Walter D. Johnson

Surgery and radiotherapy: complementary tools in the management of benign intracranial tumors

Historically, radiation therapy has been used extensively in the treatment of malignant and aggressive intracranial tumors, and the importance of its role has been repeatedly verified by prolonged patient survival rates and increased tumor control. As more modern capabilities are employed in surgery and radiotherapy, attention is being directed to the utility of radiation as either primary or secondary treatment of benign tumors. Specifically, primary treatment encompasses irradiation of small benign tumors without biopsy confirmation of tumor type; secondary treatment involves postoperative radiation therapy, with the possibility that less-aggressive tumor resection may be performed in areas that have a higher probability of resultant neurological deficit. Current literature suggests that this is not only a possible treatment strategy, but that it may be superior to more radical resection in some cases, for example, in vestibular schwannomas and meningiomas. This article provides an overview of factors to consider in the use of radiation therapy and reviews the relationships between radiation and surgery, notably the unique complementary role each plays in the treatment of benign intracranial tumors.

Radiation therapy in the treatment of pituitary tumors

The treatment of pituitary tumors has progressed into a multidisciplinary approach that involves neurosurgeons, radiation oncologists, and endocrinologists. This has allowed improved outcomes in treatment of pituitary tumors due to a combination of surgical, medical, and radiation therapies. In this study, the authors review the role of radiation therapy in the treatment of pituitary adenomas.

Variety of spinal vascular pathology seen in adult Cobb syndrome.

Cobb syndrome is a rare clinical entity that includes the combination of a vascular skin nevus and an angioma in the spinal canal present at identical dermatomal level(s) (cutaneomeningospinal angiomatosis). To date, 38 cases have been reported, only 18 of which are in adults (> 18 years of age). The majority of these cases have been described in the era predating current neuroimaging techniques, and most authors have assumed that each case involves similar vascular pathology. This report highlights 2 patients presenting with similar thoracic cutaneous vascular nevi yet with markedly differing spinal vascular pathology. A 29-year-old man presented with cutaneous hemangioma and a progressive paraparesis and paresthesia of the lower extremities. A 20 x 20-cm port-wine stain over his right upper midback (T6-10) correlated precisely with MR imaging that demonstrated an enhancing epidural mass between T-6 and T-10 causing compression of the cord and cord edema. A 34-year-old man also presented with progressive myelopathy and a 15 x 20-cm port-wine stain within the same dermatomal region as a Type III spinal arteriovenous malformation. Workup for each patient included pre- and postoperative contrast-enhanced MR imaging with vascular sequencing and spinal angiography. The first patient was treated with bilateral laminectomy at the T6-10 levels, with significant postoperative improvement in motor strength. The second patient underwent coil embolization of an intranidal aneurysm, with follow-up embolization 8 years later. Cobb syndrome is an unusual entity in the adult population and should be considered when there is a constellation of cutaneous manifestation and underlying neurological deficit. The vascular skin nevus associated with Cobb syndrome is accompanied by a wide variety of vascular pathologies.

Neurosurgical Care: Availability and Access in Low-Income and Middle-Income Countries

