Global Neurosurgery Research Articles

Global Neurosurgery Research Committee: Mini Strategic Plan

Most of the world’s population resides in developing countries. Lower- and middle-income countries (LMICs)shoulder a high burden of both communicable and non-communicable diseases1. Neurological disorders are theleading cause of disability and account for the second-highest number of global deaths2. In addition, over fivemillion patients with conditions treatable by neurosurgery do not have access to it; the populations most at riskare in Africa and Southeast Asia due to the workforce imbalance 3,4. This may be one factor that has resulted inminimal neurosurgical research output from LMICs, despite the heterogeneous pathologies and large patientnumbers seen daily by neurosurgeons. Only 4.5% of papers published in high-impact neurosurgical journalshave an LMIC affiliation5. The underrepresentation of scientific literature from LMIC is a significant obstaclethat negatively impacts global neurosurgery. As equity in the provision of neurosurgical care is at the centre ofour discipline, it is essential that neurosurgical research capacity is developed globally. This stems from aposition that the provision of high-quality care relies on the conduct of high-quality research.

Interface of Global Neurosurgery and Technological Innovation:

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The Role of Medical Students in Global Neurosurgery Committee 1.0

In 2019, the World Federation of Neurosurgical Societies (WFNS) established an ad hoc Global Neurosurgery Committee (GNC) to coordinate its global efforts to promote equitable neurosurgical care. Medical students have been essential to the GNC since its first generation (“GNC 1.0”). We describe the integration of medical students in GNC 1.0 and provide suggestions on the incorporation of medical students into the second-generation GNC (“GNC 2.0”).

Global Neurosurgery Committee 1.0: A Model for Virtual Collaboration in Global Surgery

The World Federation of Neurosurgical Societies (WFNS), the governing body for national and regional neurosurgical societies worldwide, established the ad hoc Global Neurosurgery Committee (GNC) in 2019. This international board of neurosurgeons collaborated virtually in pursuit of defined goals and targets related to neurosurgical equity. We summarize the work of the WFNS GNC, highlight the role of virtual collaboration in global surgery, and delineate best practices for virtual collaboration in global surgery.

Early Stages of Global Neurosurgery

The year 2015 was pivotal for the growth of global neurosurgery. In January, the United Nations (UN) adopted the Sustainable Development Goals (SDGs), replacing the expiring Millennial Development Goals. The SDGs were more comprehensive, having 17 Goals with 169 associated targets; a significant number of these included the necessity for surgical care to achieve the targets. 1
 In early Spring 2015, publication of Global Surgery 2030: evidence and solutions for achieving health, welfare, and economic development - The Lancet Commission on Global Surgery created a paradigm shift in the understanding of surgical needs worldwide, particularly in access to safe, timely and affordable surgical care for billions of individuals and large gaps in global surgical health workforce.2 At around the same time, Disease Control Priorities 3rd Edition, Volume 1, Essential Surgery laid out the economic case for surgical care, particularly in low resource settings.3 In May, the 68th World Health Assembly unanimously approved WHA resolution 68.15 on strengthening emergency and essential surgical care as a component of universal health coverage.4 
 The adoption of SDGs and WHA 68.15 provided the political impetus toward making surgical care a global priority, DCP3 created the health economic basis for global surgical care, and the Lancet Commission developed the factual needs basis for greatly enlarging global surgical service delivery.
 The World Health Organization (WHO) is the health technical arm of the UN. The WHA is composed of the health ministers of all UN Member States (countries) and is the governing body of WHO, setting the global health agenda and steering WHO’s work. The WHO Emergency and Essential Surgical Care (EESC) Programme5 was given the mandate to implement WHA resolution 68.15; a task that could only be achieved through extensive worldwide partnerships, such as the World Federation of Neurosurgical Societies (WFNS), which has official working relations as a non-state actor with WHO.6
 September 9-12, 2015, the 15th Interim Meeting of the World Federation of Neurosurgical Societies (WFNS) met in Rome, Italy.7 For the first time, a neurosurgeon was Lead of WHO EESC, creating a unique opportunity for optimally augmenting this WHO/WFNS partnership going forward. The Foundation for International Education in Neurosurgery (FIENS) held a session during this meeting, further highlighting future prospects.

