A cohort of minimally invasive spine surgeries in Nigeria

A cohort of minimally invasive spine surgeries in Nigeria | medRxiv /* */ /* */ <!-- <!-- /*! * yepnope1.5.4 * (c) WTFPL, GPLv2 */ (function(a,b,c){function d(a){return"[object Function]"==o.call(a)}function e(a){return"string"==typeof a}function f(){}function g(a){return!a||"loaded"==a||"complete"==a||"uninitialized"==a}function h(){var a=p.shift();q=1,a?a.t?m(function(){("c"==a.t?B.injectCss:B.injectJs)(a.s,0,a.a,a.x,a.e,1)},0):(a(),h()):q=0}function i(a,c,d,e,f,i,j){function k(b){if(!o&&g(l.readyState)&&(u.r=o=1,!q&&h(),l.onload=l.onreadystatechange=null,b)){"img"!=a&&m(function(){t.removeChild(l)},50);for(var d in y[c])y[c].hasOwnProperty(d)&&y[c][d].onload()}}var j=j||B.errorTimeout,l=b.createElement(a),o=0,r=0,u={t:d,s:c,e:f,a:i,x:j};1===y[c]&&(r=1,y[c]=[]),"object"==a?l.data=c:(l.src=c,l.type=a),l.width=l.height="0",l.onerror=l.onload=l.onreadystatechange=function(){k.call(this,r)},p.splice(e,0,u),"img"!=a&&(r||2===y[c]?(t.insertBefore(l,s?null:n),m(k,j)):y[c].push(l))}function j(a,b,c,d,f){return q=0,b=b||"j",e(a)?i("c"==b?v:u,a,b,this.i++,c,d,f):(p.splice(this.i++,0,a),1==p.length&&h()),this}function k(){var a=B;return a.loader={load:j,i:0},a}var l=b.documentElement,m=a.setTimeout,n=b.getElementsByTagName("script")[0],o={}.toString,p=[],q=0,r="MozAppearance"in l.style,s=r&&!!b.createRange().compareNode,t=s?l:n.parentNode,l=a.opera&&"[object Opera]"==o.call(a.opera),l=!!b.attachEvent&&!l,u=r?"object":l?"script":"img",v=l?"script":u,w=Array.isArray||function(a){return"[object Array]"==o.call(a)},x=[],y={},z={timeout:function(a,b){return b.length&&(a.timeout=b[0]),a}},A,B;B=function(a){function b(a){var a=a.split("!"),b=x.length,c=a.pop(),d=a.length,c={url:c,origUrl:c,prefixes:a},e,f,g;for(f=0;f<d;f++)g=a[f].split("="),(e=z[g.shift()])&&(c=e(c,g));for(f=0;f<b;f++)c=x[f](c);return c}function g(a,e,f,g,h){var i=b(a),j=i.autoCallback;i.url.split(".").pop().split("?").shift(),i.bypass||(e&&(e=d(e)?e:e[a]||e[g]||e[a.split("/").pop().split("?")[0]]),i.instead?i.instead(a,e,f,g,h):(y[i.url]?i.noexec=!0:y[i.url]=1,f.load(i.url,i.forceCSS||!i.forceJS&&"css"==i.url.split(".").pop().split("?").shift()?"c":c,i.noexec,i.attrs,i.timeout),(d(e)||d(j))&&f.load(function(){k(),e&&e(i.origUrl,h,g),j&&j(i.origUrl,h,g),y[i.url]=2})))}function h(a,b){function c(a,c){if(a){if(e(a))c||(j=function(){var a=[].slice.call(arguments);k.apply(this,a),l()}),g(a,j,b,0,h);else if(Object(a)===a)for(n in m=function(){var b=0,c;for(c in a)a.hasOwnProperty(c)&&b++;return b}(),a)a.hasOwnProperty(n)&&(!c&&!--m&&(d(j)?j=function(){var a=[].slice.call(arguments);k.apply(this,a),l()}:j[n]=function(a){return function(){var b=[].slice.call(arguments);a&&a.apply(this,b),l()}}(k[n])),g(a[n],j,b,n,h))}else!c&&l()}var h=!!a.test,i=a.load||a.both,j=a.callback||f,k=j,l=a.complete||f,m,n;c(h?a.yep:a.nope,!!i),i&&c(i)}var i,j,l=this.yepnope.loader;if(e(a))g(a,0,l,0);else if(w(a))for(i=0;i (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0];var j=d.createElement(s);var dl=l!='dataLayer'?'&l='+l:'';j.src='//www.googletagmanager.com/gtm.js?id='+i+dl;j.type='text/javascript';j.async=true;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-P4HH5NV'); Skip to main content Home About Submit ALERTS / RSS Search for this keyword Advanced Search A cohort of minimally invasive spine surgeries in Nigeria View ORCID Profile Oluwafemi F. Owagbemi , View ORCID Profile Temitayo O. Ayantayo , View ORCID Profile Olawale A.R. Sulaiman doi: https://doi.org/10.1101/2025.03.14.25323958 Oluwafemi F. Owagbemi 1 Department of Neurosurgery, RNZ Clinic , Victoria Island, Lagos State, Nigeria Find this author on Google Scholar Find this author on PubMed Search for this author on this site ORCID record for Oluwafemi F. Owagbemi Temitayo O. Ayantayo 1 Department of Neurosurgery, RNZ Clinic , Victoria Island, Lagos State, Nigeria Find this author on Google Scholar Find this author on PubMed Search for this author on this site ORCID record for Temitayo O. Ayantayo Olawale A.R. Sulaiman 1 Department of Neurosurgery, RNZ Clinic , Victoria Island, Lagos State, Nigeria Find this author