The Application of Guideline-Based Care for Traumatic Brain and Spinal Cord Injury in Low- and Middle-Income Countries: A Provider-Based Survey

Abstract

Objective: Neurosurgical guidelines have resulted in improved clinical outcomes and more optimized care for many complex neurosurgical pathologies. As momentum in global neurosurgical efforts has grown, there is little understanding about the application of these guidelines in low- and middle-income countries.

Methods: A 29-question survey was developed to assess the application of specific recommendations from neurosurgical brain and spinal cord injury guidelines. Surveys were distributed to an international cohort of neurosurgeons and neurotrauma stakeholders.

Results: A total of 82 of 222 (36.9%) neurotrauma providers responded to the survey. The majority of respondents practiced in low- and middle-income countries settings (49/82, 59.8%). There was a significantly greater mean traumatic brain injury volume in low-income countries (56% ± 13.5) and middle-income countries (46.5% ± 21.3) compared with high-income countries (27.9% ± 13.2), P < 0.001. Decompressive hemicraniectomy was estimated to occur in 61.5% (±30.8) of cases of medically refractory intracranial pressure with the lowest occurrence in the African region (44% ± 37.5). The use of prehospital cervical immobilization varied significantly by income status, with 36% (±35.6) of cases in low-income countries, 52.4% (±35.5) of cases in middle-income countries, and 95.2% (±10) in high-income countries, P < 0.001. Mean arterial pressure elevation greater than 85 mm Hg to improve spinal cord perfusion was estimated to occur in 71.7% of cases overall with lowest occurrence in Eastern Mediterranean region (55.6% ± 24).

Conclusions: While some disparities in guideline implementation are inevitably related to the availability of clinical resources, other differences could be more quickly improved with accessibility of current evidence-based guidelines and development of local data.

Keywords: AMR-US/Can, Region of the Americas (US and Canada); CT, Computed tomography; Evidence-based guidelines; Global neurosurgery; HIC, High-income country; ICP, Intracranial pressure; LIC, Low-income country; LMICs, Low- and middle-income countries; Low- and middle-income countries; MAP, Mean arterial pressure; MIC, Middle-income country; Neurotrauma; Spinal cord injury; TBI, Traumatic brain injury; TSI, Traumatic spinal injury; Traumatic brain injury; WHO, World Health Organization.

Figure 1

Heat map summarizing survey responses for implementation of selected recommendations from The Guidelines for Severe Traumatic Brain Injury, 4th edition, separated by world region and income status. Size of circle indicates the estimated percentage of cases in which the recommendation is implemented. Color density indicates average operative volume attributable to traumatic brain injury for that region or income level. WHO, World Health Organization; AFR, African region; AMR-L, region of the Americas (Latin America); AMR-US/Can, region of the Americas (US and Canada); EMR, Eastern Mediterranean region; EUR, European region; SEAR, Southeast Asia region; WPR, Western Pacific region; HIC, high-income country; MIC, middle-income country; LIC, low-income country.

Figure 2

Heat map summarizing survey responses for implementation of selected recommendations from The Guidelines for the Management of Acute Cervical Spine and Spinal Cord Injury, 2nd edition, separated by world region and income status. Size of circle indicates the estimated percentage of cases in which the recommendation is implemented. Color density indicates average operative volume attributable to traumatic brain injury for that region or income level. WHO, World Health Organization; AFR, African region; AMR-L, region of the Americas (Latin America); AMR-US/Can, region of the Americas (US and Canada); EMR, Eastern Mediterranean region; EUR, European region; SEAR, Southeast Asia region; WPR, Western Pacific region; HIC, high-income country; MIC, middle-income country; LIC, low-income country.