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

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.

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.

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.

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.

Surgical management of traumatic spinal injuries in Sylvanus Olympio Teaching Hospital

Introduction : Traumatic spinal injuries (TSI) is a global disease burden in low – and middle–income countries (LMIC). The burden of TSI is higher in LMICs than in developed countries. Despite improvements in TSI management, resource-constrained settings have not benefitted from this progress to the same extent as more developed countries.

Hypothese : Spinal implants availability and early surgery are associated with improved neurologic function.

Material and methods: This is a retrospective and descriptive study from November 2017 to October 2020. We included adult patients who presented with traumatic spine injury and who underwent surgery stabilization.

Results: A total of 93 patients were studied. The population was young (35.92 ± 9.68 years old), men (91.4%). Road traffic accidents accounted for 85% of patients. At presentation, 59.1% of patients had an incomplete neurologic deficit (ASIA B-D). The cervical spine was the most common segment injured (57%). The median time from admission to the operating room was 21.06 ± 11.8 days. After surgery, 15.3% improved by at least 1 ASIA grade. Bedsores (14%) and superficial wound infection (10.8%) were the most typical complications in our series after surgery.

Discussion : According to the AANS/CNS guideline, available literature has defined « early » surgery inconsistently, ranging from < 8 hours to < 72 hours. In our series, the median time from admission to the operating room was 21.06 ± 11.8 days (range 2-62). That finding could be explained by the fact that most low-income people have to pay out of their pocket because the rate of medical insurance coverage is low. In the study, only 17.2% of patients have public insurance, and 2.2% private insurance. We performed three types of surgery: anterior cervical discectomy and fusion, anterior cervical corporectomy with tricortical iliac crest graft and plate, and posterolateral thoracic/lumbar fusion. Implant availability for posterior cervical fusion was the principal driver of that decision in our limited resources. Type of study and level of proff: level 3, retrospective cohort study.

Establishing collaborations in global neurosurgery: The role of InterSurgeon

The global deficiency in surgical care has been highlighted in the past several years, through the publication of the Lancet Commission on Global Surgery in 2015, the passage of WHA Resolution 68.15, and concerted efforts by advocacy organizations such as the G4 Alliance. Approximately 23,300 additional neurosurgeons are estimated to be needed to address the greater than 5 million essential neurosurgical cases that are not performed annually, most in low- and middle-income countries (LMICs).

However, increasing recognition of the ease and feasibility of virtual technology prompted a shift towards virtual modes of communication. InterSurgeon (, an independent, internet-based social network platform, has allowed for formal connection between global surgery advocates who may have complementary needs and resources. This manuscript aims to: 1) characterize the current progress of InterSurgeon, 2) describe lessons learned from the creation and use of InterSurgeon, and 3) discuss future directions for InterSurgeon.

Equitable, well-designed collaborations are central to progress in global neurosurgery. InterSurgeon has catalyzed collaborations within global neurosurgery across world regions and country income status. In addition to its role in facilitating traditional in person collaborations, InterSurgeon will become an increasingly important tool for connecting surgeons worldwide as virtual collaboration and augmented reality training paradigms become important components of global surgery capacity building.

Cervical Spine Trauma in East Africa: Presentation, Treatment, and Mortality

Background Cervical spine trauma (CST) leads to devastating neurologic injuries. In a cohort of CST patients from a major East Africa referral center, we sought to (a) describe presentation and operative treatment patterns, (b) report predictors of neurologic improvement, and (c) assess predictors of mortality.

Methods A retrospective, cohort study of CST patients presenting to a tertiary hospital in Dar Es Salaam, Tanzania, was performed. Demographic, injury, and operative data were collected. Neurologic exam on admission/discharge and in-hospital mortality were recorded. Univariate/multivariate logistic regression assessed predictors of operative treatment, neurologic improvement, and mortality.

