The Role of Geographic Isolation and Indigeneity on Canadian Neurosurgical Outcomes: A Systematic Review

Introduction Timely neurosurgical care is critical, yet Canada’s specialized services are concentrated in urban centres and rarely designed with Indigenous communities. The magnitude of geographic and colonial inequities in neurosurgical care remain unclear. Therefore, the objective is to synthesise quantitative evidence on how rurality and Indigeneity affect neurosurgical mortality, access and functional recovery in Canada Methods Following PRISMA guidelines, a systematic literature search of MEDLINE, EMBASE, Cochrane Library, PsycINFO, Web of Sciences and grey‑literature sources was conducted (Jan 2000 - Nov 2024). 1697 records were identified. Following, two reviewers independently screened title and abstracts followed by full-texts and risk of bias was appraised with MINORS. Results Eleven studies (n = 13 337 patients + 310 hospitals) met inclusion criteria: six spinal‑cord injury, two traumatic brain injury, one stroke, one paediatric neuro‑oncology and one hypoxic‑ischaemic brain injury. A rural survival disparity emerged only for acute stroke (30‑day mortality 18.3–21.0 % rural vs 14.1–16.8 % urban). Transport distance did not influence TBI or SCI mortality (adjusted OR per hour 0.98, 95 % CI 0.95-1.01). Median injury‑to‑centre time was ≈3 h, yet 46 % of SCI patients waited ≥24 h for decompression; intermediate transfers doubled this risk (OR 2.48). Rural survivors achieved comparable Functional Independence Measure scores but reported more environmental barriers; Indigenous survivors experienced 70‑day longer hospital stays and six‑fold higher readmissions and complications in comparison to non-Indigenous patients?. Conclusion Outside hyper‑acute stroke, Canadian datasets reveal no rural or Indigenous mortality gap, but substantial in-hospital delays and post-discharge burdens. Policies should prioritise rural CT and telestroke expansion, “direct‑to‑OR” trauma pathways, and culturally safe discharge programs.