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E. J. Barthélemy et al.
Table 23.3 ICH score. According to the original publication by Hemphill etal., scores from 0 to 6 are respectively associated with a 30-day mortality ranging from 0%
for a score of 0 to 13% for grade 1, 26% for grade 2, 72%
for grade 3, 87% for grade 4, and nearly 100% for grades
5 and 6 [16]. GCS score indicates the initial GCS on presentation or following resuscitation; volume of ICH is
calculated using the ABC/2 method [16]
ICH score
Component Score
GCS score
3–4 2
5–12 1
13–15 0
ICH volume, mL
≥30
<30 0
Intraventricular hemorrhage
Yes 1
No 0
Infratentorial origin of ICH
Yes 1
No 0
Age
≥80
<80 0
Total score 0–6
1
1
or a combination of techniques and approaches
that are generally reserved for highly specialized referral centers. Surgical management of
SICH without an underlying vascular malformation has otherwise been a controversial area,
with earlier studies showing improvements in
mortality for some patients, but without a denite improvement in function or in the neurological decit produced by the original lesion.
More recent surgical innovations in the realm of
minimally invasive hematoma evacuation have
shown some promise, with technologies such as
endoport- and endoscope-assisted hematoma
evacuation, or stereotactic aspiration and thrombolysis, increasingly replacing standard craniotomies and microsurgical techniques for
optimizing surgical outcomes in SICH [17].
These technologies are, however, in an early
phase of development and pose barriers to
implementation in LMICs that include prohibi-
tive costs and signicant learning curves. A
health equity-driven paradigm for neurosurgical
capacity development in LMICs must, however,
focus on disruptive innovation that makes these
technologies available to patients in all settings
who stand to benet from these treatments.
These innovations may include leveraging local
engineering talent to develop minimally invasive technologies with more inexpensive yet
equally durable and effective materials and strategic partnering with institutions in HICs to
facilitate resource-sharing for transnational education, training, and research initiatives focused
on decreasing the global burden of hemorrhagic
stroke.
Management ofTraumatic
Intracranial Hypertension (TICN)
Intracranial hypertension refers to the pathological elevation of intracranial pressure.
Normal intracranial pressure has globally been
accepted to range between 0 and 20mmHg for
adults, with the exception of transient increases
of intracranial pressure which occur during
normal variations in human physiology during
events such as coughing, sneezing, breath-holding maneuvers, or some forms of heavy lifting
or physical exertion. Traumatic intracranial
hypertension (TICN) refers to the sustained
elevation of intracranial pressure beyond
20mmHg as a consequence of traumatic injury
to the head and brain. Following the paradigm
of the Monro-Kellie hypothesis, which predicts
that the closed system of the human skull can
only accommodate a xed volume of intracranial components, TICN may result from a posttraumatic increase in any of these components
such as blood (e.g., from extra- axial or intraparenchymal hemorrhage), brain parenchyma
(e.g., as a consequence of the various forms of
brain edema), or cerebrospinal uid (e.g., as a
consequence of hydrocephalus from disruption
of CSF dynamics or obstruction of CSF pathways [18].
CPPMAP IC P=-
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Treatment ofTICN
The treatment of ICN is paramount in the prevention of life-threatening posttraumatic events
such as acute herniation syndromes, as well as
in the optimization of cerebral physiology by
maintaining adequate brain tissue perfusion, as
predicted by the formula for cerebral perfusion
pressure (CPP), which is calculated as the difference between mean arterial pressure (MAP)
and intracranial pressure (ICP) [19]. See
Eq.23.1:
where CPP is cerebral perfusion pressure, MAP
is mean arterial pressure, and ICP is intracranial
pressure.
The management of ICN, especially in highincome country (HIC) contexts, is currently
entering a realm of multimodality monitoring,
which involves the placement of both external
ventricular drains that allow intermittent or continuous CSF diversion as well as measurement
of ICP when closed and intracranial monitors
that detect several other parameters of cerebral
physiology, such as brain temperature, oxygen
tension of brain tissue, cerebral blood ow, and
electroencephalography via depth electrodes.
