care. Despite the many challenges faced by LMICs in furthering neurosurgery programs such as poor resource allocation, brain drain, turbulent socioeconomic conditions, limited training facilities, and population explosion, data now being reported from LMICs the world over, exemplifies the immense positive impact that collaborations have had over the last few decades in improving neurosurgical capacity and infrastructure. So far, conventional methods of collaboration (i.e. neurosurgical missions to LMICs and training of neurosurgeons in HICs) have been effective in progressively bringing about the desired change in LMICs. However, these methods have been limited by a finite funding, pushing the global neurosurgical community to look for alternatives such as online curricula, task shifting and sharing, and long distance mentor-mentee relationships. In this review, we aim to provide an update on the current state of neurosurgical collaborations and identify the barriers in the way of collaborations and what alternative models of collaboration might be used to overcome them..

Factors Associated with Adverse Outcomes in Cameroonian Patients with Traumatic Brain Injury: A Cross-Sectional Study

BACKGROUND

The burden of traumatic brain injury (TBI) disproportionately affects low- and middle-income countries. In Cameroon, the estimated annual incidence rate is 572 cases per 100,000 people. This study investigated factors associated with adverse outcomes in the management of Cameroonian patients with TBI.

METHODS

This cross-sectional study included all patients with TBI treated between January 1 and December 31, 2018, at 2 Cameroonian referral hospitals. Sociodemographic and clinical data were extracted from patient charts and admission registries and analyzed with SPSS v.26. Independent t tests, odds ratios, and cumulative mortality hazard rates were computed. A P-value <0.05 was considered statistically significant. Also, binomial regression analyses were calculated.

RESULTS

One hundred seventy-one patients aged 38.63 ± 20.46 years old received treatment for TBI. Most patients were male (78.9%), Cameroonian (98.2%), from urban areas (75.4%), and uninsured (88.8%). The average admission length was 11.23 ± 10.71 days, during which 27.5% of patients received surgical treatment while 72.5% received non-surgical (conservative) management. From postdischarge day 12 onwards, surgically-treated patients had a greater cumulative mortality hazard rate than conservatively-treated patients. By 28 days postdischarge, 66.1% of patients had recovered completely [Glasgow Outcome Scale (GOS) = 5], 23.4% had a disability (GOS = 2-4), and 10.5% expired (GOS = 1). Complete recovery was associated with the absence of severe TBI (B = -1.42, standard error [SE] = 0.52, P = 0.006), disability was associated with increased injury-to-admission delay (B = -1.27, SE = 0.48, P = 0.009), and death was associated with severe TBI (B = 3.16, SE = 0.73, P < 0.001).

CONCLUSIONS

We identified factors associated with unfavorable outcomes among Cameroonian patients with TBI. These results can inform triage and referral practices and aid policymakers in developing context-specific prehospital guidelines.

The humanitarian aid of neurosurgical missions in Peru: A chronicle and future perspectives

Background

The unmet neurosurgical need has remained patent in developing countries, including Peru. However, continuous efforts to overcome the lack of affordable care have been achieved, being neurosurgical missions one of the main strategies. We chronicle the humanitarian labor of organizations from high-income countries during their visit to Peru, the contributions to local trainees' education, and the treatment of underserved patients. Furthermore, we discuss the embedded challenges from these missions and the future perspective on long-term partnerships and sustainability.

Methods

This is a narrative review. We searched the literature in PubMed and Google Scholar about neurosurgical missions conducted in Peru.

Results

Since 1962, twelve organizations from high-income countries have delivered humanitarian help in Peru by training local neurosurgeons, treating low-income patients, and providing surgical instrumentation. Out of the three main regions of Peru, cities on the coast and highlands have hosted most of these missions, with no reported outreach in the amazon area. About 75% of the organizations are headquartered in the United States, followed by Canada, Luxembourg, and Spain. In addition, 50% of the organizations have an active partnership. The predominant focus of these missions has been pediatrics, neuro-oncology, and spine surgery.

Conclusion

Neurosurgical missions have represented a strategy to close the disparity in education and treatment in Peru. However, additional efforts must be conducted to improve long-term partnership and sustainability, such as adopting standardized indicators for progress tracking, incorporating remote technologies for continuous training and communication, and expanding partnerships in less attended areas.

