The Current State of Rural Neurosurgical Practice: An International Perspective

Abstract

Introduction:Rural and low-resource areas have diminished capacity to care for neurosurgical patients due to lack of infrastructure, healthcare investment, and training programs. This review summarizes the range of rural neurosurgical procedures, novel mechanisms for delivering care, rapid training programs, and outcome differences across international rural neurosurgical practice.Methods:A comprehensive literature search was performed for English language manuscripts with keywords “rural” and “neurosurgery” using the National Library of Medicine PubMed database (01/1971–06/2017). Twenty-four articles focusing on rural non-neurosurgical practice were included.Results:Time to care and/or surgery and shortage of trained personnel remain the strongest risk factors for mortality and poor outcome. Telemedicine consults to regional centers with neurosurgery housestaff have potential for increased timeliness of diagnosis/triage, improved time to surgery, and reductions in unnecessary transfers in remote areas. Mobile neurosurgery teams have been deployed with success in nations with large transport distances precluding initial transfers. Common neurosurgical procedures involve trauma mechanisms; accordingly, training programs for nonneurosurgery medical personnel on basic assessment and operative techniques have been successful in resource-deficient settings where neurosurgeons are unavailable.Conclusions:Protracted transport times, lack of resources/training, and difficulty retaining specialists are barriers to successful outcomes. Advances in telemedicine, mobile neurosurgery, and training programs for urgent operative techniques have been implemented efficaciously. Development of guidelines for paired partnerships between rural centers and academic hospitals, supplying surplus technology to rural areas, and rapid training of qualified local surgical personnel can create sustainable feed-forward programs for trainees and infrastructural solutions to address challenges in rural neurosurgery.

Concussion and Mild-Traumatic Brain Injury in Rural Settings: Epidemiology and Specific Health Care Considerations

“…Access to neurological/neurosurgical care is limited by decreased hospital and specialty physician coverage, lack of transportation, financial constraints, and cultural attitudes. 11,12 To date, management practices within rural systems of care are under-characterized from a national and international perspective.…”

Evaluation of safety, effectiveness and reproducibility of telemedicine for neurosurgical screening

“…In a review of the literature in 2018, Upadhyayula et al, ( 17 ) state that the time elapsed until treatment and surgery and the absence of trained people are the risk factors with the greatest impact on mortality and unfavorable outcomes in neurosurgery. They conclude that telemedicine consultations to regional neurosurgical centers can potentially shorten the delay in diagnosis and screening, shorten the time to surgery and reduce unnecessary transfers in remote areas.…”

“…Em revisão da literatura em 2018, Upadhyayula et al, ( 17 ) estabeleceram o tempo envolvido entre o tratamento e cirurgia, e a ausência de treinamento de pessoal, que são fatores de risco com aumento do impacto na mortalidade e nos resultados em neurocirurgia. Concluiu-se que as consultas em telemedicina para centros de neurocirurgia regional podem diminuir potencialmente o atraso no diagnóstico e na triagem, e reduzir o tempo de cirurgia e as transferências desnecessárias em áreas remotas.…”

Pediatric Traumatic Brain Injury in the United States: Rural-Urban Disparities and Considerations

“…Numerous other countries have utilized telemedicine triage services to increase the accessibility of neurosurgical care. Doing so can decrease unnecessary transport while providing high quality specialized care at a fraction of the cost [13]. Finally, as documented by Graves et al, rural patients utilize PT/OT services at a higher rate following TBI.…”