Editorial. Research in global neurosurgery: informing the path to achieving neurosurgical equity
Kee B. Park
Can we build better? Challenges with geospatial and financial accessibility in the Caribbean. Illustrative case
Ellianne J dos Santos Rubio, Chrystal Calderon, Annegien Boeykens, and Kee B Park
Within the Caribbean, Curaçao provides a neurosurgical hub to other Dutch Caribbean islands. At times, the inefficiency of neurosurgical referrals leads to unsatisfactory patient outcomes in true emergency cases.
This article reports an illustrative case of a patient in need of emergency neurosurgical care, who was referred to a tertiary health institution in Curaçao. This case highlights the challenges of timely neurosurgical referrals within the Dutch Caribbean.
Highlighting this case may provide a foundation for further discussions that may improve neurosurgical care and access. Limiting long-distance surgical referrals in the acute care setting will aid in saving lives.
Third delay in traumatic brain injury: time to management as a predictor of mortality
Saksham Gupta, Monty Khajanchi, Vineet Kumar, Nakul P. Raykar, Blake C. Alkire, Nobhojit Roy, and Kee B. Park
Traumatic brain injury (TBI) is a global epidemic with an increasing incidence in low- and middle-income countries (LMICs). The time from arrival at the hospital to receiving appropriate treatment (“third delay”) can vary widely in LMICs, although its association with mortality in TBI remains unknown.
A retrospective cohort analysis with multivariable logistic regression was conducted using the Toward Improved Trauma Care Outcomes in India database, which contains data from 4 urban trauma centers in India from 2013–2015.
There were 6278 TBIs included in the cohort. The patients’ median age was 39 years (interquartile range 27–52 years) and 80% of patients were male. The most frequent mechanisms of injury were road traffic accidents (52%) and falls (34%). A majority of cases were transfers from other facilities (79%). In-hospital 30-day mortality was 27%; of patients who died, 21% died within 24 hours of arrival. The median third delay was 10 minutes (interquartile range 0–60 minutes); 34% of cases had moderate third delay (10–60 minutes) and 22% had extended third delay (≥ 61 minutes). Overall 30-day mortality was associated with moderate third delay (OR 1.3, p = 0.001) and extended third delay (OR 1.3, p = 0.001) after adjustment by pertinent covariates. This effect was pronounced for 24-hour mortality: moderate and extended third delays were independently associated with ORs of 3.4 and 3.8, respectively, for 24-hour mortality (both p < 0.001).
Third delay is associated with early mortality in patients with TBI, and represents a target for process improvement in urban trauma centers.
Barriers to neurotrauma care in low- to middle-income countries: an international survey of neurotrauma providers
Saniya Mediratta, Jacob R. Lepard, Ernest J. Barthélemy, Jacquelyn Corley, and Kee B. Park
Delays along the neurosurgical care continuum are associated with poor outcomes and are significantly greater in low- to middle-income countries (LMICs), with timely access to neurotrauma care remaining one of the most significant unmet neurosurgical needs worldwide. Using Lancet Global Surgery metrics and the Three Delays framework, the authors of this study aimed to identify and characterize the most significant barriers to the delivery of neurotrauma care in LMICs from the perspective of local neurotrauma providers.
The authors conducted a cross-sectional study through the dissemination of a web-based survey to neurotrauma providers across all World Health Organization geographic regions. Responses were analyzed with descriptive statistics and Kruskal-Wallis testing, using World Bank data to provide estimates of populations at risk.
Eighty-two (36.9%) of 222 neurosurgeons representing 47 countries participated in the survey. It was estimated that 3.9 billion people lack access to neurotrauma care within 2 hours. Nearly 3.4 billion were estimated to be at risk for impoverishing expenditure and 2.9 billion were at risk of catastrophic expenditure as a result of paying for care for neurotrauma injuries. Delays in seeking care were rated as slightly common (p < 0.001), those in reaching care were very common (p < 0.001), and those in receiving care were slightly common (p < 0.05). The most significant causes for delays were associated with reaching care, including geographic distance from a facility, lack of ambulance service, and lack of finances for travel. All three delays were correlated to income classification and geographic region.
While expanding the global neurosurgical workforce is of the utmost importance, the study data suggested that it may not be entirely sufficient in gaining access to care for the emergent neurosurgical patient. Significant income and region-specific variability exists with regard to barriers to accessing neurotrauma care. Highlighting these barriers and quantifying worldwide access to neurotrauma care using metrics from the Lancet Commission on Global Surgery provides essential insight for future initiatives aiming to strengthen global neurotrauma systems.