These monitoring modalities represent the current state of the art in neurocritical care monitoring and management for TICN, and new
protocols integrating this data into the optimization of care are the subject of recent consensus
efforts and intense research. The interested
reader can reference several of these protocols,
particularly as they relate to intracranial pressure
and brain tissue oxygen monitoring for patients
with severe TBI, on the resources page of the
website of Global Neuro or in the articles produced by the Seattle International Severe
Traumatic Brain Injury Consensus Conference
(SIBICC) [20–22].
Nonetheless, the optimization of long-term
outcomes for patients with TICN managed using
these advanced modalities remains to be seen and
comes with a cost of care that, taken together
(23.1)
with the many other costs of a HIC intensive care
unit, can exceed a daily expense of $20,000 per
patient [23, 24]. The practitioner caring for victims of TBI with TICN in a low-resource setting
therefore faces the challenge of managing TICN
in a rapid and effective manner in the absence of
many of the tools available in a HIC setting.
Recently, a group based in Latin America developed a series of stratied protocols for optimizing TBI management in resource-constricted
settings, representing the rst such set of protocols that specically consider common limitations encountered by neurosurgeons,
neurointensivists, and emergency medicine physicians in low- and middle-income countries
[11]. This “Beyond One Option for Treatment of
Traumatic Brain Injury: A Stratied Protocol
[BOOTStraP]” approach expands upon the prior
“international” protocols from HIC environments, such as the recommendations of the Brain
Trauma Foundation (BTF) and of SIBICC, by
offering TICN management options that can
readily be adapted to environments where BTF
and SIBICC protocols cannot be enacted with
integrity.
While a detailed recapitulation of the guidelines from BTF, SIBICC, or BOOTStraP is
beyond the scope the scope of this chapter, the
following principles of TICN management may
be appreciated in all such protocols and can be
used to guide the rapid relief of TICN in all
contexts:
I. Rapid assessment and stabilization of the
TBI patient at risk of TICN is key, including
maintenance of a patent airway, adequate
oxygenation, and perfusion. This includes
safely securing the patient’s airway with
intubation if required, ventilating the patient
as needed, and maintaining blood pressure
levels that adequately perfuse the brain.
Hypoxia and hypotension are well-described
secondary brain insults that increase mortality in patients with severe TBI.
II. In the absence of monitoring modalities,
acute TICN can be inferred from common
changes to the clinical and neurological
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exam that result from impending herniation
syndromes, such as worsening mental status,
worsening Glasgow coma score, nausea and
vomiting, changes in pupillary exam such as
dilation and nonreactivity to light, and stereotyped posturing such as abnormal exion
or extension which may indicate brainstem
compression.
III. When CT scanning is available, a rapid non-
contrast head and brain imaging of a patient
with TICN is key for identifying surgically
treatable causes of TICN such as epidural or
subdural hemorrhage, large intraparenchymal contusions, or diffuse posttraumatic
brain swelling.
IV. Noninvasive gestures that can optimize ICP
and treat acute TICN include head of bed
elevation to at least 30 degrees to optimize
jugular venous drainage, judicious use of
transient hyperventilation to decrease intracranial volume through intracerebral vasoconstriction, use of sedation, analgesic and
paralytic medications as available and indicated, and judicious bolus administration of
hyperosmolar therapies such as mannitol or
hypertonic saline. Note that sedating and/or
paralyzing medications can compromise the
neurological exam and result in lack of ability to reliably use the exam to manage
patients with TBI.
