This is the first comprehensive descriptive bibliometric analysis of African neurosurgery research. Akhaddar did a similar study, but the two studies differ in many ways.[28] The first difference is the database search. While we searched PubMed, Embase, and Web of Science, Akhaddar's search was limited to Pubmed. Next, we did not apply date restrictions to our search. In contrast, Akhaddar limited his search to articles published after 1999. Finally, we had two authors reviewing each article independently to improve reliability, reproducibility, and validity. This was not the case in Akhaddar's search.
South Africa ranked among the three most productive African countries with and without foreign first author contributions. Like South Africa, Uganda had a significant research output; however, when foreign first author contributions were excluded, it dropped to the fifth rank. In Akhaddar's analysis, South Africa and Uganda were first and third, respectively.[28] South Africa's ranking is understandable given its long and rich academic neurosurgery history.[29] In the case of Uganda, its high research output is associated with current and past partnerships with American and British neurosurgical institutions. Two of the most notable partners have been CURE Uganda and Duke Global Neurosurgery and Neurology.[30] CURE Uganda in particular, has contributed significantly to the development of endoscopic third ventriculostomy and choroid plexus cauterization.[31] Together, the two American partners have contributed at least 72 articles to Uganda's neurosurgery research. Our results suggest that foreign researcher involvement produces more research and leads to local neurosurgeons being more academically productive. This highlights the importance of international research collaborations in advancing African neurosurgery research. In those countries where foreign authors dominate, we would like to see a transition toward local authors taking up the key authorship positions.
Academic neurosurgery is an essential aspect of our field, but it is less developed in Africa. The median number of articles per African neurosurgeon was 0.4, much lower than their North American, European, and Asian colleagues.[24, 32, 33] The model academic neurosurgeon should excel in "clinical work, teaching, research, and administration"; however, these require a considerable amount of resources.[34] One of these resources is protected time for research. In a recent survey of young African neurosurgeons and trainees, only 29.5% reported having protected research time. The time research takes away from operations and consultations must be compensated, especially in Africa. African neurosurgeons perform more operations and consultations per neurosurgeon than their colleagues in high-income countries.[26] The focus on direct clinical activities comes at the cost of not reviewing patient outcomes promptly and not exploring therapeutic alternatives most suited to the local population. For neurosurgeons to devote time to research, they must build teams to assist them in each activity;[34] however, they must be funded for these teams to work as intended. Ironically, the opportunity for funded positions for Western neurosurgeons to work in lower-income countries means that the curation of African neurosurgical practice in the medical literature is more likely to be done by visiting fellows than local surgeons in some of the African units. Unfortunately, funding is the biggest barrier to medical research in Africa.[35, 36] Hence, to increase the research output in Africa, we must develop innovative funding strategies. The funds can equally be used to improve information management systems and expand existing research opportunities for early career researchers. This, of course, must happen against a backdrop of overall neurosurgical and surgical system strengthening, including the strategic increase in the number of neurosurgeons and anesthesiologists. To this point, the enthusiastic uptake by many African countries in strengthening surgical systems complements research capacity-building efforts.
Articles were focused on pediatric neurosurgery (25.0%), neurotrauma (19.3%), and global neurosurgery (9.7%). The number of pediatric neurosurgery and neurotrauma articles can be explained by the burden of these disease categories in Africa. Hydrocephalus and neural tube defects represent 22.3% of all neurosurgical cases, whereas traumatic brain and spine injuries constitute 39.2%.[5] As for global neurosurgery, the movement has gained momentum following the publication in 2015 of the Lancet Commission on Global Surgery report and the World Health Assembly resolution on emergency and essential surgery.[37] Since these documents were published, more journals, conferences, and academic institutions recognize the importance of global neurosurgery.[16] The World Federation of Neurosurgical Societies (WFNS), for example, has created a Global Neurosurgery Committee to coordinate initiatives that increase access to timely and affordable neurosurgical care.[38] Moreover, the WFNS has created a committee to liaise with the World Health Organization.[39] Together, these initiatives encourage the establishment of global neurosurgery as a practice and a major topic for research.