Results Of 101 patients with CST, 25 (24.8%) were treated operatively on a median postadmission day 16.0 (7.0–25.0). Twenty-six patients (25.7%) died, with 3 (12.0%) in the operative cohort and 23 (30.3%) in the nonoperative cohort. The most common fracture pattern was bilateral facet dislocation (26.7%). Posterior cervical laminectomy and fusion and anterior cervical corpectomy were the 2 most common procedures. Undergoing surgery was associated with an injury at the C4–C7 region versus occiput–C3 region (odds ratio [OR] 6.36, 95% confidence interval [CI] 1.71–32.28, P = .011) and an incomplete injury (OR 3.64; 95% CI 1.19–12.25; P = .029). Twelve patients (15.8%) improved neurologically, out of the 76 total patients with a recorded discharge exam. Having a complete injury was associated with increased odds of mortality (OR 11.75, 95% CI 3.29–54.72, P < .001), and longer time from injury to admission was associated with decreased odds of mortality (OR 0.66, 95% CI 0.48–0.85, P = .006). Conclusions Those most likely to undergo surgery had C4–C7 injuries and incomplete spinal cord injuries. The odds of mortality increased with complete spinal cord injuries and shorter time from injury to admission, probably due to more severely injured patients dying early within 24–48 hours of injury. Thus, patients living long enough to present to the hospital may represent a self-selecting population of more stable patients. These results underscore the severity and uniqueness of CST in a less-resourced setting.

Letter: Global Neurosurgery Scope and Practice

To the Editor:

Russell Andrews, the global neurosurgery section editor at the World Neurosurgery journal, argues that it is difficult to define global neurosurgery because of the breadth of articles labeling themselves as global neurosurgery.1 There are numerous definitions of global neurosurgery, but we will discuss 2 commonly used definitions. First, the World Federation of Neurosurgical Societies’ Global Neurosurgery Committee (WFNS GNC) defines global neurosurgery as, “The clinical and public health practice of neurosurgery with the primary purpose of ensuring timely, safe, and affordable neurosurgical care to all who need it.”2 Next, we can define global neurosurgery based on the definition of global surgery by Bath et al,3 that is, “the enterprise of providing improved and equitable [neuro]surgical care to the world’s population, with its core tenets as the issues of need, access, and quality.”3 The 2 definitions have more in common than they differ from one another, and the differences alone cannot explain the confusion around what is and is not global neurosurgery.

Multiple factors are responsible for the confusion around the definition and scope of global neurosurgery. A chasm separates the academic global neurosurgery community from neurosurgeons and neurosurgical organizations working toward increasing accessibility in low-resource settings.1,4 Academic neurosurgery is responsible for the 2 definitions mentioned above (de facto definitions), whereas many within the neurosurgical community are familiar with a de jure definition. Historically, global neurosurgery has been viewed as high-income country (HIC) neurosurgeons and neurosurgical organizations delivering care or investing in low- and middle-income countries (LMICs).1 This narrative is responsible for the misconception that global neurosurgery is humanitarian or international neurosurgery. While all humanitarian and international neurosurgery falls in the realm of global neurosurgery, all global neurosurgery is not international or humanitarian. This de jure definition puts LMICs on the receiving end of partnerships and fails to acknowledge that global neurosurgery initiatives equally benefit HIC institutions and neurosurgeons. For example, neurosurgery has benefited greatly from reverse innovation, including the development of endoscopic third ventriculostomy with choroid plexus cauterization in Uganda.5

Moreover, the de jure definition assumes that lack of access to safe, timely, and affordable neurosurgical care is only true in LMICs. We know from recent studies that this is not true—for example, Rahman et al6 reported significant disparities in the geographic distribution of US neurosurgeons. Also, in a review of out-of-pocket expenditures for cranial surgery at a US center, Yoon et al7 reported an increase in the proportion of patients facing financial risk.

