Key-words:
Cambodia - developing countries - epidemiology - global neurosurgery - low- and middle-income
country
Introduction
Low- and middle-income countries (LMICs) face unique struggles to address the neurosurgical
burden of their populations. There is a gross lack of surgical access for LMICs in
comparison to developed countries. Developed countries receive 75% of all surgical
procedures for the top 30% of the population, while, in comparison, only 3.5% of surgical
cases are performed on the 30% of the lowest income populations in LMICs.[[1]],[[2]] With an estimated 5 billion individuals not having access to safe surgical care,
the importance of addressing the surgical burden has become an area of growth in the
global health landscape. In addition, the surgical and neurosurgical burden within
LMICs has a more disparate distribution in terms of quality and availability of care.[[3]],[[4]],[[5]] Many studies have been done on the surgical burden of LMICs in Asia and Africa,
however, only a few studies have specifically addressed the neurosurgical burden of
Cambodia.
The population of Phnom Penh, the capital city of Cambodia, has grown remarkably from
only 30,000 in 1978 to 2 million in 2019.[[6]] After the fall of the Khmer Rouge, only 21 physicians remained in the country,
none of whom were trained neurosurgeons. This created an urgent need to rebuild the
health-care system across the whole spectrum of specialties. A revival of neurosurgery
in Cambodia has been underway through the assistance of the international neurosurgical
community. Before the introduction of formal neurosurgical training, neurosurgical
procedures were performed by general surgeons. The first formally trained Cambodian
neurosurgeon began practicing in 1998 at Calmette Hospital.
The first neurosurgical department was only established at the government-run Preah
Kossamak Hospital (PKH) in 2011. Currently, there are 34 trained neurosurgeons in
Cambodia to address the neurosurgical needs of a country with a population of over
15 million – roughly one for every 870,000, with a great majority of them working
in the capital city of Phnom Penh. The PKH has 4 neurosurgeons, 2 fellows, 4 residents,
and 10 nurses, and over the past decade, it has successfully built up an active neurosurgical
ward, thanks in part to the diplomatic partnerships with individual volunteering neurosurgeons
and numerous not-for-profit organizations from Korea, Japan, and the United States.
Given the nascent history of neurosurgery in Cambodia, very limited research has been
done to describe the patient population and the scope and limitations of neurosurgical
practices in the country. Indeed, despite the rapidly growing numbers of injuries,
the supply and quality of neurosurgical care have remained largely unknown. In order
to address this need, our study was performed to identify the gaps both in the knowledge
and the practice of neurosurgery in Cambodia. Here, we present 58 months of longitudinal
data from a single government hospital with the first neurosurgical training program
in Cambodia.
Methods
This is a longitudinal descriptive study of patients admitted with a neurosurgical
pathology to PKH, a major government hospital, in Phnom Penh, Cambodia, between September
2013 and June 2018.
There were 5490 patients admitted with neurosurgical conditions during the study period.
Data collection was performed by a single dedicated hospital research assistant, who
interviewed each patient and entered their data into an Excel database.
The population sample includes Cambodians living in Phnom Penh and the surrounding
provinces. Patient demographics (age, sex, and residing province), mechanism and time
of injury, helmet use, alcohol use, images taken (skull radiographs, computed tomography
[CT], and magnetic resonance imaging [MRI]), Glasgow Coma Scale (GCS) on admission,
diagnosis, and types of procedures were obtained from the patient records. Levels
of injury for spinal data were counted per injury, not per patient. Individuals sustaining
multiple levels of injury were grouped into each appropriate category. Basic descriptive
statistics, such as linear regression, were performed on Excel. The statistical analyses
and figures result from analyzing only the available data for each specific variable.
This study was approved by the Cambodia National Ethics Committee for Health Research,
protocol #350 NECHR.
Results
Neurosurgical overview
Patients presented from 23 provinces, traveling across the country to seek care at
PKH [[Figure 1]]. 32% of the patient admissions were directly from Phnom Penh, while the rest were
referrals from regional hospitals with inadequate neurosurgical care. The number of
patients from each area appears to correlate to the proximity to the capital. Over
the 5-year period of data collection, the number of neurosurgical cases to PKH increased
by an average of 2.2 patients/month, with a peak of 222 admissions in December of
2017 [[Figure 2]].
