Skull Base Neurosurgery in Low-Resource Settings: an International Survey to Define Capacities, Challenges, and Future Directions

Objective: Skull base pathologies pose a major unmet burden in low- and lower-middle-income countries (LLMICs), where the required specialized training, resources, and perioperative infrastructure are scarce. We aimed to evaluate the current state of skull base neurosurgery in LLMICs to characterize challenges and opportunities for capacity expansion. Methods: We distributed a structured digital survey to LLMIC skull base neurosurgeons covering pre-operative factors (disease severity, surgical capacity, patient access), intraoperative factors (training, volumes, equipment, subspecialty collaboration), post-operative factors (ICU/radiation access, outcomes), and systemic barriers to capacity expansion. Results: Eighty-four neurosurgeons from 31 LLMICs responded; most were from Africa (64.3%) and Asia (29.8%). At least 69.1% perceived national capacity as inadequate. Patients often presented with advanced disease (median severity 70.0/100), and only 52.5% of those indicated for surgery received it—most commonly due to inability to pay and inadequate resources. Operative volume was modest (mean 3.7 cases/month) with minimal endonasal approaches. Key technologies—particularly neuromonitoring, ultrasonic aspiration, and neuronavigation—were inconsistently available. Postoperative resources were similarly variable (ICU availability 61.4%; radiotherapy 46.5%). Mean surgical goal achievement was 68.8%, with a moderate-to-severe complication rate of 27.1%. Greater equipment availability and higher case volume were independently associated with better outcomes on multivariable analysis. Conclusion: Skull base neurosurgery is growing in LLMICs despite significant resource constraints. As a high-cost, high-reward intervention that extends survival and reduces disability, it warrants targeted capacity-building efforts—including equipment access, workforce training, and perioperative infrastructure—to improve surgical access in these settings.