International Neurosurgery in the Developing World

Since 2012, Jack Rock, MD, FAANS, under the auspices of the Foundation for International Education in Neurosurgery (FIENS), has traveled to Yangon, Myanmar, yearly in support of the neurosurgery training program at Yangon General Hospital and, more recently, North Okkalappa General hospital (NOGH).

Dr. Rock and Roberta Glick, MD, FAANS(L), at the Yangon boot camp.

The program at NOGH includes four faculty neurosurgeons and is directed by Win Myaing, MD. Each year the trip spans two to three weeks and most of the patients managed have brain and skull base tumors.

In addition to taking a team of medical personnel (OR head nurse, biomedical technician, advanced practice practitioner and varying surgical subspecialists) for the last four years, the program also sponsors two Myanmar neurosurgery residents each year to come to Henry Ford Hospital for two-month observorship rotations and biweekly Skype sessions focused on pre-, intra- and post-op care of patients with vascular and neoplastic diseases.

In 2017 and 2019, the program-sponsored boot camps in Yangon model those developed by the Society of Neurological Surgeons and required for PGY 1 residents in North America. These fundamentals of neurosurgery boot camps were held at the University of Medicine 1 in Yangon, Myanmar. The boot camp aims to teach and train fundamental skills to neurosurgery residents and expose local faculty to training methods. The boot camp was run in collaboration with the Myanmar Neurosurgical Society (MNS), the Foundation for International Education in Neurosurgery (FIENS), the Society for Neurological Surgeons (SNS), The University of Medicine 1 in Yangon, Myanmar, and Henry Ford Department of Neurosurgery.

Forty-five neurosurgery residents and 24 neurosurgical faculty from Myanmar, Cambodia, Nepal, Singapore, South Korea, Thailand and Viet Nam attended the Yangon boot camp. All residents attended day one presentations and activities. Day two workstations were assessed by supervising staff with checklists after each workstation rotation. Formal program evaluations were completed prior to the boot camp, immediately post-boot camp and six months post-boot camp. Evaluation questions demonstrated that participants improved from 62.75 percent prior to the boot camp to 71.50 percent six months afterwards (p=.046).

Day one activities consisted of didactic presentations in the morning, followed by small group case discussions and ending with company and faculty-supported skill station preparation for the following day’s activities. Lecture topics included:

Drs. Glick and Isabelle Germano, MD, FAANS, at the Yangon boot camp.
  • Cranial radiological assessment;
  • Neurological and neurotrauma assessments;
  • Emergency spinal radiological assessment;
  • Management of the unstable neurosurgical patient;
  • Pediatric head injury;
  • Adult head injury and intracranial pressure;
  • Patient positioning for brain tumor surgery;
  • Emergency evaluation of hydrocephalus;
  • Management of spinal cord compression;
  • Cerebrovascular anatomy;
  • Management of subarachnoid hemorrhage;
  • Third ventriculostomy and ventricular anatomy; and
  • The medical work-up of brain tumor and pituitary patients.

Day two activities consisted of 17 skills stations in the procedural room, including:

Forty-five neurosurgery residents from Vietnam, Cambodia, Nepal, Thailand and Myanmar attended the boot camp.
  • Shunt tapping and value setting;
  • ICP monitor placement and recording data interpretation;
  • Ventriculostomy and navigation;
  • Lumbar puncture and spinal drain placement;
  • Patient positioning for cranial surgery;
  • Endoscopic 3rd ventriculostomy;
  • Endoscopic transnasal surgical approach;
  • Anterior cervical plating;
  • Posterior cervical plating and lumbar pedicle fixation; and
  • Various craniotomy techniques in the cranial room, including the basics of drilling, craniotomy, dural opening and closure, cranial plating and skin closure (Table 2).

Boot camps provide fundamental didactic and technical exposure to trainees in developed and developing countries. They help standardize training in basic neurosurgical competencies, while exposing local faculty to important teaching methods. This model provides a sustainable solution to educational needs and demonstrates, to local neurosurgeons, how they can take ownership of their educational processes.

The Myanmar program in the department of neurosurgery at Henry Ford continues to sponsor clinical rotations for Myanmar residents to visit Henry Ford and, recently, started bringing Henry Ford Neurosurgery residents to Yangon. Additionally, research in traumatic brain injury supported by the Ministry of Health in Myanmar has begun at NOGH and soon will involve hospitals outside Yangon.

Kyi Hlaing, MD, North Okkalappa General Hospital faculty, reviews brain tumor MRIs and head positioning with residents in preparation for surgery.

Goat heads were used for to train residents
in drilling, craniotomy, dural suturing and
cranioplasty.