V. Insertion of an external ventricular drain
(EVD), when available, provides the most
basic invasive maneuver enabling direct
measurement of ICP, and a therapeutic
maneuver that, through CSF diversion, can
directly treat TICN. When CT scanning is
available, CT imaging should be obtained
prior to EVD insertion in order to account
for possible posttraumatic alterations in
brain anatomy that can render EVD placement difcult, or prohibitive. Otherwise, the
standard technique, following patient positioning, hair removal, and skin sterilization,
involves a stab-incision, or 1–2cm parasagittal incision at a point corresponding to the
intersection of the midpupillary line with a
perpendicular line extending from the mid-
E. J. Barthélemy et al.
Fig. 23.4 EVD entry point with utilization of the Ghajar
tripod guide. Reprinted with permission. Permission has
been obtained
point of an imaginary line connecting the
external canthus to the tragus. A burr hole is
then made at this site, followed by dural incision, and insertion of the EVD at a trajectory
that targets the frontal horn and foramen of
Monro in the ipsilateral lateral ventricle. The
trajectory is classically found by insertion
orthogonal to the skull, which can also be
reliably obtained with the use of a tripod
device such as a Ghajar guide [25] (see
Fig.23.4).
VI. While the role of decompressive craniec-
tomy in treatment of severe TBI has
remained a controversial issue, especially
in the literature coming primarily from
HIC environments, strong evidence supports the ability of decompressive craniectomy to denitively control TICN in severe
TBI patients, with many other factors inu-
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269
encing whether this treatment ultimately
improves mortality. In low-resource settings, ndings and recommendations from
HIC environments are recognized as lacking the external validity for generalized
application, and there may be a role for
early, primary decompressive craniectomy,
particularly in settings where neurocritical
care monitoring may be delayed or unavailable [26].
Diagnostic Lumbar Puncture
Overview
The lumbar puncture is a standard procedure in
the medicosurgical care of patients with a range
of neurological and neurosurgical diagnoses. The
principal indication for a lumbar puncture is to
exclude, or conrm, suspected central nervous
system infection or spontaneous subarachnoid
hemorrhage from rupture of an intracerebral
aneurysm or other vascular malformation or
anomaly of the brain. The principal contraindication for lumbar puncture is any lesion or anomaly
that increases the risk of a cerebral herniation
event, such as a space occupying mass, or other
structural anomalies of the brain resulting in
intracranial hypertension and/or obstructive
hydrocephalus. Therefore, any suspicion of a
space occupying brain mass or other structural
lesions of the brain should be investigated with
imaging where available, including CT scan of
the brain. When CT imaging is not available to
exclude such anomalies, the potential risk of
causing a herniation event must be weighed
against the potential benet of performing cerebrospinal uid analysis.
Procedure
The procedure for a lumbar puncture involves
insertion of a lumbar puncture needle at a level of
the lumbar spine caudal to the conus medullaris,
in order to minimize the risk of injury to neural
elements. Classically, needle insertion at the
interlaminar space of the L4 and L5 vertebral
body levels permits access of the lumbar cistern
with minimal risk to neural injury. If the lumbar
cistern cannot be readily accessed at this level,
the L3–L4 level is also an appropriate target that
is normally caudal to the conus medullaris.
The patient is classically positioned in a lateral decubitus position, facing away from the
operator, with the chin of the patient tucked down
toward the chest with the neck exed, with the
hips and knees of the patient exed toward the
abdomen in order to facilitate and maximize spinal exion. This positioning optimizes access to
the lumbar cistern by expanding the interlaminar
space. In this position, the skin is prepared by
cleaning and sterilizing the skin in standard sterile surgical fashion, using either iodine- or
alcohol- based cleansers. Sterile drapes are then
placed to isolate the area of lumbar puncture and
to exclude any unsterile surfaces from the eld.
The operator then cleans her/his/their hands and
dons a pair of sterile surgical gloves to perform
the procedure. The L4–L5 level is identied by
palpating the patient’s iliac crest bilaterally and
identifying the intercristal line at this level, where
it intersects the spinous processes orthogonally.
