The burden of spinal trauma in low- and middle-income countries (LMICs) is immense, and its management is made complex in such resource-restricted settings. Algorithmic evidence-based management is ...cost-prohibitive, especially with respect to spinal implants, while perioperative care is work-intensive, making overall care dependent on multiple constraints. The objective of this study was to identify determinants of decision-making for surgical intervention, improvement in function, and in-hospital mortality among patients experiencing acute spinal trauma in resource-constrained settings.
This study was a retrospective analysis of prospectively collected data in a cohort of patients with spinal trauma admitted to a tertiary referral hospital center in Dar es Salam, Tanzania. Data on demographic, clinical, and treatment characteristics were collected as part of a quality improvement neurotrauma registry. Outcome measures were surgical intervention, American Spinal Injury Association (ASIA) Impairment Scale (AIS) grade improvement, and in-hospital mortality, based on existing treatment protocols. Univariate analyses of demographic and clinical characteristics were performed for each outcome of interest. Using the variables associated with each outcome, a machine learning algorithm-based regression nonparametric decision tree model utilizing a bootstrapping method was created and the accuracy of the three models was estimated.
Two hundred eighty-four consecutively admitted patients with acute spinal trauma were included over a period of 33 months. The median age was 34 (IQR 26-43) years, 83.8% were male, and 50.7% had experienced injury in a motor vehicle accident. The median time to hospital admission after injury was 2 (IQR 1-6) days; surgery was performed after a further median delay of 22 (IQR 13-39) days. Cervical spine injury comprised 38.4% of the injuries. Admission AIS grades were A in 48.9%, B in 16.2%, C in 8.5%, D in 9.5%, and E in 16.6%. Nearly half (45.1%) of the patients underwent surgery, 12% had at least one functional improvement in AIS grade, and 11.6% died in the hospital. Determinants of surgical intervention were age ≤ 30 years, spinal injury level, admission AIS grade, delay in arrival to the referral hospital, undergoing MRI, and type of insurance; admission AIS grade, delay to arrival to the hospital, and injury level for functional improvement; and delay to arrival, injury level, delay to surgery, and admission AIS grade for in-hospital mortality. The best accuracies for the decision tree models were 0.62, 0.34, and 0.93 for surgery, AIS grade improvement, and in-hospital mortality, respectively.
Operative intervention and functional improvement after acute spinal trauma in this tertiary referral hospital in an LMIC environment were low and inconsistent, which suggests that nonclinical factors exist within complex resource-driven decision-making frameworks. These nonclinical factors are highlighted by the authors' results showing clinical outcomes and in-hospital mortality were determined by natural history, as evidenced by the highest accuracy of the model predicting in-hospital mortality.
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.
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.
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.
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.
As the second of 3 articles in this series, the aim of this article is to provide readers with an understanding of the development of neurosurgery in East Africa (foundations), the challenges that ...arise in providing neurosurgical care in developing countries (challenges), and an overview of traditional and novel approaches to overcoming these challenges and improving health care in the region (innovations). Recognizing the challenges that need to be addressed is the first step to implementing efficient and qualified surgery delivery systems in low- and middle-income countries. We reviewed the major challenges facing health care in East Africa and grouped them into 5 categories: 1) burden of surgical disease and workforce crisis; 2) global health view of surgery as “the neglected stepchild”; 3) need for recognizing the surgical system as an interdependent network and importance of organizational and equipment deficits; 4) lack of education in the community, failure of primary care systems, and net result of overwhelming tertiary care systems; 5) personal and professional burnout as well as brain drain of promising human resources from low- and middle-income countries in East Africa and similar regions across the world. Each major challenge was detailed and analyzed by authors who have worked or are currently working in the region, providing a personal perspective.
•Traumatic brain injury and spine trauma are the most common causes of death and disability in young adults.•Surgery in low-income and middle-income countries has been shown to be cost-effective.•A successful surgical system is an interdependent network.•Organizational challenges are as important as economic challenges.•Data collection might have the highest impact in global health policies.
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.
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.
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.
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.
Trauma to the thoracic, thoracolumbar (TL), and lumbar spine is common and can cause disability and neurological deficits. Using a cohort of patients suffering from thoracic, TL, and lumbar spine ...trauma in a tertiary hospital in East Africa, the current study sought to: (1) describe demographics and operative treatment patterns, (2) assess neurologic outcomes, and (3) report predictors associated with undergoing surgery, neurologic improvement, and mortality.
