Letter: Functional Neurosurgery—A Neglected Aspect of Global Neurosurgery: Call to Action

To the Editor: The field of global neurosurgery has gained momentum in recent years, with an increasing focus on expanding access to neurosurgical services in low and middle-income countries (LMICs) through partnerships, training programs, and outreach initiatives.1,2 However, there remains a significant gap in managing functional neurological disorders, leading to higher incidence and prevalence of conditions such as epilepsy and dystonia in LMICs. The prevalence of Parkinson's disease has risen by 155.51% from 1990 to 2019, with China and India having the highest cases.3 In Thailand, the prevalence of dystonia ranges from 13.6 to an alarming 19.9 per 100 000 persons, depending on the type.4 The lifetime prevalence of epilepsy is 15.4 per 1000 in rural areas of developing countries compared with 5.8 per 1000 in developed countries.5 The incidence rate of epilepsy is also higher in LMICs at 81.7 per 100.000/year compared with high-income countries (HICs) at 45 per 100.000/year.6 Despite the high burden of functional neurological diseases, the availability of neurosurgical services for these conditions in LMICs is severely limited. In many low-income countries, only a few specialized centers can offer functional neurosurgery and the procedures are often prohibitively expensive for most patients.7 Effective functional neurosurgical treatment options, such as ablative surgery and deep brain stimulation, are often lacking.8 This is due to various factors, including the need for appropriate referrals, access, and infrastructure and the absence of multidisciplinary teams. For example, the deep brain stimulation Think Tank East reported that most centers in China and India perform fewer than 10 cases per year, affecting the quality of care in centers performing such few cases.9 Another study, a scoping review of awake craniotomy in Africa, revealed that 47.4% of the included studies cited infrastructure limitations for performing awake craniotomy.10 These limitations included funding, intraoperative monitoring equipment, imaging, medications, and limited human resources. Hence, providing LMICs with simulation equipment and collaborations with centers in HICs is essential for bringing functional neurosurgery techniques to low-income settings. In addition, granting observerships for neurosurgery residents from LMICs in HICs is essential to address the limited availability of facilities. This approach allows trainees to learn from experienced surgeons in a more developed setting, improving their skills and knowledge.11 Faculties from developed nations can also be invited to train and educate neurosurgery residents in LMICs, leading to improved training and education.12 For instance, Tunisia's first epilepsy center was established through collaboration between the departments of neurosurgery and neurophysiology at Charles Nicolle Hospital in Rouen, France, resulting in a 100% seizure-free outcome for patients and no operative mortality or significant complications.13 However, despite the progress made with national societies publishing guidelines for functional neurosurgery procedures,14 there is still considerable variation in the practice of these procedures worldwide.15 Procedures are often performed on the basis of institutional tradition and surgeon preference rather than standardized protocols. This variation can result in outcome differences and hinder comparisons across institutions and countries. Creating customized protocols that consider low-income settings' distinct challenges and resources is essential. These protocols should include recommendations for patient selection, preoperative assessment, surgical techniques, postoperative management, and follow-up. Involving healthcare professionals from LMICs in the development process is critical to ensure that the guidelines are realistic and implementable in these settings because they can offer valuable perspectives on the particular difficulties faced by LMICs. Research in functional neurosurgery in LMICs is another limited aspect because of the need for more resources and funding. According to a study by Mohammed A. Azab et al, functional neurosurgery accounted for only 4.26% of Egypt's overall neurosurgical research output.16 This limited output could be attributed to the need for more training opportunities and advanced technologies in the field. Therefore, increased funding for research is crucial to developing effective and tailored protocols that meet the unique needs of functional neurosurgery in LMICs. Both private and public funding partnerships must be leveraged to ensure that the necessary resources and technologies can be developed and implemented in these settings. Private partnerships can follow established models of public–private collaborations, such as the successful example of the European Commission's support for neurodegenerative disease research.17 The need for more functional neurosurgeons is a significant challenge worldwide, particularly in LMICs, where geography, training, economic resources, practice disparity, and the absence of infrastructure further compound limited access to care. However, successful examples of tailored standardization of various functional neurosurgical procedures and education of functional neurosurgeons in LMICs have brought about positive change and improved patient outcomes. A collaborative international strategy is needed to address challenges and improve access to functional neurosurgery in LMICs, providing training opportunities for healthcare professionals in these settings and developing tailored protocols that meet the unique needs of these settings. Involving healthcare professionals from LMICs in the development process is crucial to ensure that the guidelines are practical and feasible. Only through such a comprehensive effort can we bridge the gap and improve access to functional neurosurgery for patients in LMICs, improving outcomes and advancing the field.