The needle is inserted in between the L4 and
L5 spinous processes, parallel to the oor, and
with a slightly rostral inclination to mimic the
angle produced by the anking spinous processes. As the needle is inserted, it is gently
advanced, feeling for haptic feedback from each
of the connective tissue structures encountered
before reaching the subarachnoid space. These
are the skin and subcutaneous layers: the more
dense supraspinous ligament, the thinner interspinous ligament, the ligamentum avum, and
the dural/arachnoid puncture which results in a
sudden loss of resistance and egress of cerebrospinal uid upon removal of the stylet from the
spinal needle. If opening pressure is desired, it
can be measured at this time by connection of a
manometer to the spinal needle. Several milliliters of cerebrospinal uid are collected for analysis and sent to a laboratory with biochemistry
and microbiology capacity. Standard tests
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E. J. Barthélemy et al.
Fig. 23.5 Lumbar
puncture technique
Fig. 23.6 Examples of red blood cell ndings from lumbar puncture for subarachnoid hemorrhage
Lumbar Puncture
Lying Position Sitting Position
include protein, glucose, cell count, differential,
and gram stain study, as well as culture to isolate organisms of interest. When performed to
conrm a diagnosis of acute, or subacute subarachnoid hemorrhage, the studies of interest
include cell count, and uid appearance (see
Fig.23.5 for an illustration of the lumbar puncture technique).
Cerebrospinal uid collection to diagnose
acute subarachnoid hemorrhage requires four
numbered tubes for CSF collection in order to
reliably determine whether red blood cell count
is due to traumatic lumbar puncture or due to
spontaneous subarachnoid hemorrhage. In a traumatic puncture, the red blood cell count decreases
each successive collection tube. In subarachnoid
hemorrhage, the red blood cell count is consistently high in all four collection tubes (see
Fig.23.6 for an example of CSF appearance in
subarachnoid hemorrhage).
Of note, analysis of cerebrospinal uid for the
purposes described in this chapter requires not
only the materials found in a standard lumbar
puncture kit prepared for this purpose but also the
capacity for medical laboratory studies including
assays for glucose, protein, cell count and differential, gram stain, and microbiology cultures.
More sophisticated studies for viral assay or cancer workup require more sophisticated laboratory
capacity; however, these analyses are beyond the
scope of this chapter.
Neurosurgical indications for lumbar puncture
beyond the above-described diagnoses included
obtaining access for insertion lumbar subarachnoid drain, cerebrospinal uid diversion to facilitate microsurgical resection of brain and skull
base tumors, repair of cerebrospinal uid stulae,
or reconstruction of posttraumatic cranial defects,
or a diagnostic conrmation of communicating,
normal pressure hydrocephalus. A comprehensive discussion of these lumbar puncture indications is, however, beyond the scope of this
chapter.
Table 23.4 lists the common cellular and biochemical ndings in the differential diagnosis for
meningitis.
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Table 23.4 Common ndings of CSF studies. A guide for common ndings in cellular and biochemical analysis of
cerebrospinal uid in the differential diagnosis of meningitis
Study Normal ndings Bacterial infection Viral infection Fungal infection
Opening pressure 6–20cm H2O 15–50cm H2O 6–30cm H2O 15–50cm H2O
Leukocyte count <5/uL High elevation;
usually >1000/uL
Differential Lymphocyte
predominance
Protein density <60mg/dL High elevation;
Glucose density >40% serum glucose,
or>40mg/dL
a
Note that some viruses can produce a decrease of CSF glucose density. Source: adapted from the Internet Book of
Critical Care [27]
Neutrophilic Lymphocytic Lymphocytic
80–500mg/dL
Decreased Normal
Mild elevation;
usually <1000/uL
Mild elevation;
80–500mg/dL
a
Mild elevation;
usually <1000/uL
High elevation;
80–500mg/dL
Decreased
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Brain Tumors
Presentation
Brain tumors are among the most common disease entities in neurosurgery. The most common
type of brain tumors in LMICs, especially in
Africa, are meningiomas. Patients with brain
tumors commonly present with headache which
is usually worse in the morning. The headache
is often accompanied by nausea and vomiting.
