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The white paper published by the Lancet Commission put forward surgery as a global health priority. In that paper, their findings showed that 5 billion people in the world do not have access to 'safe, affordable surgical and anesthesia services when needed,' and this inequity is more evident in lower- and middle-income countries (LMICs). These deficits are even more profound in surgical subspecialties such as neurosurgery. The paper "Global Neurosurgery: The Unmet Needs," published in 2016, addresses the system-level thinking and programs required to address the needs of neurosurgical care in lower resource settings. Neurosurgeons need to have influence, presence, and leadership role in advocating for the surgical system strengthening worldwide as it is estimated that there are 5 million emergency and essential neurosurgery neurosurgical services currently unmet, especially in LMICs. Thus, in 2019, the World Federation of Neurosurgical Societies (WFNS) established the Global Neurosurgery Committee (GNC), an ad hoc committee dedicated to organizing and furthering global neurosurgical efforts. The Committee is co-chaired by Kee B. Park, MD, MPH from the United States, and Abdessamad El Ouahabi, MD from Morocco. The body of the GNC was the Committee of 22 neurosurgeons from 19 countries; the Secretariat Team primarily managed internal GNC operations with support from the later-added Junior Committee, both of which were international medical students and trainees. One of the objectives of this Committee is to promote advocacy efforts for neurosurgical care within universal healthcare coverage. This paper explores the fifth "ADVOCATE" objective, including its significance, the GNC's efforts, and progress toward executing its defining targets.

The Global Neurosurgery Committee (GNC) of the World Federation of Neurosurgical Societies (WFNS) launched the Global Action Plan during the 2016 Bogota Declaration on Global Neurosurgery in Colombia in order to coordinate efforts and bring neurosurgeons around the world to address unmet neurosurgical care. The Global Action Plan contains five objectives: Amplify, Align, Advance, Assimilate and Advocate for neurosurgical care. In this paper, we present the goals and the work of the Advance team. The goal of the Advance objective was to “A. Map research output by region and themes, B. Establish one or more Global Neurosurgery research grant and/or award mechanisms, C. Advocate for Global Neurosurgery category/sections in major neurosurgery journals (3 or more by 2021), D. Establish funding mechanisms for training in future leaders in the public health practice of Global Neurosurgery (2 or more by 2021), E. Inclusion of Global Neurosurgery Sessions in major neurosurgery meetings (>75% by 2021), F. Establish a mentoring relationship between editorial board members from HIC and LMICs (>1 by 2021), and G. Establish a mentoring relationship between authors from HIC and LMICs (>1 by 2021).

The field of global surgery has gained attention since the publication of the Lancet Commission landmark report in 2015. The authors estimated that 5 billion people worldwide do not have access to safe, affordable surgical and anesthesia services. The paper “Global Neurosurgery: The Unmet Need,” published in 2016, launched the modern global neurosurgery era by advocating for the system-level thinking and programs required to address limited neurosurgical care in low-resource settings. At present, many individuals, academic institutions, governmental agencies, and nongovernmental organizations (NGOs) are involved in the global neurosurgery movement. These include the Program in Global Surgery and Social Change at Harvard Medical School, Duke Global Neurology and Neurosurgery, Weill Cornell Tanzania Neurosurgery Project, CURE Children’s Hospital of Uganda, and the Virtue Foundation in Mongolia. Nonetheless, as global neurosurgery efforts continue to expand, it is essential to align global neurosurgery activity in order to prevent duplication of effort. In 2019, the World Federation of Neurosurgical Societies (WFNS) established the Global Neurosurgery Committee (GNC) to promote access to safe, affordable, and timely neurosurgical care worldwide. The GNC initially included five primary objectives – Amplify, Align, Advance, Assimilate, and Advocate – with the sixth objective, Communication, added in 2021. In this manuscript, we provide an update on the Align objective team.

