Preoperative evaluation of neurosurgical patients is essential, especially in resource-limited settings where diagnostic tools may be scarce.

In the absence of advanced imaging, a detailed history and clinical examination (Focusing on general examination, neurological examination as well as other systemic examination) -In making a neurological diagnosis comprehensive general examination, and systemic exam are equally IMPORTANT -Remember, some neurological diseases are secondary pathologies with a focus on general and other systemic examination can provide critical clues for diagnosis. Assess the patient’s Glasgow Coma Scale (GCS) score, pupil reactivity, and motor/sensory deficits, never assume a neurological patient is sleeping as at the time of review. Wake him/her up! Always examine the eyes and do fundoscopy: the pupils serve as a window through which we can indirectly assess the brain. Judicious Use of Imaging: Where imaging is available, CT scans are preferred for trauma and emergency cases, while MRI is better for soft tissue and tumour evaluation. In facilities with limited imaging availability, prioritize critical cases (such as head trauma or space-occupying lesions) for scans. For trauma, the preferred CT protocol is Craniocervical CT not just brain CT. This helps to evaluate or screen for concomitant cervical spine injury commonly associated with moderate and severe traumatic brain injury. Optimize Medical Conditions: Correct any metabolic imbalances, hypertension, or other comorbidities before neurosurgical procedures. This includes managing seizures and intracranial pressure to reduce perioperative risk. Systemic hypertension could reflect raised intracranial pressure (ICP); it is a compensatory mechanism to ensure adequate blood supply to the brain in presence of raised ICP. Do not rush to normalise blood pressure. Acceptable limit is to ensure a MAP between 70-100, or a SBP < 160 mmHg.

WHO Safe Surgery Guidelines: Recommend basic preoperative protocols, including assessment of vital signs, glucose levels, and hydration status, and use of checklists to ensure preparedness.

TBI is one of the most common reasons for neurosurgical intervention in sub-Saharan Africa, often due to road traffic accidents, violence, and falls (5). Spinal cord injuries and head trauma are common due to high rates of traffic accidents, assaults and falls (6).

For all TBI cases, follow the ATLS approach which includes the primary survey which is a quick assessment (Airway and cervical spine control, Breathing and ventilation, Circulation and bleeding control, disability and neurological examination, exposure and temperature control) as a priority. Ensure that the airway is free, as patients with severe and moderate traumatic brain injuries have compromised level of consciousness.

If a CT scan is available, perform one to evaluate the severity of the injury, identify any intracranial haemorrhage, skull fractures or cervical spine injury. Decompressive Craniectomy: In cases moderate and severe TBI with elevated intracranial pressure, a decompressive craniectomy may be lifesaving. The skull is not replaced after surgery until a later date when px is brought back to the theatre for craniolplasty. It is used for severely elevated ICP Timely intervention is crucial, even in low-resource settings where sophisticated ICU care may be lacking. It is good to note that other surgeries that can be performed includes craniotomy for clot evacuation. The skull is replaced immediately after the surgery. While burr hole is for liquified blood and chronic subdural hematoma.

For suspected spinal cord injuries, ensure spinal immobilization during transport and initial management to prevent further damage.

In cases of spinal cord compression or injury (e.g., from trauma) early surgical decompression, spinal re-alignment and spine stabilization/ fixation can help prevent long-term paralysis.

Maintain adequate oxygenation and blood pressure to prevent secondary brain injury. Aggressive management of hypoxia, hypotension, and elevated intracranial pressure is critical to improving outcomes.

WHO Guidelines on Trauma Care: Advocate for early identification and treatment of TBI through CT imaging where possible. For severe cases, these guidelines recommend decompressive surgery to prevent further brain damage. Basic monitoring of intracranial pressure and stabilization of vital signs are key recommendations. WHO Trauma Guidelines for neurotrauma: Support the use of spinal immobilization and early surgical intervention for neurotrauma. The guidelines emphasize rapid triage, stabilization, and timely referral to neurosurgical centers for definitive care.

Infectious diseases, including brain abscesses and tuberculous meningitis, are common neurosurgical issues in sub-Saharan Africa.

