Child's Nervous System

, Volume 34, Issue 10, pp 1837–1846 | Cite as

Pediatric neurosurgical bellwether procedures for infrastructure capacity building in hospitals and healthcare systems worldwide

  • Michael C. DewanEmail author
  • Ronnie E. Baticulon
  • Krishnan Ravindran
  • Christopher M. Bonfield
  • Dan Poenaru
  • William Harkness
A.J. Raimondi ISPN Award



Quantifying the global burden of pediatric neurosurgical disease—and current efforts addressing it—is challenging, particularly in the absence of uniform terminology. We sought to establish bellwether procedures for pediatric neurosurgery, in order to standardize terminology, establish priorities, and facilitate goal-oriented capacity building.


Members of international pediatric neurosurgical and pediatric surgical societies were surveyed via the Research Electronic Data Capture (REDCap) platform. Among 15 proposed neurosurgical procedures, respondents assigned numerical grades of surgical necessity and selected hospital-level designation within a three-tiered system. A procedure was considered a bellwether if (a) the majority of respondents deemed it necessary for either a primary- or secondary-level hospital and (b) the procedure was graded at or above the 90th percentile on a continuous scale of essentiality. Data were compiled and analyzed using Stata software.


Complete responses were obtained from 459 surgeons from 76 countries, the majority of whom practiced in a tertiary referral hospital (88%), with a primarily public patient population (64%). Six bellwether procedures were identified for pediatric neurosurgery: shunt for hydrocephalus, myelomeningocele closure, burr holes, trauma craniotomy, external ventricular drain (EVD) insertion, and cerebral abscess evacuation. Few differences in bellwether criteria designations were observed among respondents from different World Health Organization regions and World Bank income groups.


The six bellwether procedures identified can be used as markers of infrastructure capacity at various hospital levels, hence allowing targeted neurosurgical capacity-building in low-resource settings in order to avert disability and death from childhood neurosurgical disease.


Bellwether Global Essential surgery Pediatric neurosurgery Surgery Worldwide 



African region


American region—Latin America


American region—United States and Canada


computed tomography


Emergency and Essential Surgical Care


Eastern Mediterranean region


endoscopic third ventriculostomy


European region


high-income countries


low-income countries


low- and middle-income countries


lower middle-income countries


magnetic resonance imaging


South-East Asian region


upper middle-income countries


ventriculoperitoneal shunt


World Health Organization


Western Pacific region



The authors would like to acknowledge Archit Potharazu for his graphical expertise and assistance with the pictorial display of data within this manuscript.


REDcap use and management is funded by Institute for Clinical and Translational Research grant support (UL1 TR000445 from NCATS/NIH).

