Neurosurgery in Ethiopia: A New Chapter and Future Prospects

Computed tomography imaging findings in head injury victims of conflict in Northern Ethiopia treated at the University of Gondar comprehensive specialized hospital

BACKGROUND

Head injuries pose a major global health issue, especially among young adults in developing countries. Data on head trauma patterns in conflict situations is scarce, and computed tomography (CT) is the main imaging method for evaluating acute head injuries.

OBJECTIVES

This study aimed to assess the CT scan patterns of traumatic head injury among northern Ethiopian victims of war who were treated at the University of Gondar Comprehensive Specialized Hospital during the armed conflict in 2020 and 2021.

METHODS

A cross-sectional study was conducted on 76 cases of traumatic head injury who underwent CT scans from November 1, 2020, to January 30, 2021, at the Department of Radiology. Data regarding age, sex, mechanism of injury, and CT scan findings were collected and analyzed.

RESULTS

A total of 76 patients were assessed, with 73 (96.1%) being males and a male-to-female ratio of 24:1. Ages ranged from 19 to 48 years, with the most affected group being ≤ 29 years (44 or 57.9%). Common head injury mechanisms included bullets (50%), blunt trauma (26%), and blasts (21%). Abnormal CT findings were noted in 60 cases (78.95%), with the most common findings being skull fractures (64.5%), cerebral contusions (33%), and metallic foreign bodies (36%). Scalp and brain hematoma, presence of soft tissue foreign body, pneumocephalus, and subfalcine herniation exhibited a statistically significant correlation with bullet injuries (p-value < 0.05).

CONCLUSION

This study found a high rate of abnormal CT scans mainly involving young males as the primary victims of traumatic head injuries in war-affected areas of Northern Ethiopia. The leading causes were bullet injuries, with common CT scan findings including skull fractures and cerebral contusions, many requiring immediate intervention. The high rate of abnormal CT scans in these patients underscores the need to improve access to CT scans in conflict-affected areas.

The Role of Policy in Global Neurosurgery

There have been tremendous strides over the past decade to institute strong policy as means to facilitate alignment on goals and strategies for global neurosurgical systems strengthening. In this chapter, we highlight key historic policy milestones in the global neurosurgery movement. We discuss the role of international organizations in neurosurgery, and the incorporation of neurosurgery into global health agendas. We then delve into specific examples of policies that have been established (such as comprehensive recommendations for neurotrauma, spina bifida, and hydrocephalus), highlight the role of international organizations in shaping neurosurgical policies, emphasize the importance of advocacy, and explore future directions.

Charting the success of neuronavigation in brain tumor surgery: from inception to adoption and evolution

PURPOSE

Neuronavigation, explored as an intra-operative adjunct for brain tumor surgery three decades ago, has become globally utilized with a promising upward trajectory. This study aims to chart its success from idea to adoption and evolution within the US and globally.

METHODS

A three-pronged methodology included a systematic literature search, impact analysis using NIH relative citation ratio (RCR) and Altmetric scores, and assessment of patent holdings. Data was dichotomized for US and international contexts.

RESULTS

The first neuronavigation publication stemmed from Finland in 1993, marking its inception. Over three decades, the cumulative number of 323 studies, along with the significantly increasing publication trend (r = 0.74, p < 0.05) and distribution across 34 countries, underscored its progressive and global adoption. Neuronavigation, mostly optical systems (58%), was utilized in over 19,000 cases, predominantly for brain tumor surgery (84%). Literature impact showed a robust cumulative median RCR score surpassing that for NIH-funded studies (1.37 vs. 1.0), with US studies having a significantly higher median RCR than international (1.71 vs. 1.21, p < 0.05). Technological evolution was characterized by adjuncts, including micro/exo/endoscope (21%), MRI (17%), ultrasound (10%), and CT (7%). Patent analysis demonstrated academic and industrial representation with an interdisciplinary convergence of medical and computational sciences.