Working in low- and middle-income countries: Learning from each other

•Barriers may limit LMICs-HICs collaborations: infrastructure, equipment's lack/inadequacy, political issues, brain drain.•Local training is crucial for universal health coverage; several activities are headed by Global Neurosurgery organisations.•The ​EANS Global and Humanitarian Neurosurgery Committee aims to become a gateway for partnerships between HICs and LMICs.

The Scope, Growth, and Inequities of the Global Neurosurgery Literature: A Bibliometric Analysis

BACKGROUND

Here, we evaluate the evolution and growth of global neurosurgery publications over time, further focusing on the contributions and impact of authors in low- and middle-income countries (LMICs).

METHODS

In this systematic bibliometric analysis, we conducted a two-stage blinded screening process of global neurosurgery publications from 5 databases from inception through July 2021. Articles involving multi-national/multi-institutional research collaborations, detailing any area of global neurosurgery collaboration, or influencing global neurosurgery practice were included. Statistical hypothesis testing was conducted to analyze trends and hypotheses of LMIC authorship contributions.

RESULTS

The number of global neurosurgery publications has soared in the last decade. Overall, authors from HIC countries were most commonly from the US (41.1%), Canada (4.0%), and the UK (3.9%), while authors from LMIC countries were most commonly from Uganda (4.2%), Tanzania (2.6%), Cameroon (1.8%), and India (1.8%). Over a quarter (28%) of publications had no LMIC authors, while only 11% had 3 or more LMIC authors. The proportion of LMIC authors (LMIC-R) was not correlated with the citation rate of individual articles or with the year of publication, and a positive trend emerged when the LMIC-R of top-publishing LMICs was individually examined and compared to the year of publication.

CONCLUSIONS

Despite recent growth, the number of global neurosurgery publications arising from LMICs pales in comparison to those from HICs. Collaborative efforts between certain HICs and LMICs have likely contributed to the observed increase in LMIC author independence over time.

Assessing the Success and Sustainability of Global Neurosurgery Collaborations: Systematic Review and Adaptation of the Framework for Assessment of InteRNational Surgical Success Criteria

BACKGROUND

The high unmet neurosurgical burden in low- and middle-income countries has necessitated multiple global neurosurgical collaborations. We identified these collaborations and their peer-reviewed journal publications and evaluated them using a modified version of the Framework for Assessment of InteRNational Surgical Success (FAIRNeSS).

METHODS

A systematic literature review yielded 265 articles describing neurosurgery-focused collaborations. A subset of 101 papers from 17 collaborations were evaluated with the modified FAIRNeSS criteria. Analysis of trends was performed for both individual articles and collaborations.

RESULTS

Most of the articles were general reviews (64), and most focused on clinical research (115). The leading collaboration focus was workforce and infrastructure development (45%). Composite FAIRNeSS scores ranged from 7/34 to 30/34. Average FAIRNeSS scores for individual articles ranged from 0.25 to 26.75, while collaboration-wide FAIRNeSS score averages ranged from 5.25 to 20.04. There was significant variability within each subset of FAIRNeSS indicators (P value <0.001). Short-term goals had higher scores than medium- and long-term goals (P value <0.001). Collaboration composite scores correlated with the number of papers published (R² = 0.400, P = 0.007) but not with the number of years active (R² = 0.072, P = 0.3). Finally, the overall agreement between reviewers was 53.5%, and the overall correlation was 38.5%.

CONCLUSIONS

Global neurosurgery has no established metrics for evaluating collaborations; therefore, we adapted the FAIRNeSS criteria to do so. The criteria may not be well suited for measuring the success and sustainability of global neurosurgery collaborations, creating a need to develop a more applicable alternate set of metrics.

