Neurosurgery in Resource-Poor Settings: Improving Access to Surgical Education and Outcomes Analysis of Spine Surgery in a Training Hospital in Cambodia




Still, Megan Elizabeth Hermann

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BACKGROUND: Access to basic surgical care, and neurosurgery in particular, has historically been a neglected topic in the global health sphere. However, up to 30% of the global burden of disease is surgical in nature and great strides have been made in the past few years to spotlight and begin to rectify the huge gap in access to safe, timely, and affordable surgical care around the globe. Spine pathology is a common reason for admission to neurosurgical units in low- and middle- income countries (LMICs) and can have high morbidity rates from lack of specialized institutes. However, good surgical outcomes and quality of life scores have been reported in LMICs. OBJECTIVE: This study details the complication rates and predictive factors from spine surgery at a large hospital in Cambodia, aiming to identify high-risk patients to improve surgeon understanding of these complications for improved pre-operative planning and patient counseling. METHODS: This is a retrospective review of patients admitted for spine conditions to Preah Kossamak Hospital, in Phnom Penh (2013-2017). Univariate analysis was conducted on potential predictive factors; variables with p<0.1 were entered into multivariate logistic regression models. RESULTS: 773 patients were included. 46 patients had complications including wrong level surgery, hardware failure, and infection. On multivariate analysis, patients from the provinces of Kratie (p=0.009) or Sihanoukville (p=0.036), and delay to evaluation of over one year (p=0.027) were significant predictive factors of postoperative complications and ASIA A injury (p=0.020) was a predictive factor of poor outcome. CONCLUSION: Many factors play a role in spine surgery complications in LMICs, including limited access to intra-operative technology, low follow-up rates, and minimal physiotherapy and rehabilitation capabilities. Patients with long delays in presentation, ASIA A injuries, and lumbar-level surgery may be especially susceptible to complications and post-operative morbidity. Despite this, institutions have reported encouraging spine trauma outcomes, and spine surgeries are becoming more accepted and safe operations in many LMICs. Additionally, various groups are working towards equality and training in neurosurgery around the globe using different approaches towards education.

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