This study aimed to identify factors that predict complications following cranioplasty, by conducting a retrospective cohort study at a large tertiary care center. Electronic databases were searched to identify all patients who underwent cranioplasty at our institution. Baseline demographics, perioperative variables, and outcomes were extracted. Logistic regression analyses were conducted to identify factors associated with cranioplasty complications. Of the 92 included patients, 15 (16.3%) experienced one or more complications, with 11 (73.3%) experiencing complication within 30 days of cranioplasty. Patients aged ≤60 had decreased odds of all-cause complication (OR 0.058; 95% CI 0.008–0.434) and cranioplasty graft removal (OR 0.035; 95% CI 0.004–0.321) on multivariate analysis. Titanium mesh cranioplasties were associated with increased odds of all-cause complication (OR 19.776; 95% CI 1.021–382.901), and cranioplasty removal (OR 29.780; 95% CI 1.330–666.878). A longer craniectomy–cranioplasty interval was associated with increased odds of cranioplasty removal (OR 1.005; 95% CI 1.000–1.010). An initial craniectomy indication of cerebral infarction was associated with decreased odds of all-cause complication (OR 0.042; 95% CI 0.002–0.876) and cranioplasty removal (OR 0.032; 95% CI 0.001–0.766). Elderly patients may require more aggressive follow-up and antibiotic prophylaxis in the postoperative period following cranioplasty. Additionally, avoiding the use of titanium mesh cranioplasties and prolonged craniectomy–cranioplasty intervals may further reduce complications.

When it comes to surgical subspecialties such as neurological surgery, access to care goes from being a disparity to a complete absencein many cases as access to neurosurgical care is no longer a right but a luxury. To address this need multiple organizations have workedto improve access to neurosurgery, and as global neurosurgical efforts expand a concerted effort is necessary to ensure safe,sustainable and equitable care is provided and efforts by the multiple stakeholders are not duplicated. To that end, the GlobalNeurosurgery Committee (GNC) of the World Federation of Neurosurgical Societies (WFNS) created an action plan for directedcollaboration. We introduce the GNC Action Plan here and describe its guiding principles, divided into five objectives that encompassthe necessary steps to achieve universal access to neurosurgical care: 1) amplifying access to neurosurgical care, 2) aligning globalneurosurgery activities, 3) advancing global neurosurgery research efforts, 4) assimilating neurosurgical capacity building into s urgicalsystems, and 5) advocating for neurosurgical care within Universal Health Coverage.

Given the increased demand for anesthesia and surgical services during the COVID-19 pandemic, it has become clear that surgery is acritical part of health capacity. There is an urgent need to markedly scale up surgical services within health systems strengtheningefforts, particularly in LMIC’s. We organized a panel titled “Surgery: Suturing the Gaps in Global Health Security” within th e larger series“From Pandemic to Progress: Building Capacity Through Global Surgical, Obstetric, Trauma, and Anaesthesia” during the 75th UnitedNations General Assembly (UNGA). The event was co-sponsored by the G4 Alliance and the Program in Global Surgery and SocialChange (PGSSC) at Harvard Medical School. Given the COVID-19 pandemic, the panel, along with the remainder of the UNGA this year,was virtually, greatly increasing the attendance of physicians, trainees, and policymakers worldwide. Additionally, the panel wasrecorded and made freely accessible online to allow for viewing by individuals after the session. The panelists highlighted three keythemes. Affordable and timely surgical care is critical for global health equity and investing in surgical capacity strengthe ns pandemicreadiness. Key stakeholders such as international and nongovernmental health organizations, philanthropic funders, and particularlynational and local governments must be engaged in order to promote cross-sector support. The economic impact of investing insurgical care must be emphasized. Future initiatives will build on these themes in order to improve health care access and security.

Five million neurosurgical cases go untreated each year. This is in part due to the lack of neurosurgical care providers. The World Federation of Neurosurgical Societies has spearheaded efforts to monitor the number of neurosurgical providers around the globe since 2016. In this perspective, we discuss why, when, and how the neurosurgical workforce should be measured.

BrainPath (NICO, Indianapolis, Indiana) is a tool that can be used to evacuate supratentorial hematomas due to spontaneous intracerebral hemorrhage (ICH). However, when ICH occurs in the posterior fossa, an open approach is often undertaken to evacuate the hematoma. The application of minimally invasive technology, while available, has not been well established. Our objective was to describe the use of the image-guided, minimally invasive BrainPath system to evacuate a spontaneous cerebellar hemorrhage. We present the case of a sixty-four-year-old male patient with a cerebellar hematoma due to hypertensive hemorrhage. The patient's medical record, including the history and physical, progress notes, operative notes, discharge summary, and imaging studies were reviewed to document the clinical presentation as well as the details of the operative technique and postoperative outcomes in this paper. We discuss the technical nuances of the operative points in detail. In our example case, the BrainPath system was successfully used to evacuate the cerebellar hematoma and no procedural-related complications occurred. The patient's recovery remained uncomplicated at three months of follow-up. In summary, the BrainPath system offers a less invasive alternative to open evacuation for cerebellar bleeds.