A retrospective cohort study of patient records from September 2016 to December 2020 was conducted at a prominent East Africa referral center. The study collected data on demographics, injury, and operative characteristics. Surgical indications were assessed using the AO (
) TL fracture classification system and neurological function. Logistic regression analysis identified predictors for operative treatment, neurologic improvement, and mortality.
The study showed that 64.9% of the 257 TL spine trauma patients underwent surgery with a median postadmission day of 17.0. The mortality rate was 1.2%. Road traffic accidents caused 43.6% of the injuries. The most common fracture pattern was AO Type A fractures (78.6%). Laminectomy and posterolateral fusion were performed in 97.6% of the surgical cases. Patients without neurological deficits (OR: 0.27, 95% CI: 0.13-0.54,
< 0.001) and those with longer delays from injury to admission were less likely to have surgery (OR: 0.95, 95% CI: 0.92-0.99,
= 0.007). The neurologic improvement rate was 11.1%. Univariate analysis showed a significant association between surgery and neurologic improvement (OR: 3.83, 95% CI: 1.27-16.61,
< 0.001). However, this finding was lost in multivariate regression.
This study highlights various themes surrounding the management of TL spine trauma in a low-resource environment, including lower surgery rates, delays from admission to surgery, safe surgery with low mortality, and the potential for surgery to lead to neurologic improvement.
Despite challenges such as surgical delays and limited resources in East Africa, there is potential for surgical intervention to improve neurologic outcomes in thoracic, TL, and lumbar spine trauma patients.
Neurosurgery in East Africa: Innovations Budohoski, Karol P.; Ngerageza, Japhet G.; Austard, Benedict ...
World neurosurgery,
20/May , Letnik:
113
Journal Article
Recenzirano
In the last 10 years, considerable work has been done to promote and improve neurosurgical care in East Africa with the development of national training programs, expansion of hospitals and creation ...of new institutions, and the foundation of epidemiologic and cost-effectiveness research. Many of the results have been accomplished through collaboration with partners from abroad. This article is the third in a series of articles that seek to provide readers with an understanding of the development of neurosurgery in East Africa (Foundations), the challenges that arise in providing neurosurgical care in developing countries (Challenges), and an overview of traditional and novel approaches to overcoming these challenges to improve healthcare in the region (Innovations). In this article, we describe the ongoing programs active in East Africa and their current priorities, and we outline lessons learned and what is required to create self-sustained neurosurgical service.
•East Africa remains one of the most challenging regions for neurosurgical care provision.•Numerous aid programs geared toward helping East African neurosurgery are in place; however, there is little evidence of data sharing and collaboration.•Advances have been made in neurosurgical training, development of curricula, and establishing referral centers for specialized cases, such as pediatric neurosurgery.•Collaborative efforts between aid programs and local teams have yielded real innovations, (e.g. treatment of hydrocephalus).•Areas requiring improvement include: understanding outcome patterns and their social consequences; treatments adopted to local circumstances; establishing East African research programs partnered with the international community; further development of training programs (new fellowships, teaching schedules, lectures from experts.•Government legislation to improve follow-up care and rehabilitation, preventive measures (e.g., road safety), and increasing awareness (e.g., family planning) are essential to accelerate and sustain development.
Neurosurgery in East Africa: Foundations Mangat, Halinder S.; Schöller, Karsten; Budohoski, Karol P. ...
World neurosurgery,
20/May , Letnik:
113
Journal Article
Recenzirano
This article is the first in a series of 3 articles that seek to provide readers with an understanding of the development of neurosurgery in East Africa (Foundations), the challenges that arise in ...providing neurosurgical care in developing countries (Challenges), and an overview of traditional and novel approaches to overcoming these challenges to improve healthcare in the region (Innovations). We review the history and evolution of neurosurgery as a clinical specialty in East Africa. We also review Kenya, Uganda, and Tanzania in some detail and highlight contributions of individuals and local and regional organizations that helped to develop and shape neurosurgical care in East Africa. Neurosurgery has developed steadily as advanced techniques have been adopted by local surgeons who trained abroad, and foreign surgeons who have dedicated part of their careers in local hospitals. New medical schools and surgical training programs have been established through regional and international partnerships, and the era of regional specialty surgical training has just begun. As more surgical specialists complete training, a comprehensive estimation of disease burden facing the neurosurgical field is important. We present an overview with specific reference to neurotrauma and neural tube defects, both of which are of epidemiologic importance as they gain not only greater recognition, but increased diagnoses and demands for treatment. Neurosurgery in East Africa is poised to blossom as it seeks to address the growing needs of a growing subspecialty.