401 Global Neurosurgery Advances from Trenches to Bedside: Lessons from Neurosurgical Care in War, Humanitarian Assistance, and Disaster Response

INTRODUCTION: War has influenced the development of neurosurgery. Armed conflict and mass casualty events, including Humanitarian Assistance Disaster Relief (HADR) missions, require military surgeons to innovate to meet extreme demands. Neurosurgeons serving in the military have provided a pragmatic template for global neurosurgeons to emulate in humanitarian disaster responses METHODS: We performed a narrative review of the literature examining the influence of wars and mass casualty disasters on contemporary global neurosurgery practices. RESULTS: Wartime innovations that influenced global neurosurgery include the development of triage systems and modernization with airlifts, implementation of ambulance corps, early operation on cranial injuries in hospital camps near the battlefield, use of combat body armor, and the rise of damage control neurosurgery. Workforce shortages during wars and disasters have promoted task-shifting and task-sharing in low-resource settings that catalyzed the establishment of the physician associate profession in the United States (US). Neurosurgical care has been utilized by the US as a form of "soft power" during natural and humanitarian disasters. Low-and middle-income countries (LMICs) face similar challenges in developing trauma systems and obtaining advanced technology, including neurosurgical equipment like battery-powered computed tomography scanners. These challenges— ubiquitous in low-resource settings— have underpinned innovations in triage and wound care, rapid evacuation to tertiary care centers, and minimizing infection risk. CONCLUSIONS: War and mass casualty disasters have catalyzed significant advancements in neurosurgical care both in the pre-hospital and inpatient settings. Most of these innovations originated in the military with subsequent spread to the civilian sector as military neurosurgeons and civilian neurosurgeons, who are military reservists, returned from the battlefront or other low-resource locations. LMICs have, by necessity, responded to challenges arising from resource shortages by developing innovative, context-specific care paradigms and technologies.

COVID-19 impact on the global neurosurgery resident training course and admission: A scoping review.

This study looks at how COVID-19 affected the admission and training of neurosurgical residents worldwide. From 2019 to 2021, we reviewed multiple databases (i.e., Google Scholar, Science Direct, PubMed, and Hinari) to evaluate the impact of the COVID-19 pandemic on neurosurgery resident training and admission in low middle-income countries (LMICs) and high-income countries (HICs). We then utilized a Wilcoxon signed-rank test to evaluate the difference between the two LMIC/HICs and employed Levene's test to assess the homogeneity of variances. There were 58 studies that met our inclusion criteria; 48 (72.4%) were conducted in HIC and 16 (27.6%) in LMIC. The admission of new residents was mostly canceled in HIC (31.7%; n = 13) and in LMIC (25%; n = 4) from 2019 to 2021 due to COVID-19. Learning modalities changed to include predominantly video conferencing (i.e., 94.7% [n = 54] of cases). Further, neurosurgery was largely restricted to emergency cases alone (79.6% [n = 39]), with only 12.2% (n = 6) elective cases. The result was a marked reduction in resident surgical training (i.e., 66.7% [n = 10] in LMIC and 62.9% [n = 22] in HIC), despite increased workloads in (i.e., LMIC [37.4%; n = 6] and HIC [35.7%; n = 15]). This was attributed to the marked reduction in the number of surgical patients allotted to each resident (i.e., LMIC [87.5%; n = 14] than HIC [83.3%; n = 35]). The COVID-19 pandemic markedly disrupted neurosurgical education globally. Although differences have been found between LMICs and HICs training, the reduction of neurosurgical case-loads and surgical procedures has significantly impacted neurosurgical training. The question remains, how can this "loss of experience" be redressed in the future?

Global neurosurgery: the need of the hour for developing countries

Global neurosurgery is relatively a new sub-discipline of global surgery. It is an area of study, research, practice, and advocacy that focuses on enhancing health outcomes and promoting health equity for all individuals around the world who are afflicted by neurosurgical disorders or require neurosurgical care. Low- and middle-income countries (LMICs) around the world have not benefited from advances in neurosurgery; most have little or no neurosurgical capacity in their entire country. The need of the hour is that a global problem necessitates a global response with a common vision and objectives.