Compliance with ethical standards

Conflicts of interest



  1. 1.
    Dewan MC, Rattani A, Fieggen G, Arraez MA, Servadei F, Boop FA, Johnson WD, Warf BC, Park KB (2018) Global neurosurgery: the current capacity and deficit in the provision of essential neurosurgical care. J Neurosurg.
  2. 2.
    Meara JG, Leather AJM, Hagander L, Alkire BC, Alonso N, Ameh EA, Bickler SW, Conteh L, Dare AJ, Davies J, Mérisier ED, el-Halabi S, Farmer PE, Gawande A, Gillies R, Greenberg SLM, Grimes CE, Gruen RL, Ismail EA, Kamara TB, Lavy C, Lundeg G, Mkandawire NC, Raykar NP, Riesel JN, Rodas E, Rose J, Roy N, Shrime MG, Sullivan R, Verguet S, Watters D, Weiser TG, Wilson IH, Yamey G, Yip W (2015) Global Surgery 2030: evidence and solutions for achieving health, welfare, and economic development. Lancet 386:569–624. CrossRefPubMedGoogle Scholar
  3. 3.
    Bickler SW, Rode H (2002) Surgical services for children in developing countries. Bull World Health Organ 80:829–835PubMedPubMedCentralGoogle Scholar
  4. 4.
    Warf BC (2015) “Who is my neighbor?” Global neurosurgery in a non-zero-sum world. World Neurosurg 84:1547–1549. CrossRefPubMedGoogle Scholar
  5. 5.
    Ravindra VM, Kraus KL, Riva-Cambrin JK, Kestle JR (2015) The need for cost-effective neurosurgical innovation—a global surgery initiative. World Neurosurg 84:1458–1461. CrossRefPubMedGoogle Scholar
  6. 6.
    O’Neill KM, Greenberg SLM, Cherian M, Gillies RD, Daniels KM, Roy N, Raykar NP, Riesel JN, Spiegel D, Watters DA, Gruen RL (2016) Bellwether procedures for monitoring and planning essential surgical care in low- and middle-income countries: caesarean delivery, laparotomy, and treatment of open fractures. World J Surg 40:2611–2619. CrossRefPubMedGoogle Scholar
  7. 7.
    Harris PA, Taylor R, Thielke R, Payne J, Gonzalez N, Conde JG (2009) Research electronic data capture (REDCap)—a metadata-driven methodology and workflow process for providing translational research informatics support. J Biomed Inform 42:377–381. CrossRefPubMedGoogle Scholar
  8. 8.
    Jamison DT, Breman JG, Measham AR, Alleyne G, Claeson M, Evans DB, Jha P, Mills A, Musgrove P, Eds (2006) Referral hospitals. Disease Control Priorities in Developing Countries 2nd edn. World Bank, Washington, DCGoogle Scholar
  9. 9.
    Mock CN, Donkor P, Gawande A, Jamison DT, Kruk ME, Debas HT (2015) Essential surgery: key messages from Disease Control Priorities, 3rd edition. Lancet 385:2209–2219. CrossRefPubMedGoogle Scholar
  10. 10.
    Mock C, Cherian M, Juillard C, Donkor P, Bickler S, Jamison D, McQueen K (2010) Developing priorities for addressing surgical conditions globally: furthering the link between surgery and public health policy. World J Surg 34:381–385. CrossRefPubMedGoogle Scholar
  11. 11.
    Burssa D, Teshome A, Iverson K, Ahearn O, Ashengo T, Barash D, Barringer E, Citron I, Garringer K, McKitrick V, Meara J, Mengistu A, Mukhopadhyay S, Reynolds C, Shrime M, Varghese A, Esseye S, Bekele A (2017) Safe surgery for all: early lessons from implementing a national government-driven surgical plan in Ethiopia. World J Surg 41:3038–3045. CrossRefPubMedGoogle Scholar
  12. 12.
    Grimes CE, Bowman KG, Dodgion CM, Lavy CBD (2011) Systematic review of barriers to surgical care in low-income and middle-income countries. World J Surg 35:941–950. CrossRefPubMedGoogle Scholar
  13. 13.
    Thaddeus S, Maine D (1994) Too far to walk: maternal mortality in context. Soc Sci Med 38:1091–1110CrossRefPubMedGoogle Scholar
  14. 14.
    Cowan JA, Dimick JB, Thompson BG et al (2002) Surgeon volume as an indicator of outcomes after carotid endarterectomy: an effect independent of specialty practice and hospital volume. J Am Coll Surg 195:814–821CrossRefPubMedGoogle Scholar
  15. 15.
    Cowan JA, Dimick JB, Leveque J-C et al (2003) The impact of provider volume on mortality after intracranial tumor resection. Neurosurgery 52:48–53 discussion 53–4PubMedGoogle Scholar
  16. 16.
    Dasenbrock HH, Clarke MJ, Witham TF, Sciubba DM, Gokaslan ZL, Bydon A (2012) The impact of provider volume on the outcomes after surgery for lumbar spinal stenosis. Neurosurgery 70:1346–1353– discussion 1353–4. CrossRefPubMedGoogle Scholar
  17. 17.
    Dewan MC, Rattani A, Mekary R, Glancz LJ, Yunusa I, Baticulon RE, Fieggen G, Wellons JC 3rd, Park KB, Warf BC (2018) Global hydrocephalus epidemiology and incidence: systematic review and meta-analysis. J Neurosurg.
  18. 18.
    Dewan MC, Naftel RP (2016) The global rise of endoscopic third ventriculostomy with choroid plexus cauterization in pediatric hydrocephalus. Pediatr Neurosurg 1–8. doi:
  19. 19.
    Kulkarni AV, Schiff SJ, Mbabazi-Kabachelor E, Mugamba J, Ssenyonga P, Donnelly R, Levenbach J, Monga V, Peterson M, MacDonald M, Cherukuri V, Warf BC (2017) Endoscopic treatment versus shunting for infant hydrocephalus in Uganda. N Engl J Med 377:2456–2464. CrossRefPubMedPubMedCentralGoogle Scholar
  20. 20.
    Rudolfson N, Dewan MC, Park KB, Shrime MG, Meara JG, Alkire BC (2018) The economic consequences of neurosurgical disease in low- and middle-income countries. J Neurosurg.
  21. 21.
    Sitkin NA, Farmer DL (2016) Congenital anomalies in the context of global surgery. Semin Pediatr Surg 25:15–18. CrossRefPubMedGoogle Scholar

Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2018

Authors and Affiliations

  • Michael C. Dewan
    • 1
    Email author
  • Ronnie E. Baticulon
    • 2
  • Krishnan Ravindran
    • 3
  • Christopher M. Bonfield
    • 1
  • Dan Poenaru
    • 4
  • William Harkness
    • 5
  1. 1.Department of Neurological SurgeryVanderbilt University Medical CenterNashvilleUSA
  2. 2.Department of AnatomyUniversity of the Philippines College of MedicineManilaPhilippines
  3. 3.University of MelbourneMelbourneAustralia
  4. 4.Department of Pediatric SurgeryMcGill University Health Centre and Montréal Children’s HospitalMontréalCanada
  5. 5.Great Ormond Street Hospital, Institute of Child HealthUniversity College LondonLondonUK

Personalised recommendations