Neurosurgical admission and management of traumatic brain injury: a comparative study across high and lower-middle-income country settings.

BACKGROUND

Traumatic brain injury (TBI) represents a major global health burden, with the highest incidence occurring in low- and middle-income countries (LMICs). While outcomes of severe TBI are well described, less is known about how health-system structure influences neurosurgical admission patterns and management across income settings.

MATERIALS AND

METHODS

We performed an observational cohort study comparing neurosurgical admissions and management of TBI over 1 year at a high-income country (HIC) tertiary neurosurgery centre (Institute of Neurological Sciences, Scotland) and a LMIC tertiary neurosurgery centre (Punjab Institute of Neurosciences, Pakistan). Demographics, injury characteristics, management strategies, and in-hospital outcomes were compared.

RESULTS

At the LMIC centre, 1,498 patients were admitted under neurosurgery, representing 50% of referrals, compared to 74 neurosurgical admissions from 643 referrals (11.5%) at the HIC centre. Patients admitted in Pakistan were significantly younger than those in Scotland (median 33 vs 48yrs ;p < 0.001), with no difference in sex distribution (p = 0.9). Mechanisms of injury differed significantly, with road traffic accidents predominating in Pakistan and falls in Scotland (p < 0.001). Mild and moderate TBI accounted for a greater proportion of neurosurgical admissions in Pakistan, whereas severe TBI was more common among neurosurgical admissions in Scotland (p < 0.001). Overall, surgical intervention was more frequent in Scotland than in Pakistan (53% vs 30%; p < 0.001), driven by differences in the management of mild and moderate TBI (48% vs 28%; p < 0.001). Surgical intervention rates for severe TBI did not differ significantly (57% vs 40%;p = 0.2). In-hospital mortality was similar between settings (8.0% vs 9.7%;p = 0.6).

CONCLUSIONS

Marked differences in neurosurgical admission and management patterns for TBI between HIC and LMIC settings appear to reflect underlying health-system structure rather than differences in neurosurgical practice. A high burden of conservatively managed mild and moderate TBI admissions in LMICs highlights opportunities for strengthening trauma systems, referral pathways, and information infrastructure to improve efficiency and sustainability of neurosurgical care.