Historical determinants of neurosurgical inequities in Africa and the African diaspora: A review and analysis of coloniality.

The movement to decolonize global health challenges clinicians and researchers of sub-disciplines, like global neurosurgery, to redefine their field. As an era of racial reckoning recentres the colonial roots of modern health disparities, reviewing the historical determinants of these disparities can constructively inform decolonization. This article presents a review and analysis of the historical determinants of neurosurgical inequities as understood by a group of scholars who share Sub-Saharan African descent. Vignettes profiling the colonial histories of Cape Verde, Rwanda, Cameroon, Ghana, Brazil, and Haiti illustrate the role of the colonial legacy in the currently unmet need for neurosurgical care in each of these nations. Following this review, a bibliographic lexical analysis of relevant terms then introduces a discussion of converging historical themes, and practical suggestions for transforming global neurosurgery through the decolonial humanism promulgated by anti-racist practices and the dialogic frameworks of conscientization.

Current Neurosurgical Care in Ethiopia Using the Lens of the Lancet Global Health Commission on High-Quality Health Systems.

Neurosurgery is a rapidly developing specialty in Ethiopia. Previous global neurosurgery studies have highlighted the need for synchronizing workforce increase with improving quality, access, and capacity to provide neurosurgical care. To evaluate Ethiopia's neurosurgical system and highlight the critical interventions required for the sustained development of Ethiopian neurosurgery as part of a high-quality health system (HQHS). A comprehensive survey was sent to all practicing neurosurgeons. Public databases on Ethiopian census reports and current road infrastructure were used for spatial analysis of neurosurgical access. The survey response rate was 90% (45/50). Most respondents were men (95.6%), aged 30 to 40 years (82%), who worked at national referral hospitals (71%). The reported annual caseload per practicing neurosurgeon was >150 cases for 40% of urban and 20% of rural neurosurgeons. Head and spine neurotrauma and tumors were the most common neurosurgical indications. Computed tomography scanner was the most widely available diagnostic equipment (62%). 76% of respondents indicated the presence of postoperative rehabilitation care at their institutions. Thirteen percent and 27% of the nation lived within a 2-hour and 4-hour driving distance from a neurosurgical center, respectively. The results highlight the need for vital improvements in neurosurgical capacity to sustain progress toward HQHS. Promoting sustained development in all components of HQHS can be achieved by diversifying the workforce and training residency candidates committed to practicing in underserved regions. Additional strategies might include establishing a national registry for neurosurgical data and implementing policy changes conducive to improving perihospital care and other health system components.

Equity in neurosurgery: a worldwide survey of women neurosurgeons.

The global neurosurgery workforce does not have a defined stance on gender equity. The authors sought to study and characterize the demographic features of the international women neurosurgery community and to better understand the perceptions and reflections of their neurosurgical careers. The objective was to define and characterize the workplace inequities faced by the global women neurosurgeon community. A 58-item cross-sectional survey was distributed to the global women neurosurgery community. The survey was distributed via an online and mobile platform between October 2018 and December 2020. Responses were anonymized. The authors utilized chi-square analysis to differentiate variables (e.g., career satisfaction) between various groups (e.g., those based on academic position). The authors calculated 95% CIs to establish significance. Among 237 respondents, approximately 40% were between the ages of 26 and 35 years. Within their respective departments, 45% identified themselves as the only woman neurosurgeon in their practice. Forty-three percent stated that their department supported women neurosurgeons for leadership roles. Seventy-five percent of respondents were members of organized neurosurgery professional societies; of these, 38% had been involved in leadership roles. Almost 60% of respondents postponed their decision to get pregnant because of resident or work-related influences. This survey provides international feedback for characterizing and understanding the experiences of women neurosurgeons worldwide. Future research should aim to understand all neurosurgeons' experiences throughout the pipeline and career life cycle of neurosurgery in order to improve the field of neurosurgery.