BACKGROUND An estimated 5 billion people worldwide lack access to basic surgical care. In particular, the vast majority of low-income and middle-income countries (LMICs) currently struggle to provide adequate neurosurgical services. Significant barriers exist, including limited access to trained medical, nursing, and allied health staff; lack of equipment; and availability of services at reasonable distance and at reasonable cost to patients. An accurate assessment of current neurosurgical capacity in LIMCs is an essential first step in tackling this deficit. OBJECTIVE To quantify the neurosurgical operational capacity and assess access to neurosurgical services in LMICs, by taking into account the location of workforce and services. METHODS A total of 141 LMICs were contacted and asked to report the number of currently practicing neurosurgeons, access to computed tomographic and magnetic resonance imaging, and availability of neurosurgical equipment (microscope, endoscope, bipolar diathermy, high-speed neurosurgical drill). A proposed World Federation of Neurosurgeons classification was used to stratify cities based on the level of neurosurgical care that could be provided. The data were geocoded and analyzed in Redivis (Redivis Inc.) to assess the percentage of the population covered within a 2-hour travel time of a city offering differing levels of neurosurgical care. RESULTS 68 countries provided complete data (response rate, 48.2%). Eleven countries reported having no practicing neurosurgeons. The average percentage of the population with access to neurosurgical services within a 2-hour window is 25.26% in sub-Saharan Africa, 62.3% in Latin America and the Caribbean, 29.64% in East Asia and the Pacific, 52.83% in South Asia, 79.65% in the Middle East and North Africa, and 93.3% in Eastern Europe and Central Asia. CONCLUSIONS There are several challenges to the provision of adequate neurosurgical services in low-resource settings. This study used mapping techniques to determine the current global neurosurgical workforce capacity and distribution. We have used our findings to identify areas for improvement. These include increasing and improving neurosurgical training programs worldwide, recruiting students and young physicians into the field, and retaining existing neurosurgeons within their home countries.

Global neurosurgery: the current capacity and deficit in the provision of essential neurosurgical care. Executive Summary of the Global Neurosurgery Initiative at the Program in Global Surgery and Social Change

OBJECTIVEWorldwide disparities in the provision of surgical care result in otherwise preventable disability and death. There is a growing need to quantify the global burden of neurosurgical disease specifically, and the workforce necessary to meet this demand.METHODSResults from a multinational collaborative effort to describe the global neurosurgical burden were aggregated and summarized. First, country registries, third-party modeled data, and meta-analyzed published data were combined to generate incidence and volume figures for 10 common neurosurgical conditions. Next, a global mapping survey was performed to identify the number and location of neurosurgeons in each country. Finally, a practitioner survey was conducted to quantify the proportion of disease requiring surgery, as well as the median number of neurosurgical cases per annum. The neurosurgical case deficit was calculated as the difference between the volume of essential neurosurgical cases and the existing neurosurgical workforce capacity.RESULTSEvery year, an estimated 22.6 million patients suffer from neurological disorders or injuries that warrant the expertise of a neurosurgeon, of whom 13.8 million require surgery. Traumatic brain injury, stroke-related conditions, tumors, hydrocephalus, and epilepsy constitute the majority of essential neurosurgical care worldwide. Approximately 23,300 additional neurosurgeons are needed to address more than 5 million essential neurosurgical cases-all in low- and middle-income countries-that go unmet each year. There exists a gross disparity in the allocation of the surgical workforce, leaving large geographic treatment gaps, particularly in Africa and Southeast Asia.CONCLUSIONSEach year, more than 5 million individuals suffering from treatable neurosurgical conditions will never undergo therapeutic surgical intervention. Populations in Africa and Southeast Asia, where the proportion of neurosurgeons to neurosurgical disease is critically low, are especially at risk. Increasing access to essential neurosurgical care in low- and middle-income countries via neurosurgical workforce expansion as part of surgical system strengthening is necessary to prevent severe disability and death for millions with neurological disease.

Neurosurgery and Sustainable Development Goals

BACKGROUND On September 25, 2015, the United Nations General Assembly adopted a 17-goal action plan to transform the world by the year 2030, ushering in the Era of Sustainable Development. These Sustainable Development Goals (SDGs) were designed to continue where the preceding Millennium Development Goals left off, expanding on the Millennium Development Goal successes, and facing the challenges encountered during the previous decade and a half. The current Era of Sustainable Development and its impact on a breadth of neurosurgical concerns provide several unprecedented opportunities to enhance political prioritization of neurosurgical care equity. Neurosurgeons could therefore be well positioned to participate in the leadership of these global health development and policy reform efforts. METHODS Each of the 17 SDGs was reviewed and analyzed for its relevance to the public health aspects of neurosurgery. The analysis was guided by a review of the literature performed in PubMed, Google Scholar, and the databases of the World Health Organization. RESULTS Among the 17 SDGs, 14 were found to be of direct or indirect relevance to neurosurgeons and neurosurgical care delivery. Results of this analysis are presented and discussed, and recommendations are provided for using this knowledge to inform the emerging discipline of global neurosurgery. CONCLUSIONS This article contributes to the global neurosurgery movement by providing the socially and globally conscious neurosurgeon with a compass for directing the place of neurosurgery in the international agenda for sustainable development.