To clarify the misconception, we must return to the WFNS GNC’s definition. This definition does not differentiate between HICs and LMICs, and it does not focus on times of humanitarian crisis. As a result, we can say that global neurosurgery is not defined by the country’s income category but rather by the existence of barriers to seeking, reaching, and receiving safe, timely, and affordable neurosurgical care. To reach this goal, global neurosurgery borrows from health systems research to devise holistic solutions that will increase access to care.2–4

Early global neurosurgeons learned that staff education and purchase of equipment and consumables without buy-in from local leadership or investments in information management were unsustainable and inefficient.3,4 As a result, global neurosurgeons have adopted a systems-engineering mindset to identify problems and map out solutions.4 They analyze interactions between the health system’s components (workforce, service delivery, infrastructure, information management, funding, and governance). They design interventions in collaboration with stakeholders because they understand that health systems are complex and have many essential parts.8 No part can independently provide the output of the whole, and the health system’s performance is not always improved if its parts are improved independently.8 Similarly, a sports team will not be improved simply because the best players at each position have been recruited. Team managers must factor in the relationships between players, players’ strengths and weaknesses, and team culture during recruitment.

Public Awareness Knowledge of Availability And Willingness to Use Neurosurgical Care Services in Africa: A CrossSectional ESurvey Protocol

Background: Barriers to care cause delays in seeking, reaching, and getting care. These delays affect low-and middle-income countries (LMICs), where 9 out of 10 LMIC inhabitants have no access to basic surgical care. Knowledge of healthcare utilization behavior within underserved communities is useful when developing and implementing health policies. Little is known about the neurosurgical health-seeking behavior of African adults. This study evaluates public awareness, knowledge of availability, and readiness for neurosurgical care services amongst African adults.

Methodology: The cross-sectional study will be run using a self-administered e-survey hosted on Google Forms (Google, CA, USA) disseminated from 10th May 2021 to 10th June 2021. The Questionnaire would be in two languages, English and French. The survey will contain closed-ended, open-ended, and Likert Scale questions. The structured questionnaire will have four sections with 42 questions; Sociodemographic characteristics, Definition of neurosurgery care, Knowledge of neurosurgical diseases, practice and availability, and Common beliefs about neurosurgical care. All consenting adult Africans will be eligible. A minimum sample size of 424 will be used. Data will be analyzed using SPSS version 26 (IBM, WA, USA). Odds ratios and their 95% confidence intervals, Chi-Square test, and ANOVA will be used to test for associations between independent and dependent variables. A P-value <0.05 will be considered statistically significant. Also, a multinomial regression model will be used.

Dissemination: The study findings will be published in an academic peer-reviewed journal, and the abstract will be presented at an international conference.


The burden of neurosurgical diseases is enormous in low- and middle-income countries, especially in Africa.
Unfortunately, most neurosurgical needs in Africa are unmet because of delays in seeking, reaching, and getting care.
Most efforts aimed at reducing barriers to care have focused on improving the neurosurgical workforce density and infrastructure. Little or no efforts have been directed towards understanding or reducing the barriers to seeking care.
We aimed to understand public awareness, willingness to use, and knowledge of the availability of neurosurgical care in Africa.
The study findings can inform effective strategies that promote the utilization of neurosurgical services and patient education in Africa.

Global Landscape of Glioblastoma Multiforme Management in the Stupp Protocol Era: Systematic Review Protocol

Background: Glioblastoma multiforme is the most common and aggressive primary adult brain neoplasm. The current standard of care is maximal safe surgical resection, radiotherapy with concomitant temozolomide, followed by adjuvant temozolomide according to the Stupp protocol. Although the protocol is well adopted in high-income countries (HICs), little is known about its adoption in low- and middle-income countries (LMICs). The aim of this study is to describe a protocol design for a systematic review of published studies outlining the differences in GBM management between HICs and LMICs.

Methods: A systematic review will be conducted. MedLine via Ovid, Embase and Global Index Medicus will be searched from inception to date in order to identify the relevant studies. Adult patients (>18 years) with histologically confirmed primary unifocal GBM will be included. Surgical and chemoradiation management of GBM tumours will be considered. Commentaries, original research, non-peer reviewed pieces, opinion pieces, editorials and case reports will be included.