Patients get temporary relief from the headache
due to the hyperventilation associated with the
vomiting. Moreover, patients with brain tumors
present with progressive neurologic decits
such as weakness of the limbs, visual deterioration, cranial nerve decit, or change in mentation. Seizure is also a common manifestation
which could be focal onset or generalized.
Patients with infratentorial brain tumors arising
from either the cerebellum or the brain stem
present with gait disturbance, ataxia, vertigo or
diplopia.
Classication ofBrain Tumors
Brain tumors are broadly classied as primary or
secondary (metastatic). Primary brain tumors are
those tumors arising from the brain tissue or surrounding structures. They can be of glial or nonglial origin.
The most common benign brain tumor in
adults is meningioma, while glioblastoma is the
most common malignant brain tumor. In children, the most common tumors are pilocytic
astrocytoma and medulloblastoma.
The most widely used classication of brain
tumors is the World Health Organization (WHO)
classication of Central Nervous System tumors.
It provides nomenclature and grading of CNS
tumors which are important for treatment
planning.
Diagnostics forBrain Tumors:
Challenges andApproaches
Magnetic resonance imaging (MRI) is the diagnostic of choice for brain tumors followed by
computed tomography (CT). Contrast-enhanced
MRI and CT scan help characterize brain tumors.
CT is an important imaging modality to assess
the bone involvement by the tumors and to diagnose calcications associated with the tumors.
Access to these imaging modalities is limited
in LMICs and the cost is also expensive [28]. As
a result, patients with brain tumors are diagnosed
late, and it is common to see patients who had
advanced diseases with big tumors. Available
MRI machines also have low resolution and the
CT scans are usually 16 to 32 slices [29].
Interpretation of imaging ndings is also limited
due to the shortage of radiologists. Neurosurgeons
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E. J. Barthélemy et al.
are usually expected to interpret imaging ndings
and plan treatment accordingly.
Spine Stabilization andUrgent
Repair and/or Decompression
Overview
Traumatic injuries of the spine can pose multiple
challenges to neurosurgeons and orthopedic
spine surgeons in any context. The variability of
resource availability in LMIC settings can aggravate these challenges at every stage of care. While
the principles of prehospital care, including spinal immobilization in any patient with suspected
spinal injury, can be generalized to several key
principles and maneuvers, denitive diagnosis
and management are more challenging and ideally undertaken by a team with specic spinal
surgery expertise, which is generally the domain
of neurosurgeons, or spine surgery-specialized
orthopedists.
The generalities of spinal anatomy can be
found in any standard medical textbook. The
regions of greatest interest by frequency of
injury in the existing spine trauma literature
include the sub-axial cervical spine and the thoracolumbar spine. Other regions, including the
cranio- cervical, cervicothoracic, sacrum, and
sacropelvic regions, may also be injured and
require tailored approaches to care; however,
spinal anatomy and biomechanics render the cervical spine and the thoracolumbar region, most
susceptible to injury in the most common mechanisms of spinal injury, including motor vehicle
accidents, falls, occupational injuries, and athletic injuries. We will therefore focus on managing suspected injury to the cervical, or
thoracolumbar, spine.
In the vast majority of cases, indications for
surgery require radiological demonstration of the
patho-anatomy of spinal injury, with clinical neurological and/or destabilizing musculoskeletal
ndings referable to radiological ndings. In HIC
contexts, the challenges of determining surgical
indications for neurotrauma have resulted in the
development of several predictive algorithms and
frameworks that may be useful in resourcerestricted settings, if and when such frameworks
are validated. They include the classication
schemes of AO Spine, the Subaxial Cervical
Spine Injury Classication Scale (SLICS), and
the Thoracolumbar Injury Classication and
Severity Scale (TLICS) [30]. At the time of writing, an international collaboration led by a group
based in Columbia, South America, is producing
detailed algorithms to guide practitioners in lowand middle-income countries, as was recently
done for traumatic brain injury with BOOSTRAP
TBI [11].
