Can Non-Neurosurgeons Operate on Traumatic Brain Injuries in Non-Metropolitan Areas? A Scoping Review

Abstract

Traumatic brain injuries (TBIs) with increased intracranial pressure (ICP) require time-sensitive surgical intervention. In non-metropolitan areas, neurosurgeons are often unavailable to provide definitive treatment. Therapeutic surgical intervention by a non-neurosurgeon, for example, general surgeons, is a potential alternative; however, the feasibility and utility of non-specialist intervention are poorly defined within the literature. A scoping review was conducted within Scopus, Emcare, MEDLINE and CINAHL for original literature about emergency neurosurgical interventions performed by a non-neurosurgeon for TBIs in non-metropolitan settings without prompt access to a neurosurgeon. This search yielded 20 studies that included over 2000 surgical interventions in 13 countries. General surgeons most commonly performed the procedures on patients with computed tomography (CT)-confirmed lesions. Mortality rates were heterogeneous, ranging from 0% to 67% in small cohorts with variable follow-up periods. Mortality was consistently higher in patients with subdural haematomas (SDHs) opposed to extradural haematomas (EDHs). Morbidity was measured in 13 studies, commonly via the Glasgow outcome scale (GOS). Most studies had access to remote neurosurgical advice via telehealth. Overall, these 20 studies provided incomplete information regarding mortality rates and functional outcomes from this alternative practise. The present study concludes that emergency decompression by a non-neurosurgeon for patients with severe TBIs may be lifesaving for patients without timely access to a neurosurgical centre. Our study further highlights the need for further research, training and resource allocation, including strengthening telecommunication pathways, to support patient access to lifesaving neurosurgical interventions in these environments, and ultimately address surgical inequalities in rural and remote regions of the world.

Keywords: brain injuries; decompressive craniectomy; emergency medical services; hospitals; neurosurgery; rural; traumatic.

FIGURE 1

PRISMA flow diagram. PRISMA flow diagram of the study selection process. CINAHL, cumulative index of nursing and allied health; EBSCO, Elton B. Stephens Company.