Figure 1: Provinces of Cambodia and distribution of neurosurgical patients admitted to Preah
Kossamak Hospital
Figure 2: Monthly admissions to Neurosurgery Department at Preah Kossamak Hospital from September
2013 to June 2018
Admissions to PKH were broadly categorized into cranial and spinal pathologies, which
were then subcategorized into traumatic and nontraumatic admissions. Cranial cases
constituted 74% of the overall admissions, while spinal cases made up the remaining
26%. 89% of the cranial pathologies were of traumatic origin, while the remaining
11% had a nontraumatic origin. Among the spinal admissions, the breakdown was 47%
traumatic and 53% nontraumatic. Approximately 1 in every 5 patients with cranial pathologies
received surgical intervention (21% traumatic and 20% nontraumatic), while approximately
1 in every 2 spinal pathologies received surgical intervention (47% for traumatic
and 56% for nontraumatic) [[Figure 3]]a.
Figure 3: (a) Overview of neurosurgical admissions to Preah Kossamak Hospital categorized into
spinal and cranial cases with further subcategorization by admission type and surgical
intervention. (b) Gender distribution among the subcategories
The majority of trauma cases for both cranial and spinal groups were males, who made
up 78% of the traumatic cranial admissions and 72% of the traumatic spinal admissions.
The male predominance was less markedly skewed among nontraumatic admissions (60%
in nontraumatic cranial and 52% in nontraumatic spinal groups) [[Figure 3]]b.
Among the patients with cranial pathologies, those in their 20s and 30s made up the
highest proportions, 39% and 19%, respectively. Among those with spinal pathologies,
those in their 30s made up the largest proportion at 20%, however, patients' ages
were more evenly distributed compared to cranial cases [[Figure 4]]a and [[Figure 4]]b. In terms of the time of injury, more injuries took place in the evening, reaching
the peak between the hours of 6 PM and 7 PM [[Figure 5]].
Figure 4: (a) Age and gender distribution of cranial admissions. (b) Age and gender distribution
of spinal admissions
Figure 5: The time of injury sustained for the overall neurosurgical admissions
Cranial pathologies
Characteristics
Of the 4139 cranial admissions, 89% were traumatic in etiology. Consistent with patterns
of injury in other LMICs, the top three mechanisms of head injuries were road traffic
accidents (RTAs; 79.4%, n = 2928), fall from height greater than standing (8.5%, n
= 314), and assault (7.2%, n = 264). Among the RTAs, helmet use in this current study
was found to be only 13.7%, while alcohol involvement was found to be 38.8% [[Table 1]].
Table 1: Cranial admission characteristics (n=4139)
Diagnostic evaluation and management
At PKH, X-ray and CT imaging modalities are available, however, there are no MRI capabilities
on-site. 94.7% of all cranial admissions underwent CT imaging (n = 3920), while 37%
received plain skull X-ray (n = 1535). Only 2.5% of cranial cases underwent MRI evaluation
at outside hospitals (n = 104) [[Table 1]].
Among the traumatic cranial pathologies, the three most common diagnoses were concussion
(30.7%, n = 1138), contusion (19%, n = 705), and skull fracture (12.6%, n = 468).
Epidural hematoma and subdural hematoma made up 12.3% and 11.3% of the diagnoses in
the cranial admissions, making them the fourth and fifth most common cranial diagnoses
at PKH. Nontraumatic cranial diagnoses included stroke and tumors, accounting for
39.4% and 18.8%, respectively [[Table 2]]. Without stroke intervention capabilities, endovascular interventions were not
performed at PKH.
Table 2: Top primary cranial diagnoses and procedures
Patients were clinically categorized at the time of admission into mild (GCS 13–15),
moderate (GCS 9–12), or severe brain injury (GCS 3–8), with records available for
3686 of the patients. 71% of these patients had a mild brain injury, while 16% and
10% of these patients presented with moderate and severe brain injury, respectively
[[Figure 6]].
Figure 6: Glasgow Coma Scale of traumatic cranial patients on admission
In terms of surgical intervention, the most commonly performed procedures were craniotomy,
craniectomy, and bone fragment elevation among traumatic cranial admissions, and for
nontraumatic cranial admissions, they were craniectomy, burr hole, and extirpation
[[Table 2]].
