Changing Trends and Challenges of Spine Surgery in a Developing Country Mark C. Chikani 1,2 , Mathew Mesi 1 , Okwuoma Okwunodulu 2 , Wilfred Mezue 1 , Samuel Ohaegbulam 2 , Chika Ndubuisi 2 , Linda Iroegbu 2 , Sunday Nkwerem 2 - BACKGROUND: Spine conditions are common and the surgery is evolving even in developed economies. This study aims to review the changing trends and challenges of spine surgery, particularly from a low-income country. - METHODS: This is a retrospective study of patients who were surgically treated for spine conditions in Enugu, Nigeria. Patient records from 2006 to 2016 were reviewed. Relevant clinical information was extracted from the operation theater logbooks and patient case files. - RESULTS: A total of 463 spine surgical procedures were carried out on the same number of patients. The number of treated patients has been on the increase and shows a male predominance. Pediatric spine cases accounted for 1.5%, adult/middle aged patients accounted for 77.8%. Degenerative conditions, trauma, and neoplasms were the most frequent indications for operation, accounting for 52.3%, 30.5%, and 11.4%, respectively. The most commonly operated region was cervical and lumbar regions among male (49.3%) and female (51.8%) patients, respectively. Spine fixation was required in 137 patients (29.6%). A paradigm shift from trauma to degenerative conditions among patients was noted after 2010. Prior to 2009, spine wiring techniques were the most common spine stabilizing method, but from 2011 to 2013 anterior cervical discectomy and anterior cervical discectomy and fusion predominated, and thereafter pedicle screws predominated. Cost impli- cations, lack of trained personnel, and lack of and basic equipment pose significant challenges to spine care. - CONCLUSIONS: The trend in spinal surgery has improved rapidly and consistently in Nigeria over the 10 years of the study and is related to increasing expertise, more available facilities, and implant availability. INTRODUCTION S everal authors have lucidly chronicled the evolution and description of the myriad issues facing neurosurgery practice in Africa, particularly sub-Saharan Africa. 1-4 In this part of the world, neurosurgery, like other sub-specialties of sur- gery, is considered a luxury. 5 Where neurosurgical services are available, access is greatly impaired by distance and/or affordability. The average percentage of the population with 2-hour access to a public facility offering neurosurgical care is 24.3% in sub-Saharan Africa. 6 In Nigeria, trauma surgery remains the major neurosurgical burden in most centers. 7-9 Poor infrastructure requisite for specialized neurosurgical services has no doubt fueled medical tourism to countries with better services. This has in turn become a cog in the wheel of progress in most developing countries. Recently, there has been significant progress in treatment of spine conditions in Africa with acceptable safety over the years. 5,10 Spine surgery in Nigeria has changed rapidly over the last 10 to 15 years, and Memfys Hospital is at the forefront of this change. In the last few years, the specialty has evolved rapidly, with many centers offering spine surgery springing up in the large commercial cities, and the last year marked the formation of the maiden spinal sur- geons’ association. To highlight the scope and rapidity of this evolution, we looked at the changing trends and challenges of spine care at Memfys Hospital Enugu over the 10-year period between 2006 and 2016. The different trends in the extent of surgery, the materials used, and types of operation reflect the availability of re- sources and manpower over the 10 years covered by this review. Key words - Developing country - Spine surgery - Trends Abbreviations and Acronyms ACDF: Anterior cervical discectomy and fusion ASIA: American Spinal Injury Association From the 1 Neurosurgery Unit, Department of Surgery, University of Nigeria Teaching Hospital, Enugu; and 2 Department of Neurosurgery, Memfys Hospital for Neurosurgery, Enugu, Nigeria To whom correspondence should be addressed: Mark C. Chikani, M.D. [E-mail: markochikani@yahoo.com] Citation: World Neurosurg. (2019) 130:e815-e821. https://doi.org/10.1016/j.wneu.2019.06.229 Journal homepage: www.journals.elsevier.com/world-neurosurgery Available online: www.sciencedirect.com 1878-8750/$ - see front matter ª 2019 Published by Elsevier Inc. WORLD NEUROSURGERY 130: e815-e821, OCTOBER 2019 www.journals.elsevier.com/world-neurosurgery e815 Original Article