CONCLUSION

Since its inception thirty years ago, neuronavigation has been adopted worldwide, and it has evolved with adjunct technology integration to enhance its meaningful use. The current neuronavigation innovation pipeline is progressing, with academic and industry partnering to advance its further application in treating brain tumor patients.

Bridging the Global Technology Gap in Neurosurgery: Disparities in Access to Advanced Tools for Brain Tumor Resection

BACKGROUND AND OBJECTIVES

The advent of advanced technologies has brought unprecedented precision and efficacy to neurosurgical procedures for brain tumor resection. Despite the remarkable progress, disparities in technology access across different nations persist, creating significant challenges in providing equitable neurosurgical care. The purpose of the following work was to comprehensively analyze the existing disparities in access to innovative neurosurgical technologies and the impact of such disparities on patient outcomes and research. We seek to shed light on the extent of the problem, the underlying causes, and propose strategies for mitigating these disparities.

METHODS

A systematic review of published articles, including clinical studies, reports, and healthcare infrastructure assessments, was conducted to gather data on the availability and utilization of advanced neurosurgical technologies in various countries.

RESULTS

Disparities in technology access in neurosurgery are evident, with high-income countries benefiting from widespread implementation, while low- and middle-income countries face significant challenges in technology adoption. These disparities contribute to variations in surgical outcomes and patient experiences. The root causes of these disparities encompass financial constraints, inadequate infrastructure, and insufficient training and expertise.

CONCLUSION

Disparities in access to advanced neurosurgical technology remain a critical concern in global neurosurgery. Bridging this gap is essential to ensure that all patients, regardless of their geographic location, can benefit from the advancements in neurosurgical care. A concerted effort involving governments, healthcare institutions, and the international community is required to achieve this goal, advancing the quality of care for patients with brain tumors worldwide.

Risk Factors for Neural-Tube Defects Detected in Utero: A Prospective Community-Based Study from Addis Ababa

BACKGROUND

A recent community-based study from Addis Ababa identifying Neural Tube Defect (NTD) cases by ultrasound examination of pregnant women showed a higher prevalence of 17 per 1000 fetuses. The risk factors behind the high prevalence remain unclear.

METHODS

Altogether 891 of the 958 women participated in the ultrasound examination. Thirteen with unaffected twin pregnancies were excluded. Among 878 singleton pregnancies, 15 NTD cases were identified. Serum Folate, vitamin B12, and homocysteine levels were measured in case-mothers and a sub-set of 28 noncase mothers. Because of the modest sample size, exact logistic regression analysis was used to estimate associations between risk factors and NTDs.

RESULTS

Serum vitamin status was generally poor for participants in the study. Still, relatively higher values of folate or vitamin B12 in serum, appeared to be protective for NTD (odds ratio [OR] = 0.61 per ng/ml, 95% Confidence interval [CI]: 0.42-0.85 and OR = 0.67 per 100 pg/ml, 95% CI: 0.41-1.02, respectively). High serum homocysteine was associated with higher risk of NTD (OR = 1.3 per μmol/l, 95% CI: 1.02-1.8). Women aged 30 years or more had an OR of 3.5 (95% CI: 1.1-12) for having a NTD child, and families with NTD children had lower household income. Women in the NTD group also had more spontaneous abortions or stillbirths in previous pregnancies. Self-reported intake of folate did not appear to protect against NTDs.

CONCLUSIONS

Within this high-prevalence community, poor vitamin status was identified as a risk factor for NTDs detected at ultrasound examination. Improving food security and fortification of foods or food ingredients could be alternative measures.

Perioperative Care and Outcomes of Patients with Brain Tumors Undergoing Elective Craniotomy: Experience from an Ethiopian Tertiary-Care Hospital

OBJECTIVE

To describe patients, perioperative care, and outcomes undergoing supratentorial and infratentorial craniotomy for brain tumor resection in a tertiary-care hospital in Ethiopia.

METHODS

A retrospective cohort study of patients consecutively admitted between January 1, 2021, and December 31, 2021, was performed. We characterized patients, perioperative care, and outcomes.

