The Utility of Local Anesthesia for Neurosurgical Interventions in a Low-Resource Setting: A Case Series

Mortality and Outcome in Patients Older Than 80 Years of Age Undergoing Burr-Hole Drainage of Chronic Subdural Hematoma

OBJECTIVE

Chronic subdural hematoma is frequently seen within the elderly population and neurosurgeons are confronted with patients older than 80 years presenting with symptomatic chronic subdural hematoma. However, data on surgical outcome are scarce. The aim of this study is to analyze the mortality and outcome after burr-hole drainage in patients older than 80 years.

METHODS

This is a single-center retrospective study including patients who underwent burr-hole drainage of chronic subdural hematoma between the years 2016 and 2019. The cohort was divided into 3 age groups (80-84 years; 85-89 years; >90 years). Primary outcome was 30-day and overall mortality, whereas secondary outcome measures were recurrence rates, postoperative bleeding rates, and outcome measured by the modified ranking scale. Uni- and multivariate analysis was conducted to assess for potential risk factors for mortality, recurrence and postoperative bleeding rates.

RESULTS

In total, 107 patients with a mean age of 85.5 ± 3.9 years were included. Mortality rate was less than 10% in each group, showing no significant difference between them (P = 0.455). No significant difference in recurrence and postoperative bleeding rates was seen (P = 0.491 and P = 0.532). Modified Ranking scale score differed significantly at release, whereas at follow-up no difference was seen. After uni- and multivariate analysis, age was not correlated with higher recurrence, postoperative bleeding, or mortality rates. Preoperative midline shift was found to be an independent risk factor for recurrence.

CONCLUSIONS

In patients older than 80 years undergoing burr-hole drainage for chronic subdural hematoma, age was not directly correlated with higher recurrence, postoperative bleeding, or mortality rates.

Design and Implementation of a Hospital-based Trauma Surveillance Registry in a Resource-Poor Setting: A Cost Analysis Study

INTRODUCTION

Trauma is a leading cause of morbidity and mortality globally, with a disproportionate burden affecting low- and middle-income countries (LMIC). Rapid urbanization and differences in transportation patterns result in unique injury patterns in LMIC. Trauma registries are essential to determine the impact of trauma and the nature of injuries in LMIC to enable hospitals and healthcare systems to optimize care and to allocate resources.

METHODS

A retrospective database analysis of prospectively collected data in the Kamuzu Central Hospital (KCH) Trauma Registry from 2018 - 2019 was performed. Activity-based costing, a bottom-up cost analysis method to determine the cost per patient registered, was completed after systematically analyzing the standard operating procedures of the KCH trauma registry.

RESULTS

During the study period, 12,616 patients were included in the KCH Trauma Registry. Startup costs for the trauma registry are estimated at $3,196.24. This sum includes $1815.84 for personnel cost, $200 for database initiation (REDCap database), $342.50 for initial data clerk training, and $787.90 for registry and office supplies. Recurrent costs occurring in 2018, included personnel, technology, supply, and facility costs. Five data clerks, one data clerk manager, and a registry manager are required for 24/7 data collection, data integrity, and database maintenance, with an estimated cost of $29,697.24 per year. Yearly recurrent data clerk training costs are $137.00. Internet and facility costs for a data clerk office and secure record storage are $1632.60 per year. Supplies for the completion of trauma intake forms (binders, paper, pens) are $1431.80 per year. The total annual cost of the trauma registry at a tertiary hospital in Malawi is $33,361.64, which costs $2.64 per patient registered in the registry in 2018.

CONCLUSION

Trauma registries are necessary for the assessment of the local trauma burden and injury pattern, but require significant financial commitment and time. To fully capture the local burden of trauma in resource-limited settings, acquiring, validating, and analyzing accurate data is crucial. Anticipating the financial burden of a trauma surveillance registry ahead of time is imperative.

A Systematic Review of Neurosurgical Care in Low-Income Countries

OBJECTIVE

More than 5 billion individuals lack access to essential surgical care. Neurosurgical care is especially limited in low-income countries (LICs). Studies describing neurosurgical care in LICs are critical for understanding global disparities in access to neurosurgical procedures. To better understand these disparities, we conducted a systematic review of the literature identifying neurosurgical patients in LICs.

METHODS

MEDLINE (PubMed), Embase (embase.com), and Cochrane Library (Wiley) databases were systematically searched to retrieve studies describing neurosurgical care in LICs as defined by the World Bank Country and Lending Groups income classification. All databases were searched from their inception; no date or language limits were applied. All the articles were blindly reviewed by 2 individuals. Data from eligible studies were extracted and summarized.

RESULTS

Of the 4377 citations screened, 154 studies met inclusion criteria. The number of publications substantially increased over the study period, with 49% (n = 76) of studies published in the last 5 years. Twenty-six percent (n = 40) of studies had a first author, and 30% (n = 46) had a senior author, affiliated with a country different from the LIC of study. The most common neurosurgical diagnosis was traumatic brain injury (24%, n = 37), followed by hydrocephalus (26%, n = 40), and neoplastic intracranial mass (10%, n = 16). Of LICs, 43% (n = 15/35) had no published neurosurgical literature.

CONCLUSIONS

There is a significant deficit in the literature on neurosurgical care in LICs. Efforts must focus on supporting research initiatives in LICs to improve publication bias and understand disparities in access to neurosurgical care in the lowest-resource countries.

Challenges and opportunities for effective data collection in global neurosurgery: traumatic brain injury surveillance experience in Malawi

Global health research can transform clinical and surgical practice worldwide. Partnerships between US academic centers and hospitals in low- and middle-income counties can improve clinical care at the host institution hospital and give the visiting institution access to a large volume of valuable research data. Recognizing the value of these partnerships, the University of North Carolina (UNC) formed a partnership with Kamuzu Central Hospital (KCH) in Lilongwe, Malawi. The Department of Neurosurgery joined the partnership with KCH and designed a Head Trauma Surveillance Registry. The success of this registry depended on the development of methods to accurately collect head injury data at KCH. Since medical record documentation is often unreliable in this setting, data collection teams were implemented to capture data from head trauma patients on a 24-hours-a-day, 7-days-a-week basis. As data collection improved, pilot groups tested methods to collect new variables and the registry expanded. UNC provided onsite and remote oversight to strengthen the accuracy of the data. Data accuracy still remains a hurdle in global research. Data collection teams, oversight from UNC, pilot group testing, and meaningful collaboration with local physicians improved the accuracy of the head trauma registry. Overall, these methods helped create a more accurate epidemiological and outcomes-centered analysis of brain injury patients at KCH to date.