Julius Okudu Ebinu

Response to Parsi: Enhancing Early Medical Training to Support Equitable Access to Neurology and Neurosurgery in Rural Canada

Introduction: Access to neurosurgical care is essential for addressing elective and non-elective neurosurgical conditions. Disparities in healthcare access in Canada persist, disproportionately affecting rural, Indigenous and socioeconomically disadvantaged populations. This scoping review sought to identify barriers and facilitators influencing neurosurgical access to care while highlighting gaps in the literature on equity-deserving groups. Methods: A systematic literature search of articles published from January 2000 to August 2024 was conducted using MEDLINE, EMBASE, Cochrane Library, PsycINFO and Scopus. Gray literature from governmental and non-governmental organizations was also reviewed. Of 1400 identified records, eight studies met the inclusion criteria. These studies were analyzed using inductive coding and thematic analysis to explore socioeconomic, geographic, racial, gender-based and cultural barriers. Results: Four major themes emerged: delays in access, alternative healthcare options, policy barriers and communication and coordination. Barriers including transportation gaps, socioeconomic inequities and systemic discrimination were prominent, especially for rural and Indigenous populations. Facilitators like telehealth and improved inter-hospital coordination showed promise but were hindered by infrastructure limitations and cultural misalignments. Few studies addressed the intersectionality of these barriers, highlighting gaps in understanding their cumulative impact. Conclusion: The findings in this review underscore the need for systemic reforms, including equitable resource allocation, digital infrastructure expansion and culturally congruent care. Addressing these barriers is critical to ensuring timely and equitable neurosurgical care across Canada. Future research should prioritize intersectional approaches to better understand overlapping access challenges and evaluate the efficacy of tailored interventions.

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.

Background: Thoracolumbar (TL) fractures are uncommon injuries in the pediatric population. Surgery is recommended for TL fractures with significant deformity, posterior ligamentous complex disruption, or neurological compromise. The Thoracolumbar Injury Classification and Severity Scale (TLICS) has been validated in pediatric populations and serves as a valuable tool for guiding treatment decisions. However, there remains a lack of clarity regarding the appropriate treatment for patients with a TLICS of 4. While conservative and surgical techniques have been described, most studies focused on adult populations, and there is no consensus on the appropriate management in the pediatric population. We reviewed our institutional experience of TL fractures in young children with TLICS of 4, managed both non-operatively and operatively. Methods: A retrospective review of a single institution’s experience managing pediatric patients (<18 years old) with TL fractures receiving a TLICS of 4 from 2015 to 2023 was conducted to determine the clinical outcomes following non-operative and operative treatment. Results: Among 11 pediatric patients, 4 were managed with bracing alone, primarily for posterior column fractures, using a thoracolumbar sacral orthosis (TLSO). Four patients underwent minimally invasive screw fixation (MISF), for Chance or posterior column fractures, with an average operative time of 143 min, blood loss of 29 cc, length of stay (LOS) of 9.8 days, and a follow-up interval of 6 months. Three patients received open posterior screw fixation (OPSF), most commonly for Chance fractures, with averages of 129 min operative time, 225 cc blood loss, 9.7 days LOS, and 4 months follow-up. Both MISF and OPSF utilized intra-operative imaging, with lower radiation exposure in the MISF group. One MISF patients had hardware failure evident by screw lucency on follow-up imaging. Conclusions: Bracing and surgery are safe management options for pediatric TL fractures receiving a TLICS of 4. MISF is an effective alternative treatment strategy, comparable to OPSF, with the advantage of reduced blood loss and radiation exposure. Further studies with age-matched cohorts and long-term outcomes may help determine the optimal management course.

BACKGROUND: Traumatic bilateral lumbosacral facet dislocations without fractures are extremely rare. Only 7 cases have been documented since the first description by Watson-Jones in 1974. Although various treatment strategies have been reported, no consensus has been reached regarding the best surgical approach. OBSERVATIONS: A 35-year-old female presented for medical attention following a high-speed motor vehicle collision. She sustained multiple injuries, including an abdominal aortic injury requiring emergent thoracic endovascular aortic repair. She was found to have bilateral lumbosacral dislocation without fracture (L5–S1) and was noted to be neurologically intact. Once medically stabilized, the patient was taken to the operating room for minimally invasive reduction and stabilization of her lumbosacral spine. Postoperatively, the patient was neurologically intact and remained stable with no deficits and appropriate lumbosacral alignment throughout her 2-year follow-up. LESSONS: The authors report a minimally invasive approach to the management of bilateral lumbosacral facet dislocation without fracture. Although conventional open approaches have been described previously, consideration should be given to minimally invasive strategies in select patients to facilitate their rehabilitative postoperative course.

Magnetic resonance imaging (MRI) and clinicopathological tools have led to the identification of a wide spectrum of autoimmune entities that involve the spine. A clearer understanding of the unique imaging features of these disorders, along with their clinical presentations, will prove invaluable to clinicians and potentially limit the need for more invasive procedures such as tissue biopsies. Here, we review various autoimmune diseases affecting the spine and highlight salient imaging features that distinguish them radiologically from other disease entities.

Back pain is the single leading cause of disability worldwide. Despite the prevalence and morbidity of lower back pain, we still lack a gold-standard treatment that restores the physiological function of degenerated intervertebral discs. Recently, stem cells have emerged as a promising strategy for regenerative therapy for degenerative disc disease. In this study, we review the etiology, pathogenesis, and developing treatment strategies for disc degeneration in low back pain with a focus on regenerative stem cell therapies. A systematic search of PubMed/MEDLINE/Embase/Clinical Trials.gov databases was conducted for all human subject abstracts or studies. There was a total of 10 abstracts and 11 clinical studies (1 RCT) that met the inclusion criteria. The molecular mechanism, approach, and progress of the different stem cell strategies in all studies are discussed, including allogenic bone marrow, allogenic discogenic cells, autologous bone marrow, adipose mesenchymal stem cells (MSCs), human umbilical cord MSC, adult juvenile chondrocytes, autologous disc derived chondrocytes, and withdrawn studies. Clinical success with animal model studies is promising; however, the clinical outcomes of stem cell regenerative therapy remain poorly understood. In this systematic review, we found no evidence to support its use in humans. Further studies on efficacy, safety, and optimal patient selection will establish whether this becomes a viable, non-invasive therapeutic option for back pain.

Spinal cord injury (SCI) is a devasting condition with no reliable treatment. Spina bifida is the most common cause of congenital SCI. Cell-based therapies using mesenchymal stem/stromal cells (MSCS) have been largely utilized in SCI. Several clinical trials for acquired SCI use adult tissue-derived MSC sources, including bone-marrow, adipose, and umbilical cord tissues. The first stem/stromal cell clinical trial for spina bifida is currently underway (NCT04652908). The trial uses early gestational placental-derived mesenchymal stem/stromal cells (PMSCs) during the fetal repair of myelomeningocele. PMSCs have been shown to exhibit unique neuroprotective, angiogenic, and antioxidant properties, all which are promising applications for SCI. This review will summarize the unique properties and current applications of PMSCs and discuss their therapeutic role for acquired SCI.