Global neurosurgery: current and potential impact of neurosurgeons at the World Health Organization and the World Health Assembly. Executive summary of the World Federation of Neurosurgical Societies–World Health Organization Liaison Committee at the 71st World Health Assembly
Gail Rosseau, Walter D. Johnson, Kee B. Park, Miguel Arráez Sánchez, Franco Servadei, and Kerry A. Vaughan
Since the creation of the World Health Organization (WHO) in 1948, the annual World Health Assembly (WHA) has been the major forum for discussion, debate, and approval of the global health agenda. As such, it informs the framework for the policies and budgets of many of its Member States. For most of its history, a significant portion of the attention of health ministers and Member States has been given to issues of clean water, vaccination, and communicable diseases. For neurosurgeons, the adoption of WHA Resolution 68.15 changed the global health landscape because the importance of surgical care for universal health coverage was highlighted in the document. This resolution was adopted in 2015, shortly after the publication of The Lancet Commission on Global Surgery Report titled “Global Surgery 2030: evidence and solutions for achieving health, welfare and economic development.” Mandating global strengthening of emergency and essential surgical care and anesthesia, this resolution has led to the formation of surgical and anesthesia collaborations that center on WHO and can be facilitated via the WHA. Participation by neurosurgeons has grown dramatically, in part due to the official relations between WHO and the World Federation of Neurosurgical Societies, with the result that global neurosurgery is gaining momentum.
Effect of frameless stereotaxy on the accuracy of C1–2 transarticular screw placement
Orin Bloch, Langston T. Holly, Jongsoo Park, Chinyere Obasi, Kee Kim, and J. Patrick Johnson
Object. In recent studies some authors have indicated that 20% of patients have at least one ectatic vertebral artery (VA) that, based on previous criteria in which preoperative computerized tomography (CT) and standard intraoperative fluoroscopic techniques were used, may prevent the safe placement of C1–2 transarticular screws. The authors conducted this study to determine whether frameless stereotaxy would improve the accuracy of C1–2 transarticular screw placement in healthy patients, particularly those whom previous criteria would have excluded.
Methods. The authors assessed the accuracy of frameless stereotaxy for C1–2 transarticular screw placement in 17 cadaveric cervical spines. Preoperatively obtained CT scans of the C-2 vertebra were registered on a stereotactic workstation. The dimensions of the C-2 pars articularis were measured on the workstation, and a 3.5-mm screw was stereotactically placed if the height and width of the pars interarticularis was greater than 4 mm. The specimens were evaluated with postoperative CT scanning and visual inspection. Screw placement was considered acceptable if the screw was contained within the C-2 pars interarticularis, traversed the C1–2 joint, and the screw tip was shown to be within the anterior cortex of the C-1 lateral mass.
Transarticular screws were accurately placed in 16 cadaveric specimens, and only one specimen (5.9%) was excluded because of anomalous VA anatomy. In contrast, a total of four specimens (23.5%) showed significant narrowing of the C-2 pars interarticularis due to vascular anatomy that would have precluded atlantoaxial transarticular screw placement had previous nonimage-guided criteria been used.
Conclusions. Frameless stereotaxy provides precise image guidance that improves the safety of C1–2 transarticular screw placement and potentially allows this procedure to be performed in patients previously excluded because of the inaccuracy of nonimage-guided techniques.
Outcome in patients undergoing surgery for spinal injury in an Ethiopian hospital
Martin Andreas Lehre, Lars Magnus Eriksen, Abenezer Tirsit, Segni Bekele, Saba Petros, Kee B. Park, Marianne Lundervik Bøthun, and Knut Wester
The objective of this study was to investigate epidemiology and outcome after surgical treatment for spinal injuries in Ethiopia.
Medical records of patients who underwent surgery for spine injuries at Myungsung Christian Medical Center in Addis Ababa, Ethiopia, between January 2008 and September 2012 were reviewed retrospectively. Assessment of outcome and complications was determined from patient consultations and phone interviews.
A total of 146 patients were included (129 males, 17 females). Their mean age was 31.7 years (range 15–81 years). The leading cause of injury was motor vehicle accidents (54.1%), and this was followed by falls (26.7%). The most common injury sites were lumbar (41.1%) and cervical (34.2%) regions of the spine. In 21.2% of patients, no neurological deficit was present before surgery, 46.6% had incomplete spinal cord injury (American Spinal Injury Association [ASIA] Impairment Scale [AIS] Grade B-D), and 32.2% had complete spinal cord injury (AIS Grade A). Follow-up was hampered by suboptimal infrastructure, but information regarding outcome was successfully obtained for 110 patients (75.3%). At follow-up (mean 22.9 months; range 2–57 months), 25 patients (17.1%) were confirmed dead and 85 patients (58.2%) were alive; 49 patients (33.6%) underwent physical examination. At least 8 of the 47 patients (17.0%) with a complete injury and 29 of the 68 patients (42.6%) with an incomplete injury showed neurological improvement. The reported incidences of pressure wounds, recurrent urinary tract infections, pneumonia, and thromboembolic events were 22.5%, 13.5%, 5.6%, and 1.1%, respectively.
Patients showed surprisingly good recovery considering the limited resources. Surgical treatment for spine injuries in Ethiopia is considered beneficial.
The economic consequences of neurosurgical disease in low- and middle-income countries
Niclas Rudolfson, Michael C. Dewan, Kee B. Park, Mark G. Shrime, John G. Meara, and Blake C. Alkire
The objective of this study was to estimate the economic consequences of neurosurgical disease in low- and middle-income countries (LMICs).