BackgroundThe use of quantitative and qualitative scientometrics provides deductive and inductive insights into the landscape of research in a specific area. In this manuscript, the authors identified the major contributors of African neurosurgery and emerging terms.MethodsArticles on African neurosurgery were searched on Web of Science and 8 other repositories without language or date restrictions. The H-index, co-author, author country, time trend, and keyword analyses were done using Bibexcel and VOSviewer.Results115 articles on African neurosurgery were published in 36 journals by 90 first authors. The journals with the most articles were World Neurosurgery (46, 40.0%), Journal of Neurosurgery Pediatrics (8, 7.0%), and Neurosurgery (7, 6.1%). There was a rapid increase in the number of articles from 2010 and the median number of citations was 8 (IQR: 4-16). Qureshi MM had the highest H-index score (6) while Warf BC (5, 4.3%), Adeleye AO (4, 3.5%), and El Khamlichi (4, 3.5%) contributed the most to the 115 articles. The articles by Lanzino G (1999), Warf BC (2011), and Warf BC (2005) were the most influential. The U.S.A. had the largest node and South Africa, Kenya and Uganda were the most impactful African countries. Pediatric neurosurgery dominated the keywords and global neurosurgery was an emerging term. ConclusionThe most cited articles on African neurosurgery are published in prestigious specialty journals and neurosurgeons from Southern and East Africa are the most impactful local researchers. Future research should analyze the differences between African regions.

BackgroundAfrican neurosurgical practice is faced with numerous challenges. Although there have been improvements in recent years, some problems persist. Research can help identify these problems and propose solutions for the growth of African neurosurgery. In this study, we decided to evaluate the landscape of African research.MethodsPubMed, Embase, and Web of Science were searched from inception to April 24, 2020. Duplicate articles were excluded, and at least two authors reviewed non-duplicate articles on Rayyan. After data had been extracted, they were analyzed to generate descriptive statistics (number of articles and articles per local neurosurgeon). The Kruskal Wallis test and Spearman's correlation were used for bivariate data analyses.ResultsThe authors reviewed 667 articles on neurosurgery in 34 (63%, n=54) African countries. Malawi (4.50), South Africa (3.33), and Benin (2.33) had the highest number of articles per local neurosurgeon (after excluding articles by foreign researchers). Foreign researchers published 1.0 (IQR=2.5) articles per country. Articles were published in World Neurosurgery (120, 18.0%), South African Medical Journal (44, 6.6%), and Journal of Neurosurgery Pediatrics (34, 5.1%). The articles were on pediatric neurosurgery (167, 25.0%) and neurotrauma (129, 19.3%). Also, the majority (411, 61.6%) of studies were cross-sectional.ConclusionAfrican neurosurgeons produce a median of 0.4 articles and publish in well-established journals. Collaboration with foreign researchers significantly increases local research output. In the future, we should assess the impact of this research.

Background Neurotrauma is a leading cause of morbidity and mortality around the world. Assessment of injury prevention and prehospital care for neurotrauma patients is necessary to improve care systems. Methods A 29-question electronic survey was developed based on the Enhancing the Quality and Transparency Of health Research (EQUATOR) checklist to assess neurotrauma policies and laws related to safety precautions. The survey was distributed to members of World Health Organization regions that were considered to be experienced medical authorities in neurosurgery and traumatic brain injury. Results There were 82 (39%) responses representing 46 countries. Almost all respondents (95.2%) were within the neurosurgical field. Of respondents, 40.2% were from high-income countries (HICs), and 59.8% were from low- and middle-income countries (LMICs). Motor vehicle accidents were reported as the leading cause of neurotrauma, followed by workplace injury and assault. Of respondents, 84.1% reported having a helmet law in their country. HICs (4.38 ± 0.78) were ranked more likely than LMICs (2.88 ± 1.34; P = 0.0001) to enforce helmet laws on a scale of 1–10. Effectiveness of helmet laws was rated as 3.94 ± 0.95 out of 10. Measures regarding prehospital care varied between HICs and LMICs. Patients in HICs were more likely to use public emergency ambulance transportation (81.8% vs. 42.9%; P = 0.0004). All prehospital personnel having emergency training was also reported to be more likely in HICs than LMICs (60.6% vs. 8.7%; P = 0.0001). Conclusions When injuries occur, timely access to neurosurgical care is critical. A focus on prehospital components of the trauma system is paramount, and policymakers can use the information presented here to implement and refine health care systems to ensure safe, timely, affordable, and equitable access to neurotrauma care.