Letter to the Editor Regarding “The Scope, Growth, and Inequities of the Global Neurosurgery Literature: A Bibliometric Analysis.”

Letter to the Editor Regarding “The Scope, Growth, and Inequities of the Global Neurosurgery Literature: A Bibliometric Analysis.”

There are always two sides to every story: the LMICs perspective on Global Neurosurgery

There are always two sides to every story: the LMICs perspective on Global Neurosurgery

The NED foundation experience: A model of global neurosurgery

IntroductionThe 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 questionTo 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 methodA 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. Results138 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 ConclusionIn 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.

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..

Greek reflections on global neurosurgery

IntroductionLarge 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 questionTo evaluate if special social groups face similar problems in Greece. Material and methodsThe 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. ResultsA 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 conclusionAn 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.

Social Media for Global Neurosurgery. Benefits and limitations of a groundbreaking approach to communication and education

IntroductionSocial 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 questionTo 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 methodsWe 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. ResultsBy 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 conclusionThe 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.

Technological Advancements for Teaching Global Neurosurgery in Low- and Middle-Income Countries

Technological Advancements for Teaching Global Neurosurgery in Low- and Middle-Income Countries

Educating the Next Generation of Global Neurosurgeons: Education for Medical Students Interested in Global Pediatric Neurosurgery

Objective: Education is a critical component of global pediatric neurosurgery with increasing attention being placed on the role of medical students in global neurosurgery. We provide a background of education for medical students interested in global pediatric neurosurgery, present existing pediatric neurosurgery resources with a focus on virtual modalities, and describe the need to create accessible resources for medical students.
 
 Methods: A narrative and anecdotal review was performed.
 
 Results: Education of medical students regarding pediatric neurosurgery is particularly important due to multidisciplinary collaboration and advocacy. Benefits of virtual education include accessibility across the world, convenience, easily updatable nature, incorporation of multimedia, minimal cost, and personalization. Existing online resources include courses focused on medical webinars, general courses, on-demand content, journals, online simulation, and social media. Few resources focused exclusively on medical students exist in pediatric neurosurgery, and none address the intersection of pediatric neurosurgery and global neurosurgery. Additional educational resources that incorporate neurosurgical knowledge with special applicability to the medical student population will capture the interest of medical students, while those incorporating global health elements will develop a commitment to global neurosurgery.
 
 Conclusion: Education of medical students is important for the sustainability of global pediatric neurosurgery. The development of educational resources for medical students interested in global pediatric neurosurgery should be encouraged.

The Role of Medical Students in Global Pediatric Neurosurgery

Objective: Medical students are important for the long-term efficacy of global pediatric neurosurgery initiatives. In this manuscript, we describe the rationale for mobilizing medical students in global pediatric neurosurgery, delineate the potential impact of this mobilization, and detail how to increase exposure of medical students to global pediatric neurosurgery.
 
 Methods: A narrative review was conducted and supplemented with an anecdotal review.
 
 Results: Medical students are a critical asset for global pediatric neurosurgery due to their motivation and diligence, time management and organizational skills, technological proficiency, innovative perspective, and resourcefulness. Fostering the next generation of global pediatric neurosurgeons is important to facilitate long-term engagement in pediatric neurosurgery, ensure the sustainability of global pediatric neurosurgery, develop capacities to collaborate with diverse partners, teach knowledge and skills for engaging in advocacy and capacity-building, and facilitate determination of effective strategies for making progress in global pediatric neurosurgery. Opportunities for medical student involvement include reading key manuscripts; finding mentors; becoming involved in university-based global neurosurgery groups, auxiliary organizations, World Federation of Neurosurgical Societies Global Neurosurgery Committee, InciSion, or general neurosurgery medical student and trainee interest groups.
 
 Conclusion: Medical students represent a valuable asset for addressing the global burden of pediatric neurosurgical disease, ameliorating workforce and equipment deficits, and facilitating access to timely and affordable pediatric neurosurgical care. Involving medical students through existing opportunities and developing additional pathways specific to medical students will strengthen the impact and reach of global pediatric neurosurgical initiatives.