The Current State of Neurosurgery in Iceland

BACKGROUND

Although surgical conditions account for 32% of the global burden of diseases, approximately 5 billion people worldwide lack access to timely and affordable, surgical and anesthetic services. Disparities in access to surgical care are most evident in low- and middle-income countries, often resulting from a lack of surgical infrastructure. However, the establishment of surgical infrastructure, particularly for specialty surgical services including neurosurgery, is challenging in countries with small populations, irrespective of income classification, due to the distribution of high costs among a lesser number of individuals. One such nation is Iceland. Despite high-income status, high quality of life, literacy, and educational attainment, the population of Iceland has often lacked access to local neurosurgical care, with the establishment of the domestic neurosurgical system in 1971 and continued externalization of complex neurosurgical procedures to neighboring nations and neurosurgeons.

METHODS

A narrative review was conducted.

RESULTS

This article provides the first-ever examination of neurosurgery in Iceland. We discussed the history and the social, political, and economical contexts in Iceland. We examined the history of neurosurgery in Iceland, which provided brief biographic sketches of pioneers who have catalyzed the establishment of neurosurgical care and training in Iceland, and characterize the current state of neurosurgery in Iceland.

CONCLUSIONS

Recommendations derived from the experiences of Icelandic neurosurgeons may guide the international community in future initiatives.

Peripheral nerve surgery in Serbia: "Think global, act local" and the privilege of service

Introduction

The phrase "think globally, act locally", which has often been used to refer to conservation of the environment, highlights the importance of maintaining a holistic perspective and stipulates that each individual has a role to play in their community and larger world. Although peripheral nerve surgery has been largely unemphasized in global neurosurgical efforts, a wide disparity in peripheral nerve surgery is presumed to exist between high-income and low- and middle-income countries. Serbia is an upper middle-income country with a long history of peripheral nerve surgery.

Research question

How can understanding the development of peripheral nerve surgery in Serbia advance global education and improve peripheral nerve surgery worldwide?

Material and methods

An anecdotal and narrative review of recent advances in peripheral nerve surgery in Serbia was conducted. The World Federation of Neurosurgical Society (WFNS) Peripheral Nerve Surgery Committee discussions on improving peripheral nerve surgery education were summarized.

Results

In this manuscript, we describe the application of "think globally, act locally" to peripheral nerve surgery by providing an account of the development of peripheral nerve surgery in Serbia. Then, we report measures taken by the WFNS Peripheral Nerve Surgery Committee to improve education on peripheral nerve surgery in LMICs.

Discussion and conclusion

Viewing the development of peripheral nerve surgery in Serbia through the lens of "think globally, act locally" may guide the development of peripheral nerve surgery in LMICs.

Global neurosurgery over a 60-year period: Conceptual foundations, time reference, emerging Co-ordinates and prospects for collaborative interventions in low and middle income countries

Introduction

We evaluated salient initiatives invested in global neurosurgery over a 60-year period.

Research question

What are the Phases, Achievements, Challenges, and Lessons of Global Neurosurgery.

Methods

A 60-year retrospective study from 1960 to 2020 analyzing the major phases, lessons, and progress notes. We reviewed the foundational need questions and innovated tools used to answer them.

Results

Three phases defining our study period were identified. In the early phase, birthing academic units and the onset of individual volunteerism were dominant concepts. The 2nd phase is summarized by the rise of volunteerism and surgical camps.The third phase is heralded by advocacy and strategies for achieving care equity. The defining moment is the Lancet commission for global surgery summit in 2015. Lessons include the need for evaluation of the resources of recipient and donor locations using novel global surgery tools.

Conclusion

Global neurosurgery over the 60-year study period is summarized by indelible touchstones of personal and group efforts as well as triumphs derived from innovations in the face of formidable challenges.

Future Directions for Global Clinical Neurosurgical Training: Challenges and Opportunities

OBJECTIVE

Expanded access to training opportunities is necessary to address 5 million essential neurosurgical cases not performed annually, nearly all in low- and middle-income countries. To target this critical neurosurgical workforce issue and advance positive collaborations, a summit (Global Neurosurgery 2019: A Practical Symposium) was designed to assemble stakeholders in global neurosurgical clinical education to discuss innovative platforms for clinical neurosurgery fellowships.