RESULTS

The final sample comprised 153 patients; 144 (94%) were 18 years and over, females (n = 48, 55%) with primarily American Society of Anesthesiologists physical class II (n = 97, 63.4%) who underwent supratentorial (n = 114, 75%), or infratentorial (n = 39, 25%) tumor resection. Patients were routinely admitted (95%) to floor/wards before craniotomy; Inhaled anesthetic (isoflurane 88%/halothane 12%) was used for maintenance of general anesthesia. Propofol (n = 93, 61%), mannitol (n = 73, 48%), and cerebrospinal fluid drain (n = 28, 18%), were used to facilitate intraoperative brain relaxation, while the use of hyperventilation was rare (n = 1). The average estimated blood loss was 1040 ± 727 ml; 37 (24%) patients received tranexamic acid, and 57 (37%) received a blood transfusion. Factors associated with extubation were a) infratentorial tumor location: relative risk (RR) 0.45 (95% confidence interval [CI] 0.29-0.69), preoperative hydrocephalus: RR 0.51, (95% CI 0.34-0.79), shorter total anesthesia duration: 277.8 + 8.8 versus 426.77 + 13.1 minutes, P < 0.0001, lower estimated blood loss: 897 + 68 ml versus 1361.7 + 100 ml, P = 0.0002, and cerebrospinal fluid drainage to facilitate brain relaxation: RR 0.52, 95% CI 0.32-0.84). Approximately one in ten patients experienced postoperative obstructive hydrocephalus, surgical site infections, or pneumonia.

CONCLUSIONS

These findings suggest that certain factors may impact patient outcomes following craniotomy for tumor resection. By identifying these factors, health care providers may be better equipped to develop individualized treatment plans and improve patient outcomes. Additionally, the study highlights the importance of postoperative monitoring and management to prevent complications.

Prevalence of neural tube defects among pregnant women in Addis Ababa: a community-based study using prenatal ultrasound examination

PURPOSE

The primary aim of this study was to estimate the prevalence of NTDs at ultrasound examination in communities of Addis Ababa and secondarily to provide a description of the dysmorphology of the NTD cases.

METHODS

We enrolled 958 pregnant women from 20 randomly selected health centers in Addis Ababa during the period from October 1, 2018, to April 30, 2019. Of these 958 women, 891 had an ultrasound examination after enrollment, with a special focus on NTDs. We estimated the prevalence of NTDs and compared it with previously reported hospital-based birth prevalence estimates from Addis Ababa.

RESULTS

Among 891 women, 13 had twin pregnancies. We identified 15 NTD cases among 904 fetuses, corresponding to an ultrasound-based prevalence of 166 per 10,000 (95% CI: 100-274). There were no NTD cases among the 26 twins. Eleven had spina bifida (122 per 10,000, 95% CI: 67-219). Among the 11 fetuses with spina bifida, three had a cervical and one had a thoracolumbar defect while the anatomical site for 7 was not registered. Seven of the 11 spina bifida defects had skin covering, while two of the cervical lesions were uncovered.

CONCLUSION

We report a high prevalence of NTDs among pregnancies in communities of Addis Ababa based on screening by ultrasound. The prevalence was higher than in previous hospital-based studies in Addis, and the prevalence of spina bifida was particularly high.

Surgical treatment outcome of children with neural-tube defect: A prospective cohort study in a high volume center in Addis Ababa, Ethiopia

Introduction

Prevalence of neural tube defects (NTD) is high thus many children are born with a neural tube defect in Addis Ababa, and surgical closure is a commonly performed procedure at the pediatric neurosurgical specialty center.

Research question

The primary aim is to study the outcomes in children undergoing surgical closure of NTDs and to identify risk factors for readmission, complications and mortality.

Material and methods

Single-center prospective study of all surgically treated NTDs from April 2019 to May 2020.

