OBJECTIVEEducating future neurosurgeons is of paramount importance, and there are many aspects that must be addressed within the process. One of the essential issues is the disproportion in neurosurgical care, especially in low- and middle-income countries (LMICs). As stated in their report “Global Surgery 2030,” The Lancet Commission on Global Surgery has emphasized that the availability of adequate neurosurgical care does not match the burden of neurosurgical disease. A strong partnership with the local and national government is very desirable to improve the way everyone addresses this issue. In addition, international collaborative effort is absolutely essential for the transfer of knowledge and technology from a developed country to an LMIC. This paper shows what the authors have done in Yogyakarta to build an educational model that helps to improve neurosurgical care distribution in Indonesia and reduce the inequity between provinces.METHODSThe authors gathered data about the number of neurosurgical procedures that were performed in the sister hospital by using data collected by their residents. Information about the distribution of neurosurgeons in Indonesia was adapted from the Indonesian Society of Neurological Surgeons.RESULTSThe data show that there remains a huge disparity in terms of distribution of neurosurgeons in Indonesia. To tackle the issue, the authors have been able to develop a model of collaboration that can be applied not only to the educational purpose but also for establishing neurosurgical services throughout Indonesia. Currently they have signed a memorandum of understanding with four sister hospitals, while an agreement with one sister hospital has come to an end. There were more than 400 neurosurgical procedures, ranging from infection to trauma, treated by the authors’ team posted outside of Yogyakarta.CONCLUSIONSIndonesia has a high level of inequality in neurological surgery care. This model of collaboration, which focuses on the development of healthcare providers, universities, and related stakeholders, might be essential in reducing such a disparity. By using this model, the authors hope they can be involved in achieving the vision of The Lancet Commission on Global Surgery, which is “universal access to safe, affordable surgical and anesthesia care when needed.”

SUMMARYAlthough many types of sports and recreational activities have been identified as common causes of acute spinal cord injury, hockey has been a rare cause of acute cord injury in Canada or elsewhere. For example, from 1948 to 1973 there were no patients with cord injuries due to hockey in a series of 55 patients with acute cord injuries due to sports or other recreational activities admitted to two Toronto hospitals. In contrast, between 1974 and 1981, the Acute Spinal Cord Injury Unit, Sunnybrook Medical Centre treated six patients with cervical spinal injury due to hockey, five of whom were seen during a 13 month period from September, 1980 to October, 1981. Five of the six sustained a severe acute cervical spinal cord injury, and one a cervical root injury. The cord injury was complete in two cases, while three had complete motor loss but incomplete sensory loss below the level of the lesion. All were males aged 15 to 26 years. Of the players with cord injury, four struck the boards with the neck flexed, and one struck another player with the neck flexed. The one player without cord injury struck the boards with his neck extended. The commonest bony injury was a burst fracture of C5 or C6. One of the patients with a complete cord injury died three months later of a pulmonary embolus, and the other patients with cord injury showed some recovery of root function, but little or no cord recovery. The reasons for the increase in spinal injuries in hockey are unknown.

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SUMMARY:A clinicopathological study in a case of Roberts syndrome (tetraphocomelia, cleft lip and palate, and phallic hypertrophy) is reported. This patient had hydranencephaly and imperforate anus, two additional congenital abnormalities so far not reported in this syndrome.

Twenty-two patients with C-2 fractures involving the odontoid process were treated by immobilization in a halo device. Six had associated spinal cord injury (1 complete and 5 incomplete), and 16 had no spinal cord injury. The age of the patients ranged from 20 to 86 years, with a mean age of 53. There were 15 cases in which the fracture line went through the base of the odontoid process only (Type 2), 1 case with a Type 2 odontoid fracture associated with a Jefferson fracture, 4 in which the fracture line involved the body of C-2 (Type 3), and 2 cases with a Type 3 odontoid fracture associated with a Jefferson fracture. Eighteen of the patients were followed for at least 6 months (the mean follow-up period was approximately 2/12; years) to determine the results of bony fusion and neurological improvement. Three patients died early: 1 had no spinal cord injury and died of an associated head injury; 2 had spinal cord injuries and died of respiratory failure. One was lost to follow-up. Successful bony healing and stability at the fracture site as indicated by flexion and extension roentgenograms of the cervical spine were achieved in 10 (59%) of 17 patients treated with the halo ring and vest only. Early fusion was required in 1 patient, and late fusion was required in 5 patients. The remaining 2 patients refused operation. Improvement in neurological status was noted in all four surviving patients with spinal cord injury. and none of the patients without spinal cord injury developed a neurological deficit during the course of the halo treatment. The average duration of hospitalization was 27 days for those without spinal cord injury and 70 days for those with spinal cord injury. Complications related directly to the halo devices were few and minor and included scalp infection, pressure sores, loosening of the halo pins, and 1 case of osteomyelitis of the skull. We found that the halo device is useful for immobilizing the cervical spine even in the presence of diminished sensation over the trunk. Except for the presence of certain types of coexisting head injury, an absolute contraindication to its use has not been encountered. The major advantage of the halo vest is that it allows external maneuvering of bony injuries in all three planes followed by fixation when acceptable reduction is attained without the need for early operation in patients who may already be very ill. The halo vest also allows early mobilization of patients and early discharge from the hospital.