Spinal pathologies
Characteristics
Spinal admissions were less skewed toward traumatic etiologies compared to cranial
admissions. 47% of the 1459 spinal admissions were of traumatic etiology were of traumatic
etiology, with the most common mechanisms of injury being falls (51.7%, n = 354),
RTAs (38%, n = 260), and being struck by falling objects (5.4%, n = 34). This may
reflect the fact that, with the developing infrastructure, more Cambodian citizens
are using motorcycles, cars, and bicycles, severely congesting the roadways. Despite
the newly instated helmet law in 2016 that mandates all motorbike riders and passengers
to wear helmets, of the patients with spinal injury from RTAs, only 12.8% were noted
to be wearing a helmet at the time of the accident, and 12% also reporting alcohol
use before the accident [[Table 3]].
Table 3: Spinal admission characteristics (n=1459)
Diagnostic evaluation and management
As in the case of cranial admissions, patients with spinal pathology (traumatic and
nontraumatic) underwent basic radiographic studies. 1212 patients out of the 1459
spinal admissions received X-ray of their spine (83%), while CT and MRI were performed
on 803 (55%) and 551 (38%) spinal patients, respectively. Patients undergoing MR studies
were sent to off-site facilities for their imaging.
Among the traumatic spinal admissions, the most common pathologies included compression
fracture (n = 129), burst fracture (n = 84), and complete/incomplete spinal cord injury
(n = 63). There were also 310 patients who had unspecified types of spinal fracture
injury. Among the nontraumatic spinal admissions, the most common pathologies were
herniated lumbar disc (47.7%, n = 337), Pott's disease (11.6%, n = 82), and tumors
involving the spinal regions (10.5%, n = 74) [[Table 4]].
Table 4: Top primary spinal diagnoses
The lumbar spine was the most commonly involved level of injury, accounting for 40%
of the levels identified, followed by cervical spine and thoracic spine injuries [[Figure 7]].
Figure 7: Level of spinal injury
In terms of operative management, the most common procedures were posterior spinal
fusion and anterior cervical discectomy and fusion for traumatic spinal admissions
and discectomy, laminectomy, and laminoforaminotomy for nontraumatic spinal admissions
[[Table 4]].
Discussion
Neurosurgical admissions have increased steadily between 2013 and 2018 at PKH, with
notable periodicity between the dry (November–January) and rainy (April–May) seasons.
This seasonal variability likely reflects the changes in road conditions as well as
fewer motorized vehicles on the roads during the rainy season, when poor weather conditions
and flooding may be prohibitive for transportation.
Traumatic brain injuries and spine injuries generate most of the neurosurgical admissions
and operative procedures at PKH. The relative paucity of elective neurosurgical conditions,
such as degenerative spine, tumors, and vascular lesions, may not reflect the true
incidence and prevalence of these conditions but rather underdiagnosis due to a lack
of familiarity or available resources in treating these conditions. As the neurosurgical
expertise and capacity continue to expand with more training and exposure, more elective
neurosurgical cases can be identified to receive intervention.
The proportion of men among traumatic brain injuries far outnumbered that among traumatic
spinal cases. While there are no published data analyzing the gender discrepancy among
Cambodian drivers, it is possible that the ratio of male to female admissions may
be skewed due to there being more men traveling on the roads. Estimates from the World
Bank's Gender Database from 2016 also demonstrated that Cambodian men make up a higher
percentage of the labor force for low, middle, and high-income brackets, compared
to women.[[7]] This gender distribution in economic opportunities, in addition to the greater
number of men on the road, may have led to the phenomenon we observed in our study.
Cambodia's unique road infrastructure and driving practices are important factors
when considering its neurosurgical burden. These include extremely congested roads,
lack of proper lane divisions, poor helmet compliance, and inadequately policed driving
practices. These characteristics, along with the dramatic increase in the number of
registered vehicles over the past few decades, likely contributed to the high RTA
volume seen in this article. This also resembles the trends seen in other developing
nations such as Nepal, Papua New Guinea, and Uganda, which have also reported large
increases in head trauma cases.[[8]],[[9]],[[10]] They have also shown, as seen in this article, that young men in their 20s and
30s sustaining RTA-induced injuries are the demographic that contribute the most to
the nations' neurosurgical burden.[[11]],[[12]],[[13]],[[14]],[[15]],[[16]]
Conversely, nontraumatic spinal admissions at PKH more commonly involved older patients
presenting with disc herniations, infectious causes, and degenerative changes like
spinal stenosis. This pattern may be a consequence of the increasing life expectancy
in Cambodia. Indeed, the nation's life expectancy increased from 67 in 2012 to 69
in 2017, according to the World Bank.[[7]] The aging population, arising from the recent advancements in health care, may
have contributed to the appreciable prevalence of elective spinal cases for age-related
neurological pathologies.