In cases of suspected brain abscess or bacterial meningitis, start empirical antibiotic therapy immediately while awaiting culture results. In resource-limited settings, broad-spectrum antibiotics are often used initially.

For brain abscesses consider surgical drainage, especially in large abscesses or those causing significant mass effect.

In TB-endemic regions, treat suspected tuberculous meningitis aggressively with antituberculosis therapy, even in the absence of definitive diagnostic confirmation.

WHO Guidelines on Infectious Diseases: Recommend early initiation of antibiotics for suspected bacterial infections, with tailored antibiotic therapy based on local resistance patterns. For tuberculous meningitis, prolonged treatment (12-18 months) is advised, along with steroids to reduce inflammation.

Hydrocephalus, especially congenital hydrocephalus, is a common neurosurgical problem in sub-Saharan Africa, often associated with neural tube defects or infections like meningitis.

Early detection of hydrocephalus in neonates and infants is critical. Watch for clinical signs like rapid head circumference growth, bulging fontanelle, Dilated scalp veins, sutural diastasis, sunsetting, inability to feed/ failure to thrive (FTT) and delayed developmental milestones. Vomiting in infants is a late sign.

Ventriculoperitoneal (VP) shunt insertion is the standard treatment for hydrocephalus. In low-resource settings, ensure that the surgical team is proficient in the technique and that shunt materials are available.

Infection is a common complication following shunt surgery. Ensure strict aseptic technique during surgery and monitor patients closely for signs of infection postoperatively.

WHO Guidelines on Hydrocephalus Management: Recommend early intervention with shunt surgery in congenital or acquired hydrocephalus. Infection prevention is emphasized, including the use of sterile equipment and prophylactic antibiotics during surgery.

Brain and spinal cord tumours are often diagnosed late in sub-Saharan Africa, contributing to poor outcomes.

Refer patients with symptoms of brain or spinal cord tumours (e.g., persistent headaches, seizures, focal neurological deficits) early to facilities with imaging and neurosurgical capabilities.

If the tumour is accessible, surgical excision is often the first-line treatment, particularly in low-resource settings where radiation and chemotherapy may be limited.

Perform a biopsy to establish a histological diagnosis and guide further treatment, even if that may involve referral for radiation therapy elsewhere.

WHO guidelines for Brain Tumour management: Recommend early detection and surgical intervention for resectable brain and spinal cord tumours. When radiotherapy or chemotherapy is unavailable, palliative care should be offered to improve the patient’s quality of life.

Postoperative care is critical for preventing complications, especially in low-resource environments where ICU facilities may be limited.

Regularly assess the patient’s neurological status postoperatively, checking for changes in GCS, pupil reactivity, or motor function and seizure. Infection Control: Monitor for postoperative infections, particularly meningitis or wound infections. In low-resource settings, use prophylactic antibiotics judiciously and educate patients about wound care.

If intracranial pressure remains elevated postoperatively, investigate and treat based on the cause. While waiting for the cause through investigation manage it with head elevation, sedation, and osmotic diuretics like mannitol. Post operative elevated ICP post tumour surgery warrants urgent CT to evaluate tumour bed for possible hematoma or incomplete tumour excision.

WHO Postoperative Guidelines: Emphasize regular monitoring for postoperative complications, such as infection and increased intracranial pressure. These guidelines also stress the importance of pain management and early mobilization where possible.

Performing neurosurgery in resource-limited settings requires creativity, teamwork, and adaptability.

Given the shortage of neurosurgeons, task-shifting to general surgeons or medical officers with basic neurosurgical training may be necessary. Ensure team-based care involving anaesthetists, nurses, and non-physician clinicians.

Prioritize lifesaving and function-preserving surgeries (e.g., trauma, hydrocephalus, tumours causing compression). Elective surgeries can be deferred if resources are scarce.

Refer complex neurosurgical cases, such as certain brain tumours or spinal deformities, to higher-level centers with advanced capabilities when possible.

WHO Global Surgery Guidelines: Recommend building neurosurgical capacity through training and task-shifting, improving infrastructure, and developing referral networks to ensure timely access to care. The focus is on delivering essential neurosurgical services while strengthening health systems.