Results

A total of 228 children, mean age 11 days (median 4) underwent surgery during the study period. There were no in-hospital deaths. Perioperatively 11 (4.8%) children developed wound complications, none of them needed surgery and there was no perioperative mortality. The one-year follow-up rate was 62.7% (143/228) and neurological status remained stable since discharge in all. The readmission and reoperation rates were 38 % and 8 % and risk factors for readmission were hydrocephalus (80%) and open defects (88%). Hydrocephalus (P = 0.05) and younger age (P = 0.02) were identified as risk factors for mortality. The wound-related complication rate was 55% at and was associated with large defects (P = 0.04) and delayed closure due to late hospital presentation (P = 0.01).

Discussion and conclusion

The study reveals good perioperative surgical outcome and further need for systematic improvement in treatment and follow-up of NTD patients especially with hydrocephalus. We identified risk factors for wound-related complications, readmission and mortality.

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

BACKGROUND

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.

OBJECTIVE

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).

METHODS

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.

RESULTS

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.

CONCLUSION

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.

A case study of ReachAnother Foundation as a change champion for developing spina bifida neurosurgical care and advocating for primary prevention in Ethiopia

Spina bifida is a serious birth defect affecting the central nervous system, characterized by incomplete closure of the neural tube. Ethiopia has a very high prevalence of spina bifida, affecting about 40 cases per 10,000 births. Babies born with spina bifida require early closure surgery, done within the first 2-3 days after birth. Some babies need repeat surgeries to address complications, including hydrocephalus. Without medical care, babies have a high risk of death within the first 5 years of their life. Neurosurgical capacity for spina bifida closure surgery at birth is a relatively new development in Ethiopia. ReachAnother Foundation, a not-for-profit organization based in OR, USA, started work in Ethiopia in 2009 and has been instrumental in training neurosurgeons and improving treatment for spina bifida and hydrocephalus. Along with the development of neurosurgical care, the Foundation has invested in training multi-disciplinary teams to conduct patient aftercare and has launched a platform for improved patient outcomes research. As of year 2022, they support six spina bifida "Centers of Excellence" nationwide and are continuously advocating for primary prevention of spina bifida through mandatory fortification of staple foods in Ethiopia. This paper describes ReachAnother's efforts in Ethiopia in a short interval of time, benefiting numerous patients and families with spina bifida and anencephaly. We document this as a case study for other countries to model where resources are limited and the prevalence of spina bifida and hydrocephalus is high, especially in Asia and Africa.

National Trauma Registries in LMICs: Long-Overdue Priority Comment on "Neurotrauma Surveillance in National Registries of Low- and Middle-Income Countries: A Scoping Review and Comparative Analysis of Data Dictionaries"

The burden of trauma-related mortality is inversely related to income on an individual and national scale. Barthélemy et al highlight the significant variation of neurotrauma data included in national injury registries of low- and middle-income countries (LMICs) when compared to the World Health Organization (WHO) minimal dataset for injury (MDI). Moreover, the authors emphasize that the non-existence and underutilization of nationally standardized trauma registries hinder the data-driven identification of factors contributing to neurotrauma and subsequent attempts to improve neurotrauma care. Establishing a nationally standardized trauma registry should be prioritized by all stakeholders involved in curbing trauma-related mortality and building research capacity in LMICs. In this commentary, previous successful efforts to establish and maintain robust registries in LMICs through local and international partnerships are highlighted. The lessons and challenges chronicled in establishing such registries can inform future efforts to implement a nationally standardized trauma registry.

Organizational peer support to enable rehabilitating surgical services in Northern Ethiopia

The ongoing violent conflict in Northern Ethiopia has caused displacement, death, and destruction. Health services infrastructure became one of the primary victims of the war, leaving millions unable to access essential surgical health services at a time when demand for surgical interventions is on the rise. Rehabilitating surgical services was identified as a priority by the federal government, regional health bureaus, and humanitarian organizations, forming an integral part in rebuilding communities after war. Under the auspices of the Federal Ministry of Health of Ethiopia, a hospital twinning program between providers in non-conflict and conflict affected areas was first introduced in December 2021, now including 13 active partnerships. The program builds on a previous best practice gained from the Ethiopian Hospital Alliance for Quality to strengthen local health care providers in regaining capabilities to serve local populations. Field experience of two hospital twinning projects have shown significant scope of organizational peer support at times of crisis, successfully enabling conflict-afflicted hospitals to regain the capacity necessary to re-introduce surgical services. While overcoming challenges such as lack of basic supplies including electricity and blood may be required to further increase the scope of this program in Northern Ethiopia, relative success highlights important lessons for similar approaches in areas affected by conflict, or natural disasters.