Eight of the top ten target journals were foreign specialty journals, and these journals housed 39.7% of African neurosurgery research. These eight journals are among the most respected and impactful core neurosurgery journals in the world.[40] The proportion of articles in these journals is a testament to the quality of African neurosurgery research. The ranking of World Neurosurgery is not surprising given its scope, large readership, and the possibility to publish without paying charges.[41] Also, the presence of two pediatric neurosurgery journals is logical given the number of pediatric neurosurgery articles. Four regional journals were among the top 15 journals, and none of them was a specialty journal. The first regional specialty journal, the African Journal of Neurological Sciences, ranked twentieth, and although it has more articles published, we did not find them in our database search. This is because the African Journal of Neurological Sciences is not indexed on PubMed, EMBASE, or Web of Science. We found this journal's articles in the supplemental hand search after performing a backward citation analysis of indexed articles. Similarly, the Egyptian Journal of Neurosurgery, one of the continent's premier specialty journals, is not indexed in these databases. African neurosurgeons should encourage the development of regional specialty journals by submitting research and volunteering as reviewers. Also, funders should support research efforts but also editorial efforts and the establishment of local journals. These solutions will help increase the quantity and quality of publications in these regional journals, thereby increasing the chances of getting indexed in international databases.[42]
The African context is so particular that local neurosurgeons need to adapt international guidelines to their context. However, this adaptation must be informed by appraised scientific evidence. Appraised scientific evidence favors standardization in practice, and the rejection of erroneous practices improves patient outcomes and highlights gaps in the literature.[43] Most studies (69.1%) were observational, and we did not find an evidence-based clinical guideline for neurosurgical practice specific to Africa. Beyond publication, scientific findings should inform daily practice, and for this to happen, African neurosurgeons must organize evidence-based neurosurgery activities. The generation of evidence-based practice guidelines is a multistep process that involves planning, literature searches, organization of meetings, appraisal, writing, peer review, and dissemination.[44] Professional societies have the resources and credibility to coordinate these efforts and should therefore spearhead these projects.
We recognize a few limitations to our study. First, our definition of African neurosurgery research excludes research published by African neurosurgeons on practice in other regions. These include research that African neurosurgeons might have published while in residency, observership, or fellowship training. As a result, our results do not encompass the entirety of African neurosurgery research. However, we must note that trying to identify articles published by African neurosurgeons while in a different country would have been a time-consuming and likely unrealistic task that would not provide information on the research productivity of neurosurgeons practicing within the context of African countries. There is no doubt that many African neurosurgeons have contributed substantially to neurosurgery literature; however, this is not reflected in the indexed literature. Unindexed platforms have inchoate search algorithms that do not allow a reproducible and comprehensive boolean search. Some document sources like Google Scholar contain duplicate articles, include abstracts and even grey literature. As a result, we only used Google Scholar for supplemental hand research (as mentioned in the methods). Also, Google Scholar does not provide some of the bibliometric metadata needed for our analysis. Our findings highlight two facts: no African specialty journals are indexed on databases, and most African neurosurgeons publish in non-indexed journals. We must correct these issues immediately - the articles published by these brilliant academic neurosurgeons should be made available to the world. The African neurosurgery community must push for the indexation of African journals on major databases. Another reason the full body of work in Africa is not accurately represented is the authors' affiliation. Many prolific African neurosurgeons have worked at non-African academic institutions. As such, some of their contributions would not be captured in our search strategy. Our decision to identify African neurosurgeons based on their affiliations is based on previous research. When calculating the academic productivity of neurosurgeons and institutions, it is customary to include the contributions of neurosurgeons irrespective of nationality but rather based on affiliation.[2,37]
Next, we divided the total number of articles by the current number of neurosurgeons to calculate the number of articles per local neurosurgeon. The result, therefore, does not reflect the productivity of current neurosurgeons. Countries that have experienced a recent increase in their number of neurosurgeons are disadvantaged because their new practitioners have not had enough time to contribute to the local research. Nevertheless, we believe our calculation of articles per local neurosurgeon is a proxy of academic output. In addition, our search of online databases could have biased our findings, given that few African journals are indexed in the major international databases.[45] Finally, we did not evaluate the impact of the studies with citation metrics. We will be discussing the impact of these studies in the second part of this study. Despite all the limitations, our study gives an insight into the landscape of neurosurgery research in Africa.