Mr. Teguo educates the anesthesia team and the future IONM technologist on proper electrode placement.

The stated mission of the ASA Committee on Global Health is to enhance, support, educate, represent and collaborate for safe anesthesia practice worldwide. As an ASA Committee on Global Health scholarship recipient, Dr. Simmons traveled to CURE Uganda in 2017 and fully felt the pull of that mission. It was during this trip, and subsequent visits thereafter, that the framework was set for the creation of an educational and clinical program that would significantly improve surgical and anesthesia care, support economic development with job creation, and improve career satisfaction of clinicians via the implementation of the first intraoperative neuromonitoring (IONM) program in Uganda. At the University of Colorado Hospital, where Drs. Simmons and Montejano practice, the Section of Neuroanesthesia supervises and directs the IONM program. Utilizing these unique skills and recognizing the need for this technology and its ability to enhance patient outcomes, work began toward training and educating both a supervising physician and IONM technologist. After nearly two years of preparation with meetings and strategy sessions, as well as education and training, the program was launched in March 2022. The overall success of the project demonstrates the great potential of collaboration between departments of anesthesiology, neurosurgery, and hospital leadership despite cultural differences and geographic locations.

Low- and middle-income countries (LMICs) can face unique and often unprecedented challenges when incorporating IONM into surgical practice. Some of these challenges include both material and personnel resource limitations, power grid suitability and electricity grounding issues, surgeon and anesthesiologist familiarity and comfort with the technology, and, finally, cost.

Despite ongoing efforts, building access to neurosurgical care in LMICs has proven difficult. The same can be said about access to IONM, which at its core finds a worldwide shortage of certified intraoperative neuromonitoring (CNIM) technologists and interpreting physicians. Irrespective of the known benefits of IONM for neurosurgical procedures in preventing iatrogenic injuries resulting in permanent and debilitating damage, cost continues to be prohibitive for its widespread adoption (World Neurosurg 2021;152:e220-6; Spine Deform 2021;9:315-25). Uganda, like virtually all of Sub-Saharan Africa, faces similar challenges.

Taking time out for a photo between cases. From left: Drs. Okechi Humphrey, Neurosurgeon; Colby Simmons, Anesthesiologist; and Emmanuel Wegoye, Chief of Neurosurgery.

According to a recent inquiry made to the American Board of Registration of Electroencephalographic and Evoked Potential Technologists (ABRET) database, there are 121 total CINM technicians outside of the United States, with only six individuals for the entire continent of Africa. Individuals with training to interpret IONM are even more scarce worldwide. To our knowledge, one individual is currently in training in Uganda, and there are other individuals who provide the service without certification. This leaves neurosurgeons interested in operating on individuals with complex pathologies without access to a service that could prevent a catastrophic surgical outcome. This is likely due to an inexorable cycle where a lack of personnel and funding leads to a lack of utilization of IONM, which in turn leads to limited opportunities for individuals to train and later implement their skill set. Training CNIM technicians can be expensive and time-consuming, though necessary to provide safe and effective patient care. To become a CNIM, individuals must undertake rigorous didactic training, log 100-150 cases, and pass a certification exam. Without a clear path to a stable practice, it is reasonable that individuals would choose not to undertake such training.

Without access to these specialists, many surgeons will not attempt the most complex tumor resections for fear of injuring patients or will perform subtotal resections, which are likely to be only palliative in nature (J Am Acad Orthop Surg Glob Res Rev 2022;6:e21.00273).

Anesthesia and neurosurgical services at CURE Uganda

CURE Children’s Hospital of Uganda is a specialized pediatric neurosurgical hospital located in Mbale City in eastern Uganda. The hospital offers inpatient and outpatient neurosurgical care for children from all over the country and neighboring countries. Over the years, there has been an increase in the number of neurosurgeries performed, from approximately 500 to over 1,600 surgeries per year. The majority of patients who present to CURE are afflicted by hydrocephalus (65%-75%) or spina bifida (15%-20%), with brain and spine tumors and other congenital anomalies accounting for the rest of the disease burden. The number of children presenting with complex neurosurgical diseases like spinal lipomyelomeningoceles, spinal tumors, posterior fossa brain tumors, and supratentorial tumors has recently doubled. For these complex neurosurgical diseases, surgery without IONM poses a great risk for injury to neural tissues, leading to catastrophic neurological outcomes postoperatively. Before the introduction of IONM at CURE Uganda, most of these children were not able to be cared for at CURE’s facilities for fear of causing greater harm.

CURE Uganda and the Department of Anesthesiology at the University of Colorado have partnered to develop and implement a new IONM program at CURE Uganda. The goal of the partnership is to improve surgical outcomes and reduce the neurological risk associated with surgical intervention for patients undergoing complex spine and intracranial surgeries. The implementation process has been successful and is progressing well due to the hard work and dedication of the Ugandan team as well as the support and commitment from the administration at CURE Uganda and the University of Colorado. Although still in its early stages, the effect on patient lives has been substantial, allowing patients who would otherwise continue to suffer from their disease a chance at a better quality of life. Ongoing virtual case-based discussions and remotely supported management allow the Ugandan team the ability to offer IONM nearly independently, with hopes of turning CURE Uganda into a training hub for IONM for Uganda and East Africa.

Patients deserve access to safe surgery and anesthesia care regardless of geographic location or socioeconomic status. Until March 2022, patients in Uganda with complex neurosurgical conditions who would benefit from IONM would be resigned to leaving the country for care or to attempt surgery without this invaluable service. However, with the successful implementation of IONM at CURE Uganda, there now exists a third option. It is our hope that future collaborations will allow for equally successful implementations to occur at many sites around the world.