Healthcare Leaders Develop Strategies for Expanding National Surgical, Obstetric, and Anaesthesia Plans in WHO AFRO and EMRO Regions

BackgroundWorldwide, five billion people lack access to safe, affordable surgical, obstetric, and anaesthesia (SOA) care when needed. In many countries, a growing commitment to SOA care is culminating in the development of national surgical, obstetric, and anaesthesia plans (NSOAPs) that are fully embedded in the National Health Strategic Plan. This manuscript highlights the content and outputs from a World Health Organization (WHO) lead workshop that supported country-led plans for improving SOA care as a component of health system strengthening.MethodsIn March 2018, a group of 79 high-level global SOA stakeholders from 25 countries in the WHO AFRO and EMRO regions gathered in Dubai to provide technical and strategic guidance for the creation and expansion of NSOAPs.ResultsDrawing on the experience and expertise of represented countries that are at different stages of the NSOAP process, topics covered included (1) the global burden of surgical, obstetric, and anaesthetic conditions; (2) the key principles and components of NSOAP development; (3) the critical evaluation and feasibility of different models of NSOAP implementation; and (4) innovative financing mechanisms to fund NSOAPs.ConclusionsLessons learned include: (1) there is unmet need for the establishment of an NSOAP community in order to provide technical support, expertise, and mentorship at a regional level; (2) data should be used to inform future priorities, for monitoring and evaluation and to showcase advances in care following NSOAP implementation; and (3) SOA health system strengthening must be uniquely prioritized and not hidden within other health strategies.

Operative and consultative proportions of neurosurgical disease worldwide: estimation from the surgeon perspective

OBJECTIVEThe global magnitude of neurosurgical disease is unknown. The authors sought to estimate the surgical and consultative proportion of diseases commonly encountered by neurosurgeons, as well as surgeon case volume and perceived workload.METHODSAn electronic survey was sent to 193 neurosurgeons previously identified via a global surgeon mapping initiative. The survey consisted of three sections aimed at quantifying surgical incidence of neurological disease, consultation incidence, and surgeon demographic data. Surgeons were asked to estimate the proportion of 11 neurological disorders that, in an ideal world, would indicate either neurosurgical operation or neurosurgical consultation. Respondent surgeons indicated their confidence level in each estimate. Demographic and surgical practice characteristics-including case volume and perceived workload-were also captured.RESULTSEighty-five neurosurgeons from 57 countries, representing all WHO regions and World Bank income levels, completed the survey. Neurological conditions estimated to warrant neurosurgical consultation with the highest frequency were brain tumors (96%), spinal tumors (95%), hydrocephalus (94%), and neural tube defects (92%), whereas stroke (54%), central nervous system infection (58%), and epilepsy (40%) carried the lowest frequency. Similarly, surgery was deemed necessary for an average of 88% cases of hydrocephalus, 82% of spinal tumors and neural tube defects, and 78% of brain tumors. Degenerative spine disease (42%), stroke (31%), and epilepsy (24%) were found to warrant surgical intervention less frequently. Confidence levels were consistently high among respondents (lower quartile > 70/100 for 90% of questions), and estimates did not vary significantly across WHO regions or among income levels. Surgeons reported performing a mean of 245 cases annually (median 190). On a 100-point scale indicating a surgeons perceived workload (0-not busy, 100-overworked), respondents selected a mean workload of 75 (median 79).CONCLUSIONSWith a high level of confidence and strong concordance, neurosurgeons estimated that the vast majority of patients with central nervous system tumors, hydrocephalus, or neural tube defects mandate neurosurgical involvement. A significant proportion of other common neurological diseases, such as traumatic brain and spinal injury, vascular anomalies, and degenerative spine disease, demand the attention of a neurosurgeon-whether via operative intervention or expert counsel. These estimates facilitate measurement of the expected annual volume of neurosurgical disease globally.