Introduction 33 million people worldwide face catastrophic health expenditures each year from surgery and anesthesia. This study aims to collate the current literature on out-of-pocket (OOP) costs of Bellwether neurosurgical procedures in low- and middle-income countries (LMICs) to provide a basis for calculations of financial burdens, determine deficits in the literature, and guide further research efforts. Method MEDLINE/PubMed, Embase, Cochrane Library, Google Scholar and Relief Web were searched for articles containing data on OOP costs for neurosurgical Bellwether procedures in LMICs. Of 415 relevant publications that were identified, 4 met inclusion criteria. Results One study from Uganda found median direct medical and non-medical costs to be USD 118.06 and USD 84.33, respectively. A study from Vietnam found the total medical care and surgery for head injury OOP cost to be USD 287.30 and USD 63, respectively. A multi-country study found the cost of neuroimaging to vary by country income level and public/private institutions with a range of USD 14 to USD 286. Discussion There is great variability in OOP expenses for neurosurgical Bellwether procedures, but the average cost to the patient did not exceed USD 300. When assessing patient expenditures, attention should be given to average country income, as the cost of a medical expense may be lower in an LMIC but the impact on the patient greater due to lower income. More studies on OOP costs for neurosurgical interventions in LMICs are needed to provide evidence for policy changes geared towards financial risk protection.

Introduction 33 million people worldwide face catastrophic health expenditures each year from surgery and anesthesia. This study aims to collate the current literature on out-of-pocket (OOP) costs of Bellwether neurosurgical procedures in low- and middle-income countries (LMICs) to provide a basis for calculations of financial burdens, determine deficits in the literature, and guide further research efforts. Methods MEDLINE/PubMed, Embase, Cochrane Library, Google Scholar and Relief Web were searched for articles containing data on OOP costs for neurosurgical Bellwether procedures in LMICs. Of 415 relevant publications that were identified, 4 met inclusion criteria. Results One study from Uganda found median direct medical and non-medical costs to be USD 118.06 and USD 84.33, respectively. A study from Vietnam found the total medical care and surgery for head injury OOP cost to be USD 287.30 and USD 63, respectively. A multi-country study found the cost of neuroimaging to vary by country income level and public/private institutions with a range of USD 14 to USD 286. Discussion There is great variability in OOP expenses for neurosurgical Bellwether procedures, but the average cost to the patient did not exceed USD 300. When assessing patient expenditures, attention should be given to average country income, as the cost of a medical expense may be lower in an LMIC but the impact on the patient greater due to lower income. More studies on OOP costs for neurosurgical interventions in LMICs are needed to provide evidence for policy changes geared towards financial risk protection.

Here the authors demonstrate open craniofacial reconstruction for the correction of craniosynostosis, using techniques refined by Dr. James T. Goodrich at Montefiore Medical Center. They present the operative management of a case of unilateral coronal synostosis in a 12-month-old child, who presented with right forehead prominence and calvarial asymmetry. The patient had an excellent correction of her head shape with an uneventful postoperative course. This video highlights the authors’ multidisciplinary approach to complete cranial vault remodeling, utilizing a Marchac bandeau construct and split calvarial graft mosaic technique. The video can be found here: https://vimeo.com/519489422.

Although the current COVID-19 pandemic has had a sudden and negative effect on the ability to train neurosurgeons, especially in LMICs, the increased use of social media and virtual platforms (in our case, Zoom) is markedly improving the interactions between the leadership of the WFNS and neurosurgeons around the globe The feedback from the audience will serve as a reliable driver of how the WFNS will respond to the pandemic vis-a-vis training The WFNS leadership has been quick to adapt to the pandemic and has proactively encouraged the use of virtual platforms for its activities Three recommendations surfaced from the discussions: harmonization of the present "several randomly organized webinars by various WFNS committees" to create a coherent and essential curriculum suitable for LMIC trainees and accepted by national accreditation authorities, reinforcement of twinning programs with more organized collaborations between high-income countries and LMICs, and the development and validation of novel educational and training tools such as virtual meetings, virtual laboratories, and surgical simulation using augmented reality

The COVID-19 pandemic has stretched health care resources to a point of crisis throughout the world. To answer the call for care, health care workers in a diverse range of specialties are being retasked to care for patients with COVID-19. Consequently, specialty services have had to adapt to decreased staff available for coverage coupled with a need to remain available for specialty-specific emergencies, which now require a dynamic definition. In this Invited Commentary, the authors describe their experiences and share lessons learned regarding triage of patients, staff safety, workforce management, and the psychological impact as they have adapted to a new reality in the Department of Neurosurgery at Montefiore Medical Center, a COVID-19 hot spot in New York City.