The authors estimated gross domestic product (GDP) losses and the broader welfare losses attributable to 5 neurosurgical disease categories in LMICs using two distinct economic models. The value of lost output (VLO) model projects annual GDP losses due to neurosurgical disease during 2015–2030, and is based on the WHO’s “Projecting the Economic Cost of Ill-health” tool. The value of lost economic welfare (VLW) model estimates total welfare losses, which is based on the value of a statistical life and includes nonmarket losses such as the inherent value placed on good health, resulting from neurosurgical disease in 2015 alone.
The VLO model estimates the selected neurosurgical diseases will result in $4.4 trillion (2013 US dollars, purchasing power parity) in GDP losses during 2015–2030 in the 90 included LMICs. Economic losses are projected to disproportionately affect low- and lower-middle-income countries, risking up to a 0.6% and 0.54% loss of GDP, respectively, in 2030. The VLW model evaluated 127 LMICs, and estimates that these countries experienced $3 trillion (2013 US dollars, purchasing power parity) in economic welfare losses in 2015. Regardless of the model used, the majority of the losses can be attributed to stroke and traumatic brain injury.
The economic impact of neurosurgical diseases in LMICs is significant. The magnitude of economic losses due to neurosurgical diseases in LMICs provides further motivation beyond already compelling humanitarian reasons for action.
Global neurosurgery: continued momentum at the 72nd World Health Assembly
Gail Rosseau, Walter D. Johnson, Kee B. Park, Peter J. Hutchinson, Laura Lippa, Russell Andrews, Franco Servadei, and Roxanna M. Garcia
Global neurosurgery is the practice of neurosurgery with the primary purpose of delivering timely, safe, and affordable neurosurgical care to all who need it. This field is led by neurosurgeons, and global neurosurgery sessions are now part of every major international neurosurgical meeting. The World Federation of Neurosurgical Societies (WFNS) is working to coordinate activities and align all related activities for greater impact. This report updates the contributions made by the WFNS-WHO Liaison Committee at the most recent World Health Assembly (WHA) in 2019. The WHA is a decision-making body of the World Health Organization (WHO), attended by its 194 Member States. The WFNS has maintained official relations as a nongovernmental organization with the WHO for over 30 years, and this year 15 neurosurgical delegates attended events during the WHA. Participation by neurosurgeons continues to grow as many WHA events focused on global surgery have intrinsically involved neurosurgical leadership and participation. This year, resolution WHA72.31, entitled “Emergency and trauma care, Emergency care systems for universal health coverage: ensuring timely care for the acutely ill and injured,” was passed. This resolution provides further opportunities for neurosurgical advocacy as the landscape of global surgery gains recognition and momentum.
A comparison of publication to TBI burden ratio of low- and middle-income countries versus high-income countries: how can we improve worldwide care of TBI?
Maria Pia Tropeano, Riccardo Spaggiari, Hernán Ileyassoff, Kee B. Park, Angelos G. Kolias, Peter J. Hutchinson, and Franco Servadei
Traumatic brain injury (TBI) is a global public health problem and more than 70% of trauma-related deaths are estimated to occur in low- and middle-income countries (LMICs). Nevertheless, there is a consistent lack of data from these countries. The aim of this work is to estimate the capacity of different and heterogeneous areas of the world to report and publish data on TBI. In addition, we wanted to estimate the countries with the highest and lowest number of publications when taking into account the relative TBI burden.
First, a bibliometric analysis of all the publications about TBI available in the PubMed database from January 1, 2008, to December 31, 2018, was performed. These data were tabulated by country and grouped according to each geographical region as indicated by the WHO: African Region (AFR), Region of the Americas (PAH), South-East Asia Region (SEAR), European Region (EUR), Eastern Mediterranean Region (EMR), and Western Pacific Region (WPR). In this analysis, PAH was further subdivided into Latin America (AMR-L) and North America (AMR-US/Can). Then a “publication to TBI volume ratio” was derived to estimate the research interest in TBI with respect to the frequency of this pathology.
Between 2008 and 2018 a total of 8144 articles were published and indexed in the PubMed database about TBI. Leading WHO regions in terms of contributions were AMR-US/Can with 4183 articles (51.36%), followed by EUR with 2003 articles (24.60%), WPR with 1507 (18.50%), AMR-L with 141 articles (1.73%), EMR with 135 (1.66%), AFR with 91 articles (1.12%), and SEAR with 84 articles (1.03%). The highest publication to TBI volume ratios were found for AMR-US/Can (90.93) and EUR (21.54), followed by WPR (8.71) and AMR-L (2.43). Almost 90 times lower than the ratio of AMR-US/Can were the ratios for AFR (1.15) and SEAR (0.46).
An important disparity currently exists between countries with a high burden of TBI and those in which most of the research is conducted. A call for improvement of data collection and research outputs along with an increase in international collaboration could quantitatively and qualitatively improve the ability of LMICs to ameliorate TBI care and develop clinical practice guidelines.