Results: Primary outcomes will include rates of complications, disability-adjusted life years (DALYs), prognosis, progression-free survival (PFS), overall survival (OS) as well as rate of care abandonment and delay. Secondary outcomes will include the presence of neuro-oncology subspecialty training programs.

Discussion: This systematic review will be the first to compare the current landscape of GBM management in HICs and LMICs, highlighting pertinent themes that may be used to optimise treatment in both financial brackets.

Systematic Review Registration: The protocol has been registered on the International Prospective Register of Systematic Reviews (PROSPERO; registration number: CRD42020215843).

Global Neurosurgery and the Congress of Neurological Surgeons: Collaboration, Innovation, and Opportunity to Improve Care, Education, and Access.

Global neurosurgery encompasses the neurosurgical care and public health efforts to ensure timely and safe neurosurgical care access for all who need it (1). Over the past several decades, global neurosurgery has been championed by many individuals, which has led to a broader interest in developing larger collaborative, sustainable neurosurgical care efforts. On a national level, neurosurgical educational opportunities have grown through courses, online education, and fellowships. Given the growing global burden of neurosurgical disease, there is a significant opportunity and need for worldwide neurosurgery and neurosurgical education worldwide, especially in low- and middle-income countries (LMICs).
To advance global neurosurgery from an educational standpoint, the Congress of Neurological Surgeons (CNS), American Association of Neurological Surgeons (AANS), World Federation of Neurological Surgeons (WFNS), and other international neurosurgical societies have successfully developed programming. The CNS has led with a robust educational platform and offerings for neurosurgeons through in-person courses, fellowships, webinars, online case databases (2), publications, guidelines, and virtual grand rounds. SANS online education and questions modules offer neurosurgeons the ability to learn and self-test to advance their fund of knowledge, education, and continuing education

Current Status of Global Neurosurgery in South-East Asia

Evidence of neurosurgery dates to the bronze age with records of skull trephination; it is one of the youngest specialties, evolving rapidly over the last century (1). Although neurosurgery developed rapidly globally, education, training, and service delivery standards are heterogeneous worldwide. In a world with unequal distribution of wealth and natural resources, what can be done to improve the health care service delivery in resource-limited nations? Historical analysis shows that cooperation among species dominantly contributes to the evolution of life in its current forms. Events at any scale have global impacts, and collaboration among the population has been critical in the survival of our species at different challenging timelines in the Earth’s history.

The recent pandemic is a testament to the power and need for global collaboration for improved health care in resource-limited nations? Historical analysis shows that cooperation among species dominantly contributes to the evolution of life in its current forms. Events at any scale have global impacts, and collaboration among the population has been critical in the survival of our species at different challenging timelines in the Earth’s history. “What is Global Neurosurgery?” is beautifully penned, and various authors have shared their ideas regarding global neurosurgery (2,3). The author presented a comprehensive overview of articles published about global neurosurgery. The true meaning is acquiring a real international stature like global organizations (UNESCO, UNICEF, WHO, etc.), aiming to provide similar support services in resource-poor setups. Therefore, do we imply globalizing neurosurgery where uniform training and neurosurgery services are provided worldwide when we talk of global neurosurgery? Like other global initiatives, global neurosurgery has different perspectives, and a clear definition is not yet established. Neurosurgeons-in-training traveling outside their countries for education often face limitations in accessing these opportunities (4). Should alleviation of these restrictions constitute an essential aspect of global neurosurgery in a literal sense?

Equity in Global Neurosurgery Publications: Breaking Down Barriers in Discourse

As neurosurgery steps into a new era of global collaboration in clinical care and teaching, the academic opportunities for neurosurgeons in lower resource countries lag behind their counterparts in higher income countries. Halting the perpetuation of this historical divide requires a conscious effort in our community to equalize opportunities – not only in clinical care, but in research, publication, and mentorship opportunities. How can we render access to scientific opportunities more equitable worldwide? One solution is to give neurosurgeons an open platform that supports those interested in the global-scale advancement of our field, such as the Journal of Global Neurosurgery. This inaugural issue signals an important step in broadening research horizons and opportunities in neurosurgery across regions and national borders.