In reply: Encouraging a bare minimum while striving for the gold standard: a response to the updated WHO-WFSA guidelines

To the Editor, We are thankful for the opportunity to respond to the letter from Dr. Hendel et al. addressing the World Health Organization-World Federation of Societies of Anaesthesiologists (WHO-WFSA) International Standards for a Safe Practice of Anesthesia reiterating their previously stated concern that such standards set the bar too high. The WHO-WFSA workgroup was globally representative and was balanced for sex, geography, and high-, middle-, and low-income country membership. Thus, the advice of representatives from low-income countries in different parts of the world was sought and included. This is in contrast to the authorship group of Hendel et al. where only a part of Africa was represented among low-income countries. Hendel et al. seem to have missed the distinction made in our Standards document between emergency surgery to save life or limb and purely elective or semi-elective surgery. Their disconcerting statement ‘‘We do a disservice to those who rely on a bare minimum by implying that they should have oxygen, safety monitors, and essential medicines at all times’’ is difficult to reconcile with the setting of standards. Their statement serves to sanction all surgery independent of urgency in the absence of basic requirements. The WHO-WFSA workgroup strongly disagrees with such a sanction. The Standards document accommodates the need for anesthesia in the absence of these minimum standards in exceptional circumstances with an explicit statement that ‘‘In some resource-poor settings, even HIGHLY RECOMMENDED (i.e., minimum expected standards) may not currently be met. In these settings, the provision of anesthesia should be restricted to procedures that are absolutely essential for the immediate (emergency) saving of life or limb. If HIGHLY RECOMMENDED standards are not met, provision of anesthesia for elective surgical procedures is unsafe and unacceptable.’’ Standards are by definition ‘‘A required or agreed level of quality or attainment; something used as a measure, norm, or model in comparative evaluations’’. They are not intended to ‘‘imply’’ what that level is—they state it explicitly. How they are implemented depends on decisions made locally at a hospital, regional, or national level. We have previously pointed out that the failure of local political processes does not represent the failure of appropriate standards. Standards are a tool to be used in the political process of establishing best practices in the interests of patient safety and wellbeing. We wish to assure Hendel et al. that the WFSA is playing a very active role, together with national societies, in ensuring that anesthesia is an integral part of national This reply is jointly published in the Canadian Journal of Anesthesia and Anesthesia & Analgesia.

Survey of Emergency and Essential Surgical, Obstetric and Anaesthetic Services Available in Bangladeshi Government Health Facilities

ObjectiveEvaluate the capacity of government-run hospitals in Bangladesh to provide emergency and essential surgical, obstetric and anaesthetic services.MethodsCross-sectional survey of 240 Bangladeshi Government healthcare facilities using the World Health Organisation Situational Analysis Tool to Assess Emergency and Essential Surgical Care (SAT). This tool evaluates the ability of a healthcare facility to provide basic surgical, obstetric and anaesthetic care based on 108 queries that detail the infrastructure and population demographics, human resources, surgical interventions and reason for referral, and available surgical equipment and supplies. For this survey, the Bangladeshi Ministry of Health sent the SAT to sub-district, district/general and teaching hospitals throughout the country in April 2013.ResultsResponses were received from 240 healthcare facilities (49.5% response rate): 218 sub-district and 22 district/general hospitals. At the sub-district level, caesarean section was offered by 55% of facilities, laparotomy by 7% and open fracture repair by 8%. At the district/general hospital level, 95% offered caesarean section, 86% offered laparotomy and 77% offered open fracture treatment. Availability of anaesthesia services, general equipment and supplies reflected this trend, where district/general hospitals were better equipped than sub-district hospitals, though equipment and infrastructure shortages persist.ConclusionThere has been overall impressive progress by the Bangladeshi Government in providing essential surgical services. Areas for improvement remain across all key areas, including infrastructure, human resources, surgical interventions offered and available equipment. Investment in surgical services offers a cost-effective opportunity to continue to improve the health of the Bangladeshi population and move the country towards universal healthcare coverage.