•The first independent neurosurgical departments in East Africa were established in the 1960s and 1970s.•The first local neurosurgical training program for East, Central, and Southern Africa, NSTP-ECSA, was approved as a in 2005.•Two agencies—FIENS and the NED foundations—were greatly influential for the development of NSTP-ECSA.•Data on neurosurgical disease burden in East Africa is scarce; traumatic brain and spine injuries and neural tube defects play a significant role.•Establishing national registries to record disease burden are needed to direct resources appropriately.
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 (
) describe presentation and operative ...treatment patterns, (
) report predictors of neurologic improvement, and (
) assess predictors of mortality.
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.
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,
= .011) and an incomplete injury (OR 3.64; 95% CI 1.19-12.25;
= .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,
< .001), and longer time from injury to admission was associated with decreased odds of mortality (OR 0.66, 95% CI 0.48-0.85,
= .006).
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.
4.
Study Design:
Retrospective case series.
Objective:
Little is known about operative management of traumatic spinal injuries (TSI) in low- and middle-income countries (LMIC). In patients undergoing ...surgery for TSI in Tanzania, we sought to (1) determine factors involved in the operative decision-making process, specifically implant availability and surgical judgment; (2) report neurologic outcomes; and (3) evaluate time to surgery.
Methods:
All patients from October 2016 to June 2019 who presented with TSI and underwent surgical stabilization. Fracture type, operation, neurologic status, and time-to-care was collected.
Results:
Ninety-seven patients underwent operative stabilization, 23 (24%) cervical and 74 (77%) thoracic/lumbar. Cervical operations included 4 (17%) anterior cervical discectomy and fusion with plate, 7 (30%) anterior cervical corpectomy with tricortical iliac crest graft and plate, and 12 (52%) posterior cervical laminectomy and fusion with lateral mass screws. All 74 (100%) of thoracic/lumbar fractures were treated with posterolateral pedicle screws. Short-segment fixation was used in 86%, and constructs often ended at an injured (61%) or junctional (62%) level. Sixteen (17%) patients improved at least 1 ASIA grade. The sole predictor of neurologic improvement was faster time from admission to surgery (odds ratio = 1.04, P = .011, 95%CI = 1.01-1.07). Median (range) time in days included: injury to admission 2 (0-29), admission to operating room 23 (0-81), and operating room to discharge 8 (2-31).
Conclusions:
In a cohort of LMIC patients with TSI undergoing stabilization, the principle driver of operative decision making was cost of implants. Faster time from admission to surgery was associated with neurologic improvement, yet significant delays to surgery were seen due to patients’ inability to pay for implants. Several themes for improvement emerged: early surgery, implant availability, prehospital transfer, and long-term follow-up.
Study Design:
Retrospective cost-effectiveness analysis.
Objectives:
While the incidence of traumatic spine injury (TSI) is high in low-middle income countries (LMICs), surgery is rarely possible due ...to cost-prohibitive implants. The objective of this study was to conduct a preliminary cost-effectiveness analysis of operative treatment of TSI patients in a LMIC setting.
Methods:
At a tertiary hospital in Tanzania from September 2016 to May 2019, a retrospective analysis was conducted to estimate the cost-effectiveness of operative versus nonoperative treatment of TSI. Operative treatment included decompression/stabilization. Nonoperative treatment meant 3 months of bed rest. Direct costs included imaging, operating fees, surgical implants, and length of stay. Four patient scenarios were chosen to represent the heterogeneity of spine trauma: Quadriplegic, paraplegic, neurologic improvement, and neurologically intact. Disability-adjusted-life-years (DALYs) and incremental-cost-effectiveness ratios were calculated to determine the cost per unit benefit of operative versus nonoperative treatment. Cost/DALY averted was the primary outcome (i.e., the amount of money required to avoid losing 1 year of healthy life).
Results:
A total of 270 TSI patients were included (125 operative; 145 nonoperative). Operative treatment averaged $731/patient. Nonoperative care averaged $212/patient. Comparing operative versus nonoperative treatment, the incremental cost/DALY averted for each patient outcome was: quadriplegic ($112-$158/DALY averted), paraplegic ($47-$67/DALY averted), neurologic improvement ($50-$71/DALY averted), neurologically intact ($41-$58/DALY averted). Sensitivity analysis confirmed these findings without major differences.
Conclusions:
This preliminary cost-effectiveness analysis suggests that the upfront costs of spine trauma surgery may be offset by a reduction in disability. LMIC governments should consider conducting more spine trauma cost-effectiveness analyses and including spine trauma surgery in universal health care.
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