Nonsurgical Stabilization
Options for nonsurgical stabilization of the
injured spine are limited primarily to orthotic
braces and more invasive cervical spine stabilization devices. Orthotic braces include the cervical
collar, the cervicothoracic brace, the thoracolumbar sacral orthosis (TLSO), and the lumbosacral
orthosis. More invasive options for cervical spine
stabilization without surgery include a halo
orthosis or, when available, Gardner-Wells cervical traction tongs. All of these devices are associated with a cost of production or acquisition that
must be considered within the socioeconomic
constraints of the context where they may be
used.
Noninvasive orthoses range in rigidity from
soft, more exible braces that may remind
patients to limit movement without providing
signicant support to the far more rigid and/or
custom-made orthoses that more securely restrict
harmful movement of injured spinal segments.
The principal role of such braces, particularly in
the cervical spine, is to transiently provide immobilization of injured spinal segments until denitive care can be provided. They may also have a
role in conservative management of spinal injury
and/or postoperative recovery from a spinal
fusion to facilitate arthrodesis of the segments of
interest.
Halo orthosis may be used as a conservative
management approach in craniocervical spinal
injury when surgical correction cannot be per-
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273
formed or when a nonsurgical treatment appears
to be possible with more denitive immobilization
than can be achieved with a cervical collar.
Traction using Gardner-Wells tongs is reserved
for patients with subluxation injuries of the cervical spine that can be treated with closed reduction
using cervical traction.
Rapid Surgical Decompression/
Repair
The two principal modalities of surgical care
for spinal injury include decompression and
stabilization. Decompression refers to the surgical removal of traumatic lesions that compress either the spinal cord, or conus medullaris,
or nerves. While some lesions, such as traumatic herniation of cervical discs, require an
anterior approach, adequate spinal decompression for most traumatic indications can be
accomplished from a posterior approach in the
cervical, thoracic, or lumbar spine, with the
patient position prone. As described above,
indications for surgery should be conrmed
with imaging. Spinal MRI without contrast is
the most useful study for denitive assessment
of neural elements of the spine with suspected
injury; however, MRI may also be an absent or
prohibitively expensive resource in many LMIC
settings. In these cases, computed tomography
imaging can provide invaluable information
about osseous patho-anatomy and facilitate
deductions about soft tissue injury. At minimum, X-ray studies should be available to
guide surgical decision-making.
Ideally, neurophysiologic monitoring would
provide a means of assessing neurological compromise and the patient with spinal injury both
before and after positioning the patient for surgery. Blood loss should be anticipated before surgery, minimized using meticulous hemostasis,
and factored into the plans for surgery so that
availability of blood for transfusion is conrmed
if signicant blood loss is anticipated.
The general procedure for laminectomy
begins with carefully ipping the intubated and
sedated patient prone, avoiding any uncoordi-
nated or sudden movements during this maneuver that might exacerbate an existing injury. If
intraoperative X-ray is available, such as a C-arm,
then the site of surgery is localized using intraoperative X-ray. If this imaging is not available,
then localization must be done using preoperative
imaging studies and anatomic landmarks; for
fracture dislocations, a palpable step-off readily
identies the side of interest. Hair is removed,
and a midline incision as planned. After a standard sterile surgical prepping and draping, an
incision is made over the level(s) of interest, and
a subperiosteal dissection is performed, exposing
the spinous processes and laminae at the levels of
interest. Care is taken to protect the facet joints
and their overlying capsules. Using a combination of available rongeurs and osteotomes, the
spinous processes, supraspinous and interspinous
ligaments, and the laminae are removed, taking
care to preserve the facet joints, and the pars
interarticularis, bilaterally. Care is taken to prevent injury to any neurovascular elements, or violation of the thecal sac; however, in the setting of
trauma, there may already be a traumatic cerebrospinal uid stula. This is primarily repaired
as possible using appropriately sized suture and/
or local autograft of fat and/or muscle. Synthetic
adhesives, such as DuraSeal Exact, can be helpful if/when available to augment such dural
repair.