METHODS

The Global Neurosurgery Education Summit was held in November 2021, with 30 presentations from directors and trainees in existing global neurosurgical clinical fellowships. Presenters were selected based on chain referral sampling from suggestions made primarily from young neurosurgeons in low- and middle-income countries. Presentations focused on the perspectives of hosts, local champions, and trainees on clinical global neurosurgery fellowships and virtual learning resources. This conference sought to identify factors for success in overcoming barriers to improving access, equity, throughput, and quality of clinical global neurosurgery fellowships. A preconference survey was disseminated to attendees.

RESULTS

Presentations included in-country training courses, twinning programs, provision of surgical laboratories and resources, existing virtual educational resources, and virtual teaching technologies, with reference to their applicability to hybrid training fellowships. Virtual learning resources developed during the coronavirus disease 2019 pandemic and high-fidelity surgical simulators were presented, some for the first time to this audience.

CONCLUSIONS

The summit provided a forum for discussion of challenges and opportunities for developing a collaborative consortium capable of designing a pilot program for efficient, sustainable, accessible, and affordable clinical neurosurgery fellowship models for the future.

Language and Geographic Representation of Neurosurgical Journals: A Meta-Science Study

OBJECTIVE

Medical journals have a role in promoting representation of neurosurgeons who speak primary languages other than English. We sought to characterize the language of publication and geographic origin of neurosurgical journals, delineate associations between impact factor (IF) and language and geographic variables, and describe steps to overcome language barriers to publishing.

METHODS

Web of Science, Scopus, and Ulrich's Serial Analysis system were searched for neurosurgery journals. The journals were screened for relevance. Language of publication, country and World Health Organization region, World Bank income status and gross domestic product, and citation metrics were extracted.

RESULTS

Of 867 journals, 74 neurosurgical journals were included. Common publication languages were English (52, 70.3%), Mandarin (5, 6.8%), and Spanish (4, 5.4%). Countries of publication for the greatest number of journals were the United States (23, 31.1%), United Kingdom (8, 10.8%), and China (6, 8.1%). Most journals originated from the Americas region (29, 39.2%), the European region (28, 37.8%), and from high-income countries (n = 54, 73.0%). Median IF was 1.55 (interquartile range [IQR] 0.89-2.40). Journals written in English (1.77 [IQR 1.00-2.87], P = 0.032) and from high-income countries (1.81 [IQR 1.0-2.70], P = 0.046) had highest median IF. When excluding outliers, there was a small but positive correlation between per capita gross domestic product and IF (β = 0.021, P = 0.03, R² = 0.097).

CONCLUSIONS

Language concordance represents a substantial barrier to research equity in neurosurgery, limiting dissemination of ideas of merit that currently have inadequate outlets for readership. Initiatives aimed at increasing the accessibility of neurosurgical publishing to underrepresented authors are essential.

Increasing Equity in Medical Student Neurosurgery Education Through Distance Learning

OBJECTIVE

Addressing equitable opportunities for medical student (MS) education is important for minimizing disparities in neurosurgical care. However, international MSs, particularly from low- and middle-middle income countries (LMICs) may lack access to educational opportunities compared with their contemporaries in high-income countries. We compare the usefulness of virtual neurosurgery training camps (VNTC) between U.S. and international MSs.

METHODS

A survey assessing demographics, baseline interests, and ratings of usefulness was sent to attendees after the VNTC. Ratings were compared between international and U.S. MSs.

RESULTS

Thirty-three (27.7%) of 119 attendees were international MSs, of whom 24 (72.7%) were from LMICs. International MSs were more likely to hold an advanced degree (P = 0.0009), more likely to be MS3/MS4s (P = 0.0111) or postdoctoral (P < 0.0001), and less likely to be MS1/MS2s (P = 0.0059). After the VNTC, international MSs reported greater increase in interest in neurosurgery in general (P = 0.0009) and subspecialties of spine (P = 0.0002), peripheral nerve (P = 0.002), vascular (P = 0.0468), functional/epilepsy (P = 0.001), pediatric (P = 0.0285), and trauma/neurocritical care (P = 0.0067). International MSs reported greater post-VNTC willingness to pursue a career in neurosurgery (P = 0.0001), likelihood of taking a year off during medical school (P = 0.0363), and preparedness for subinternships (P = 0.0003). International MSs reported greater increases in awareness of burnout (P = 0.0157) and work-life balance in neurosurgery (P = 0.0249).

