Operative Epidemiology of the First Five Years in a New African Neurosurgery Training Centre: The Experience in Rural Kenya at Tenwek Hospital 2016 to 2021

Abstract

Background One strategy to increase the availability of neurosurgical services in underserved regions within Sub-Saharan African countries is to create new residency training programs outside of cosmopolitan cities where programs may already exist. In 2016 Tenwek Hospital in rural western Kenya began offering full-time neurosurgical services and in 2020 inaugurated a residency training program. This review highlights the operative epidemiology of the first 5 years of the hospital's neurosurgical department.

Methods A retrospective review of all cases performed by a neurosurgeon at Tenwek Hospital between September 2016 and February 2022 was performed. Patient demographics, surgical indications, length of stay, and in-hospital mortality rates were collected.

Results A total of 1756 cases were retrievable. Of these, 1006 (57.3%) were male and mean age was 30 years (range 1 day to 97 years). Mean length of stay was 11 ± 2 days and in-hospital mortality rate was 4.4% (77 patients). The most common pathologies in children comprised hydrocephalus and spina bifida (42.5% and 21.1%, respectively); in adults, cranial trauma (28.2%), oncology (25.2%), and degenerative spine (18.5%) were most common. Trauma was the leading cause of death.

Conclusions The neurosurgical caseload of a rural hospital in an underserved area can provide not only an adequate neurosurgical volume, but a robust and varied exposure that is necessary for training safe and competent surgeons who are willing to remain in their countries of origin.

Introduction The establishment of neurosurgical training programs within Africa has proven to result in increased regional retention of graduates.1,2 While the vast majority of African-trained neurosurgeons remain in Africa, concerns have been raised about the ability of the training infrastructure in Sub-Saharan Africa (SSA) to properly train residents to practice independently.3, 4, 5 Indeed, in 2016 only 37% of neurosurgeons surveyed in SSA felt that their training programs adequately prepared them.6 Two cited training barriers, among others, included a lack of equipment, as well as an inadequate number and variety of operative cases.

Within Kenya, the College of Surgeons of East, Central and Southern Africa (COSECSA) now has flourishing neurosurgical training programs in the urban cities of Nairobi, Mombasa, and Eldoret, with a proportionate rise in the number of trained neurosurgeons operating within the country.7 A challenge has been to spread access to rural areas where patients may not have the socioeconomic resources necessary to seek care in urban centers. One additional COSECSA neurosurgery program, however, exists in such an area at Tenwek Hospital, located in Bomet County, Kenya (Figure 1).

Tenwek Hospital is a medical ministry of the Africa Gospel Church. It was established in 1937 and currently has grown to 563 beds, including an intensive care unit capacity of 13. The hospital serves millions of Kenyans mostly in the western part of the country, with occasional referrals from both neighboring and distant African countries. The neurosurgery department at Tenwek was officially established in September 2016 with the arrival of a full-time neurosurgeon (W.R.C.), and in January 2020 joined the few centers in the country training neurosurgery residents. The site features a computed tomography scanner and now has a broad array of neurosurgical adjuncts such as electric drills, an operating microscope, flexible and rigid endoscopes, neuromonitoring, aneurysm clips, and spinal instrumentation. This retrospective review of operations performed during the first 5 years of the neurosurgical department at Tenwek Hospital is purposed to demonstrate that a robust operative experience can in fact be had by trainees in a rural SSA training center.