Upon completion of decompression procedures, if no stabilization is required, then the
wound is closed in layers, starting with approximation and primary closure of the fascia incision,
followed by successive supercial levels of subcutaneous, and nally epidermal closure.
Surgical Stabilization
Stabilization refers to placement of spinal
implants, such as screws and rods, to rigidly,
internally immobilize destabilized levels for
healing and, when indicated, to facilitate osseous
fusion of injured levels. In the cervical spine, lateral mass screws are typically placed, using one
of the screw insertion techniques that aim to
achieve good bone purchase while minimizing
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the risk of injury to the vertebral arteries, or cervical spinal nerves. The An technique for screw
insertion places the screw entry point in the
lateral mass at approximately 1mm medial to the
center and uses a cephalo-lateral trajectory with
cranial inclination of about 10–15 degrees and
lateral trajectory of about 25–30 degrees [31].
Screws placed in the thoracic and lumbar
spine generally target the particles. At these levels, intraoperative X-ray is a vital tool for assuring accuracy of screw placement. When not
available, classic anatomical landmarks and some
intraoperative techniques may be used to achieve
the best approximation of pedicle trajectory. One
example of intraoperative technique that can
optimize pedicle screw placement in the absence
of adequate intraoperative imaging is the concept
of lamina-pedicle perpendicularity, described by
Elky etal. [32, 33] This technique, utilizing the
nearly orthogonal orientation of each thoracic or
lumbar pedicle to the sagittal inclination given by
the edge of the inferior lamina, has shown
remarkable accuracy in its ability to estimate the
location of thoracic and lumbar screws for safe
screw placement.
Upon completion of screw placement at indicated levels, rods typically made from titanium or
other biologically compatible metals are bent as
needed to achieve the desired spinal curvature or
correction and subsequently secured to the heads
of the screws for completion of internal xation.
Following internal xation of indicated spinal
levels, arthrodesis may be initiated by facet capsule disruption and decortication of the joint surfaces at each pair of intervening intervertebral
joints. Generally, bony fusion across spinal levels
of desired arthrodesis requires 3months or more
of healing time. Stabilization of fusion levels
with instrumentation facilitates early mobilization and rehabilitation in the postoperative period,
which in turn enables patients to more quickly
resume activities of daily living and, as possible,
professional activities. In resource-limited contexts, the lack of spinal instrumentation can
therefore pose a barrier to optimal clinical and
socioeconomic outcomes following spine surgery. Surgeons treating patients with spinal
pathology in LMICs must therefore carefully
consider the risks and benets of intervention
when the tools required for optimal treatment
may not be available. In these contexts, a health
equity-driven agenda for advancing neurosurgical capacity may require a combination of charitable support from international medicosurgical
device companies, strategic partnerships with
institutions in HICs for global neurosurgical program development, and a long-term plan for local
health system strengthening designed to fully
address unmet needs for neurosurgical care [34].
Summary/Conclusion
The eld of neurosurgery constitutes a vast array
of pathology requiring human and material
resources that are often inadequate, or completely absent from the healthcare systems of
LMICs. Despite these challenges, a growing
number of clinicians, researchers, educators, and
health policy experts and advocates are recognizing the unmet need for neurosurgical care
around the world and the impact of the indispensable requirement to respond to this need in
order to advance global health equity, economic
welfare, and social justice [1, 35]. This chapter
introduces selected neurosurgical disorders,
management strategies, and techniques that the
authors have found to be especially relevant to
the prevailing burden of neurosurgical diseases
in LMICs.
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