A. Minhas1, O. Khan1, H. Thobani2, H. Abid1, Y. Imran1, B. Dilawar2, S. Bakhshi3, S. Islam2 1Aga Khan University Medical College, Medical College, Karachi, Sindh, Pakistan 2Aga Khan University Medical College, Section Of Pediatric Surgery, Department Of Surgery, Karachi, Sindh, Pakistan 3Aga Khan University Medical College, Section Of Neurosurgery, Department Of Surgery, Karachi, Sindh, Pakistan
Introduction: Neurosurgical disease in children, ranging from traumatic brain injuries to brain tumors and congenital anomalies, requires specialized expertise for accurate diagnosis and effective management. Low- and middle-income countries (LMICs) such as Pakistan bear a disproportionately high burden of these conditions due to limited access to specialized neurosurgical care. There are currently no specialized pediatric neurosurgeons in Pakistan and all cases in children are performed by adult neurosurgeons. This study aims to determine whether the lack of specialized pediatric neurosurgical care affects outcomes of neurosurgical procedures in children and to highlight the unmet need of neurosurgical care for children in Pakistan.
Methods: We conducted a retrospective chart review of all pediatric patients admitted with any condition requiring a neurosurgical consultation from 1st January 2019 till 31st July 2022 at a tertiary care hospital in Karachi, Pakistan. We described the breadth of procedures performed as well as overall outcomes of all neurosurgical cases.
Results: We identified 221 patients fulfilling the inclusion criteria for further analysis. The mean age was 9.47 ± 5.96 years out of which 149 (67.4%) were male. 95 (43%) patients were admitted due to head trauma and 126 (57.0%) due to brain tumors, out of which 37 (38.9%) and 113 (89.7%) underwent surgery respectively. Median operative blood loss was 170mL (IQR: 30-300) and length of stay was 5 days (IQR: 3-7). The most common procedures performed were craniotomies (n=97, 64.7%), tumor removal (n=62, 41.3%), ventriculoperitoneal shunt placement (n=21, 14%) and laminectomies (n=5, 0.03%). There was a high overall mortality, with 7 (7.4%) and 8 (6.3%) patients dying within 30 days of admission for neurotrauma or a brain tumor.
Conclusion: There is a limited variety and breadth of procedures being performed in Pakistan due to a lack of trained pediatric neurosurgeons. Comparing our findings with current literature, we note that Pakistan fares poorly in key quality indicators such as length of stay and operative blood loss. Furthermore, we demonstrate a high 30-day mortality rate for elective brain tumor resections. LMICs such as Pakistan have a ratio of 1 surgeon to 5.5 million people which is alarming in comparison to the worldwide ratio of 1 surgeon to 230,000 people. This substantial disparity is evident in the outcomes of our cohort of neurosurgical cases and strongly validates the need for capacity building and development of specialized pediatric neurosurgical training in Pakistan and other LMICs.