While Cambodia is making strides toward improving its health-care system and the field
of neurosurgery, it still has multiple shortcomings in its current state. Notably,
there is a lack of an extensive health-care data infrastructure and inadequate means
for communication with patients for follow-up. Without the availability of a reliable
medical record system at PKH, a thorough retrospective chart review was unable to
be performed. This, in effect, was a major limitation for this current article, as
its database relied on manual recording of data only during the time of inpatient
hospitalization. Families often travel with patient records and films to the hospital,
and often, they were unable to return for follow-up evaluation. Follow-up via phone
calls was also limited as many patients and their families did not have a mobile device.
Given these limitations with data management and postdischarge communication, many
early entries of the database were deemed incomplete during our analysis.
Furthermore, as a retrospective study of a single government hospital, this article
provides only a glimpse of the overall neurosurgical burden of Cambodia as a whole
and therefore has limited generalizability. For example, there is great variability
of resources, even among different hospitals within Phnom Penh. For example, Calmette
Hospital, with support from the French and Cambodian governments and other private
institutions, is better equipped in terms of diagnostic capabilities (such as an on-site
MRI machine) and pre- and postoperative care. Similarly, Royal Phnom Penh Hospital,
established in 2014 and affiliated with Thailand's Bangkok Dusit Medical Services
Group, boasts state-of-the-art technology, 14-intensive care unit beds, and 5 operative
rooms. Further descriptive studies from these and other hospitals with neurosurgical
capacities would be necessary for more in-depth understanding of the case volumes
and neurosurgical capacity in Cambodia.
Finally, the gaps in the insurance coverage are another ongoing issue that affects
many Cambodian patients. In Cambodia, civil servants and formally employed workers
are covered by the National Social Security Fund (NSSF) under the Ministry of Labor,
and the poorest of the poor receive nearly free access to health care through a program
known as the Health Equity Fund. However, these groups constitute only 40% of Cambodia's
population, and even their insurance plans have limitations. For example, during the
time of this study, Health Equity Fund (HEF) patients coming to PKH had to pay out
of pocket for CT imaging, as the machine was leased by a private company. It has also
been a commonplace for those covered by the NSSF to pay out of pocket for the cost
of the emergency operations (including neurosurgical operations on trauma cases),
requiring many of these patients to sell their properties or ask relatives for help.
The remaining 60% of Cambodian citizens, the “informal sector,” has also had numerous
barriers to getting access to health insurance and receiving care. With the help of
several international advisory entities, such as the Japanese International Cooperation
Agency, the Cambodian government has recently developed a National Social Protection
Policy Framework 2016–2025 both to reduce the widening economic disparity and to expand
coverage for quality health care to its citizens over the 10-year period.[[17]] These policy efforts, combined with future epidemiological studies on the quality
of surgical practices throughout Cambodia, could one day provide evidencebased recommendations
for improved neurosurgical practices and assure that those that need surgery can and
will receive the necessary treatments.
Conclusions
Our study at PKH in Phnom Penh was performed to provide a window into the neurosurgical
caseload and burden in the most populous city of Cambodia. As reported in previous
studies that looked at cranial and spinal injuries in developing nations, our findings
also revealed multiple interesting trends that uniquely reflect the economic and cultural
state of Cambodia. Our study showed that young men in their 20s and 30s dominate cases
for both cranial and spinal admissions. Given that the limited number of neurosurgeons
in Cambodia is mostly in Phnom Penh, the access to neurosurgical care is limited both
by geography and limited data and telehealth infrastructure. Our findings call for
an urgent need to implement policies to comprehensively manage head and spine injuries
in Cambodia. These policies should include the entire spectrum of head and spine injury
management from surveillance, prevention strategies, prehospital care, surgical service
delivery, and rehabilitation.[[18]] Finally, the study also revealed a great need to develop a robust electronic medical
record infrastructure for the Cambodian health-care system, not only to provide more
extensive analyses on outcomes and follow-up data but also to demonstrate a more complete
picture on the neurosurgical burden affecting Cambodia as a whole.
