Successful adaptation of twinning concept for global neurosurgery collaborations—a validation study

Access to neurosurgical care is lacking in many regions globally, and the need for treatment of neurosurgical conditions is urgent. The neurosurgical units in West African countries and regions have different capabilities; infrastructure and the access to physicians to the neurosurgical training centers is inconsistent [2, 3]. Neurosurgery is a multidisciplinary specialty, where the collaboration between different occupations is essential to optimize the treatment of patients with neurosurgical conditions. Besides the operative treatment, the successful care for the neurosurgical patients includes postoperative care, neuro-intensive care, physiotherapy, and occupational therapy, among other services such as radiology, biomedical engineering, and laboratory services, to name a few.

To address these issues, global neurosurgery partnerships has been implemented and adopted across the world, with different strategies and models for collaboration. They have been instrumental in developing neurosurgery in low- and middle-income countries (LMIC), both delivering patient care but also creating sustainable long-term frameworks for neurosurgery [8].

Modern microneurosurgery as a discipline is resource-intense and establishing it in a new environment creates unique challenges. To address these challenges, the Swedish African Neurosurgical Collaboration (SANC) has created the International Neurosurgical Twinning Modeled for Africa (INTIMA), focusing on developing established but resource-challenged neurosurgical departments in the regions of need [5, 8].

The mission described here was initiated by an invitation from Edward Francis Small University Hospital (EFSTH) and builds upon the foundation laid by the previous SANC mission with the Neurosurgical Unit of the University of Nigeria Teaching Hospital [5]. The primary aim of this study was to validate the earlier multi-step neurosurgical twinning technique INTIMA, which has been found efficient [5]. As a secondary objective, we will present data in form of surgical volume prior to, during, and after the mission, in addition to the multidisciplinary efforts made during the mission.

The EFSTH located in Banjul hosts the sole neurosurgical department of the country of The Gambia. The mission lasted between 2023–06-05 and 2023–06-16. The neurosurgical department is staffed with one neurosurgeon trained in microneurosurgery and two junior residents, and one operating room for neurosurgical patients. During the mission, the neurosurgical care was provided at the Edward Francis Small Teaching Hospital (EFSTH), Ndemban Branch, Bakau, The Gambia, with the access to two neurosurgical operating theaters.

The mission was performed on the basis of the previously described INTIMA model [5]. The phases of the model includes the Initial professional linkage (IPL) where professional friendships are created through meeting at courses and conferences. This is followed by Justification visit (JV) where an invitation is given to a neurosurgeon. In this case, the invitation came from Dr. John Jabang, EFSTH, Banjul, The Gambia. After the JV, the following phases include philanthropic travel (PT), followed by targeted benevolent donation (TBD) which for this mission the most important donation was the operating microscope (brand Möller-Wedel). Lastly, the phase of focus clinical partnerships (FCP) is initiated.

The general mission aim was to create possibilities for microneurosurgery, in addition to develop the perioperative neurosurgical care. More detailed aims included the education of the surgical nurses in the operation room, and of the nurses in the perioperative and postoperative care units, as well as the education for patients with spinal cord injury. We delivered and installed an operating microscope (Fig. 1) and Mayfield head rest, Midas Rex™ high-speed drill, together with the other support with material and equipment. During the mission, SANC was included in a symposium on epilepsy and neurosurgery and to establish research collaboration.

Before the mission, the SANC team held recurrent strategical meetings through which relationships between respective colleagues from the different occupational categories were established. The SANC team (led by JS, see Fig. 2) consisted of neurosurgeons (n = 5), neurosurgical surgical nurses (n = 2), assistant surgical nurse (n = 1), intensive care nurses with experience from neurointensive care (n = 2), occupational therapist (n = 1), biomedical engineer (n = 1), and neuroanesthesiologist (n = 1) (see Fig. 1). During part of the mission, a filmmaker was part of the team documenting this mission to further spread word of SANC.

The collaborative model of neurosurgical education and cooperation has been proven successful in East Africa to meet the challenges facing neurosurgical development [1, 4]. Density of neurosurgeons varies between parts of Africa, and neurosurgical training is essential to meet the massive needs [9]. The need of neurosurgical training in West Africa has been highlighted previously, with suggested collaborative efforts to overcome the low number of neurosurgeons in the West Africa region [6].

A successful neurosurgical collaborative mission was performed with The Gambia adopting the previously described INTIMA model [5], supporting the use of this approach in future neurosurgical missions. The most important achievements of the mission were the intensive and effective training of the local personnel, the implementation of an operating microscope, and establishing possibilities for further implementation of microneurosurgical techniques. The operation volume of EFSTH after the mission was almost doubled compared to the same time period before the mission and the complexity (classified according to BUPA) of the cases performed, such as intracranial tumors surgery (CMO 4), degenerative spinal surgery (MAJOR + 4 – CMO 3), and congenital including MMC and encephalocele (CMO 2), increased after the mission period.

The surgical performance is at the core of the neurosurgical care. The implementation of modern neurosurgical care requiring the use of an operating microscope is a key step in the development of the local neurosurgical training and while opening the possibility for a future training center. During this mission, an operating microscope was installed, and microneurosurgical principles were taught at the neurosurgical theater allowing for more complex neurosurgical cases also in the future.

Besides the critical infrastructure, we consider the implemented medical and paramedicinal knowledge the most valuable and effective achievement of the mission. Interprofessional education was performed daily between neurosurgeons, nurses, and anesthesiologists. Besides the surgeons, all members of the multidisciplinary team were included in the local education in neurointensive care nursing and occupational and physiotherapeutic care. The reparation service and education of the local staff by the biomedical engineer was highlighted by the local unit due to its crucial economical profitability. After the mission, the initiated training program for neurosurgical care and nursing has continued to extend beyond The Gambia to other West African countries, including Ghana, Liberia, and Nigeria, proving the vast interest among the nursing personnel. This multinational impact of the mission strengthens the twinning technique. Collaboration over land borders strengths further education and care and allows for adapting to new challenges such as the COVID-19 pandemic [7].

During the mission, a collaborative link with partners from Senegal was initiated. This further strengthens the INTIMA model, as exemplified by the initial successful contacts established before this mission during previous missions and outreaches between JJ and SANC as an organization. Creating a strong local framework for neurosurgical case management and neurosurgical education is paramount and creates an environment where the neurosurgical expertise present in the region can address areas of need in smaller countries with fewer neurosurgical care providers. This is also well exemplified by the continuing online training course for neurosurgical nurses.

The mission to The Gambia resulted in outstanding results and experiences that encourage future missions within SANC. The INTIMA model is a valuable framework for organizations and partnerships in global neurosurgery.

This study validated the use of the INTIMA model previously described in a mission by Swedish African Neurosurgical Collaboration (SANC). The model is sustainable and produces notable results with an increased number of surgery as well as more complex surgeries performed after the mission ended. The core strength of the model is in the multidisciplinary team securing all the aspects and steps of the neurosurgical care. Installation of an operating microscope opened for further microsurgical possibilities, excelling the neurosurgical care in The Gambia.