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As the second of 3 articles in this series, the aim of this article is to provide readers with an understanding of the development of neurosurgery in East Africa (foundations), the challenges that arise in providing neurosurgical care in developing countries (challenges), and an overview of traditional and novel approaches to overcoming these challenges and improving health care in the region (innovations). Recognizing the challenges that need to be addressed is the first step to implementing efficient and qualified surgery delivery systems in low- and middle-income countries. We reviewed the major challenges facing health care in East Africa and grouped them into 5 categories: 1) burden of surgical disease and workforce crisis; 2) global health view of surgery as "the neglected stepchild"; 3) need for recognizing the surgical system as an interdependent network and importance of organizational and equipment deficits; 4) lack of education in the community, failure of primary care systems, and net result of overwhelming tertiary care systems; 5) personal and professional burnout as well as brain drain of promising human resources from low- and middle-income countries in East Africa and similar regions across the world. Each major challenge was detailed and analyzed by authors who have worked or are currently working in the region, providing a personal perspective.

Background Extreme lateral interbody fusion (ELIF) has gained popularity as a minimally invasive technique for indirect decompression. However, graft subsidence potentially threatens long-term success of ELIF. This study evaluated whether 26-mm-wide cages can eliminate subsidence and subsequent loss of decompression in ELIF. Methods Patients undergoing ELIF surgery using a 26-mm-wide cage were analyzed retrospectively. Patient demographics and perioperative data for radiographic and clinical outcomes were recorded. Radiographic parameters included regional sagittal lumbar lordosis and foraminal and disc height. Clinical parameters were evaluated using the Oswestry Disability Index and visual analog scale. Subsidence of 26-mm-wide cages was compared with previous outcomes of patients undergoing ELIF using 18-mm-wide and 22-mm-wide cages. Results There were 21 patients and 28 spinal segments analyzed. Radiographic outcome measures such as disc and foraminal height revealed significant improvement at follow-up compared with before surgery ( P = 0.001). Postoperative to last follow-up cage subsidence translated into 0.34 mm ± 0.26 and −0.55 mm ± 0.64 in disc and foraminal height loss, respectively. Patients with 26-mm-wide cages experienced less subsidence by means of disc (26 mm vs. 18 mm and 22 mm, P ≤ 0.05) and foraminal height (26 mm vs. 18 mm, P = 0.005; 26 mm vs. 22 mm, P = 0.208) loss compared with patients receiving 18-mm-wide and 22-mm-wide cages. Conclusions The 26-mm-wide cages almost eliminated cage subsidence in ELIF. Compared with 18-mm-wide and 22-mm-wide cages, 26-mm-wide cages significantly reduced cage subsidence in ELIF at midterm follow-up. A 26-mm-wide cage should be used in ELIF to achieve sustained indirect decompression.