CONCLUSIONS

International MSs experience prolonged periods of education before applying to residency and have unmet informational needs. Distance learning is useful for international MSs. MS neurosurgery education, through online platforms, represents a long-term strategy for addressing disparities in neurosurgical care worldwide.

The Application of Guideline-Based Care for Traumatic Brain and Spinal Cord Injury in Low- and Middle-Income Countries: A Provider-Based Survey

Objective

Neurosurgical guidelines have resulted in improved clinical outcomes and more optimized care for many complex neurosurgical pathologies. As momentum in global neurosurgical efforts has grown, there is little understanding about the application of these guidelines in low- and middle-income countries.

Methods

A 29-question survey was developed to assess the application of specific recommendations from neurosurgical brain and spinal cord injury guidelines. Surveys were distributed to an international cohort of neurosurgeons and neurotrauma stakeholders.

Results

A total of 82 of 222 (36.9%) neurotrauma providers responded to the survey. The majority of respondents practiced in low- and middle-income countries settings (49/82, 59.8%). There was a significantly greater mean traumatic brain injury volume in low-income countries (56% ± 13.5) and middle-income countries (46.5% ± 21.3) compared with high-income countries (27.9% ± 13.2), P < 0.001. Decompressive hemicraniectomy was estimated to occur in 61.5% (±30.8) of cases of medically refractory intracranial pressure with the lowest occurrence in the African region (44% ± 37.5). The use of prehospital cervical immobilization varied significantly by income status, with 36% (±35.6) of cases in low-income countries, 52.4% (±35.5) of cases in middle-income countries, and 95.2% (±10) in high-income countries, P < 0.001. Mean arterial pressure elevation greater than 85 mm Hg to improve spinal cord perfusion was estimated to occur in 71.7% of cases overall with lowest occurrence in Eastern Mediterranean region (55.6% ± 24).

Conclusions

While some disparities in guideline implementation are inevitably related to the availability of clinical resources, other differences could be more quickly improved with accessibility of current evidence-based guidelines and development of local data.

The unmet global burden of cranial epidural hematomas: A systematic review and meta-analysis

OBJECTIVE

Approximately 69 million people suffer from traumatic brain injury (TBI) annually. Patients with isolated epidural hematomas (EDH) with access to timely surgical intervention often sustain favorable outcomes. Efforts to ensure safe, timely, and affordable access to EDH treatment may offer tremendous benefits.

METHODS

A comprehensive literature search was conducted. A random-effects model was used to pool the outcomes. Studies were further categorized into groups by World Bank Income classification: high-income countries (HICs) and low- and middle-income countries (LMICs).

RESULTS

Forty-nine studies were included, including 36 from HICs, 12 from LMICs, and 1 from HIC / LMIC. Incidence of EDH amongst TBI patients 8.2 % (95 % CI: 5.9,11.2), including 9.2 % (95 %CI 6.4,13.2) in HICs and 5.8 % (95 % CI: 3.1,10.7) in LMICs (p = 0.20). The overall percent male was 73.7 % and 47.4 % were caused by road traffic accidents. Operative rate was 76.0 % (95 %CI: 67.9,82.6), with a numerically lower rate of 74.2 % (95 %CI: 64.0,81.8) in HICs than in LMICs 82.9 % (95 %CI: 65.4,92.5) (p = 0.33). This decreased to 55.5 % after adjustment for small study effect. The non-operative mortality (5.3 %, 95 %CI: 2.2,12.3) was lower than the operative mortality (8.3 %, 95 %CI: 4.6,14.6), with slightly higher rates in HICs than LMICs. This relationship remained after adjustment for small study effect, with 9.3 % operative mortality compared to 6.9 % non-operative mortality.

CONCLUSION

With an overall EDH incidence of 8.2 % and an operative rate of 55.5 %, 3.1 million people worldwide require surgery for traumatic EDH every year, most of whom are in prime working age. Given the favorable prognosis with treatment, traumatic EDH is a strong investment for neurosurgical capacity building.