Assessment of the Neurosurgical Capacity in Ghana: Challenges and Opportunities

BACKGROUND

Low- and middle-income countries experience numerous challenges in the provision of neurosurgical care. However, limited information exists on the neurosurgical workforce and the constraints under which care is delivered in Ghana, West Africa.

METHODS

A 19-item survey assessing neurosurgical workforce, infrastructure, and education was administered to Ghanaian consultant neurosurgeons and neurosurgeon trainees between November 8, 2021, and January 20, 2022. The data were analyzed using summary descriptions, and qualitative data were categorized into themes.

RESULTS

There were 25 consultant neurosurgeons and 8 neurosurgical trainees (from 2 training centers) identified at 11 hospitals in Ghana totaling a workforce density of 1 neurosurgeon per 1,240,000. Most neurosurgical centers were located in Accra, the capital city. Almost half of the population did not have access to a hospital with a neurosurgeon in their region. Of hospitals, 82% had in-house computed tomography and/or magnetic resonance imaging scanners. In the operating room, most neurosurgeons had access to a high-speed drill (91%) but lacked microscopes and endoscopic sets (only 64% and 36% had these tools, respectively). There were no neurointensivists or neurological intensive care units in the entire country, and there was a paucity of neurovascular surgeries and functional neurosurgical procedures.

CONCLUSIONS

The provision of neurosurgical care in Ghana has come a long way since the 1960s. However, the neurosurgical community continues to face significant challenges. Alleviating these barriers to care will call for systems-level changes that allow for the prioritization of neurosurgical care within the Ghanaian health care system.

Neurosurgery Research Output in Ethiopia: A Scoping Review

BACKGROUND

Neurosurgery-specific research plays a critical role in improving outcomes in patients with neurosurgical diseases. Despite the high burden of neurosurgical diseases in Ethiopia, little is known about types of neurosurgical research from Ethiopia. The goal of this scoping review is to assess the quantity and types of neurosurgical research published in peer-reviewed journals by authors from Ethiopia.

METHODS

PubMed, CINAHL, Embase, and Scopus were searched for Ethiopian neurosurgery literature published from 2001 to 2021. We selected articles based on the following criteria: articles must 1) discuss topics within neurosurgery and 2) focus on clinical practice and/or public health in Ethiopia. We collected data on research originality, study designs, and clinical versus public health research. The frequencies and percentages of categorical variables were reported. All analyses were conducted using Jamovi software.

RESULTS

Of the 362 results, 89 neurosurgical research articles were included in the final analysis. Of the 89 articles, case reports/series were most common (28.7%), followed by retrospective cohort (20.7%) and prospective cohort studies (18.4%). There were 8 literature reviews (9.2%) and 1 systematic review and meta-analysis (1.1%). No randomized controlled trial was found. Of all articles, 66 (75.9%) focused on clinical practice, and 21 (23.6%) were related to the public health aspect of neurosurgery. Forty-two articles (48.3%) included authors only from Ethiopia; 37 articles (42.5%) involved collaboration between Ethiopian and authors from another country, and 8 articles (9.2%) did not have Ethiopian authors.

CONCLUSIONS

Neurosurgery research from Ethiopia is lacking, despite its high disease burden. Case reports/series and cohort studies remain the mainstay, with few systematic reviews and no randomized controlled trial. International collaboration accounts for approximately half of Ethiopian neurosurgery research output. Further research support and infrastructure should be developed to encourage neurosurgery articles from Ethiopia.