The endoscopic endonasal approach (EEA) provides visualization of four deep surgical corridors (transcribiform, transtubercular, transsellar, and transclival) with superior illumination and specialized deep-reaching instruments, as compared to microscopic techniques. Several studies have evaluated EEAs in children but do not stratify for the very young of age, whose particularly small nares and developmental anatomy may limit endonasal instrumentation. A comprehensive review of EEAs in infants and children to age 4 was performed to determine the limitations in this age group. Eighteen studies were identified describing this approach for pediatric patients and the surgical caveats and limitations were reviewed. In very small children, CSF leaks, meningioencephaloceles, tumors of the anterior skull base, and lesions at the rostral cervical spine have been successfully treated endonasally. While newer studies advocate using 2.7-mm diameter (18-cm length) lenses, 4-mm diameter rigid lenses have been used without technical difficulty. The youngest patient in whom an EEA was used was a 6-week-old for a dermoid resection. Some have advocated that due to the small nares, approaches via bilateral entry are optimal for multiple instruments, however, others, including authors of a series of 28 repaired CSF leaks demonstrate successful single nare access. EEAs are associated with less blood loss, are less likely to hinder normal growth of the skull and midface, and allow for the resection of even malignant lesions. Despite the limitations of the frontal, ethmoid, and sphenoid sinuses before age 3, reports have not documented insurmountable difficulty with EEAs even in infants. 2.7-mm diameter endoscopes are favored unilaterally or bilaterally to treat both benign and malignant lesions and preserve the young patient’s facial anatomy better than older methods. Ever improving technology has facilitated the use of this approach in patients it would otherwise be infeasible for in the past, but it still cannot overcome the anatomical constraints of certain young patients in which this approach remains unindicated. Patient selection is therefore of utmost importance and the risks and benefits of more extensive approaches in these cases must be considered.

Background The relatively decreased time spent in the operating room and overall reduction in cases performed by neurosurgical trainees as a result of duty-hour restrictions demands that the pedagogical content within each surgical encounter be maximized and crafted toward the specific talents and shortcomings of the individual. It is imperative to future generations that the quality of training adapts to the changing administrative infrastructures and compensates for anything that may compromise the technical abilities of trainees. Neurosurgeons in teaching hospitals continue to experiment with various emerging technologies—such as simulators and virtual presence—to supplement and improve surgical training. Methods The authors participated in the Google Glass Explorer Program in order to assess the applicability of Google Glass as a tool to enhance the operative education of neurosurgical residents. Google Glass is a type of wearable technology in the form of eyeglasses that employs a high-definition camera and allows the user to interact using voice commands. Results Google Glass was able to effectively capture video segments of various lengths for residents to review in a variety of clinical settings within a large, tertiary care university hospital, as well as during a surgical mission to a developing country. The resolution and quality of the video were adequate to review and use as a teaching tool. Conclusion While Google Glass harbors the potential to dramatically improve both neurosurgical education and practice in a variety of ways, certain technical drawbacks of the current model limit its effectiveness as a teaching tool.

Background: Bone morphogenetic protein–2 (BMP-2) is an available bone graft option in spinal fusion surgery. The purpose of this study is to investigate the trends of BMP-2 utilization in adult spinal deformity (ASD) surgery. Methods: The Nationwide Inpatient Sample database from 2002 to 2011 was reviewed. Inclusion criteria were patients over 18 years of age who underwent spinal fusion for ASD. Trends of BMP-2 use were examined over time, as well as stratified based on patient and surgical characteristics. All analyses were done after application of discharge weights to produce national estimates. Results: There were 54 054 patients who met inclusion criteria and were included in this study. The overall rate of BMP-2 use was 39.7% (95% confidence interval 35.0%- 44.3%). Overall, there was steady increase in its use over time, with the highest peak in 2009 (55.3% of all cases used BMP-2), and then a decrease up to 37.9% in 2011 (P Conclusion After analysis of a large nationwide database, it was found that the rate of BMP-2 use in ASD surgery is approximately 40%. There was a significant increase in use from 2002 to 2009, and a decrease thereafter. The highest rates of use were found in older patients, female patients, white patients, Medicare patients, circumferential approaches, and patients undergoing surgery in the Midwest and West regions.