on Google Scholar Find this author on PubMed Search for this author on this site ORCID record for Olawale A.R. Sulaiman For correspondence: wsulaiman{at}rnzglobal.com Abstract Full Text Info/History Metrics Data/Code Preview PDF Abstract Minimally invasive spine surgery (MISS) has gained traction since its introduction into the spine surgery armamentarium, resulting in better outcomes than the traditional open approaches. It was only recently introduced in Nigeria, where it is rarely performed. In a bid to improve access to state-of-the-art neurosurgical services in his home country, the lead author, having practiced MISS in the United States, started performing it in Nigeria in 2017. We aim to describe our MISS experience in Nigeria, a lower-middle-income country (LMIC) with high poverty indices. This is a retrospective review of our database of patients who had MISS for degenerative spine disease involving the thoracic, lumbar, and lumbosacral spine regions from April 2017 to May 2022. Demographic, perioperative, and patient-reported outcome data were retrieved and analyzed (statistical significance—p < 0.05). The same lead surgeon performed the procedures with similar operative techniques and perioperative management. The data of the 143 patients were not normally distributed. The median age was 62 years and males comprised 55.9%. About half the patients had minimally invasive (MIS) laminectomy; 45.5% and 3.5% had MIS-transforaminal lumbar interbody fusion (TLIF) and MIS-microdiscectomy, respectively. Most (73.4%) were in the lumbar spine, 25.2% involved the lumbosacral junction, and 1.4% were in the thoracic spine. Median surgery duration, estimated blood loss, and length of hospital stay were 112 mins, 50 cubic centimeters, and 3 days, respectively. The overall perioperative complication rate was 6.3%, while surgical complications occurred in 4.9% of the patients. The patient-reported outcomes (Numeric Rating Scale [NRS] scores and Oswestry Disability Index [ODI]) showed minimal important differences (MID) between baseline and one-year follow-up. This study’s perioperative parameters and complication (overall and specific) rates are comparable to those obtained from previous work on MIS lumbar decompression (laminectomy and microdiscectomy) and TLIF in higher-income countries. TLIF, whether open or minimally invasive, is more invasive, destructive, and technically demanding than decompression. It is, therefore, not surprising that MIS-TLIF resulted in statistically higher SDn, EBL, and LOS than MIS-decompression. The higher incidence of complications in MIS-TLIF compared with MIS-decompression is also not unexpected because of the instrumentation and implants involved in MIS-TLIF. In the same vein, it is unsurprising that patients who underwent MIS-TLIF had statistically higher discharge to inpatient physical therapy rates and lower discharge home rates than those who underwent MIS-decompression. The improvement between median NRS and ODI scores at the preoperative evaluation and one year after surgery were either comparable to or exceeded the MID in these patient-reported outcomes demonstrated in previous research—a two-point change for NRS and a 5.9–20 difference for ODI. Our efforts to introduce MISS as part of our practice in Nigeria are informed by the need for deploying, developing, and maintaining beneficial cutting-edge care in LMICs where the capacity exists while not neglecting the ‘stock’ procedures. MISS is available in Nigeria, and it is characterized in our practice by satisfactory patient-reported outcomes and comparable perioperative parameters and complication rates to those obtained from MISS performed in countries with higher incomes than Nigeria, where MISS is rife. Introduction Low back pain (LBP) is the leading cause of disability globally, and its incidence, prevalence, and associated disability-adjusted life years (DALYs) have increased over the last two decades because of the rising life expectancy.[ 1 – 3 ] Lumbar degenerative disc disease (DDD) is a common cause of chronic LBP in adults,[ 4 ] while its less common counterpart, thoracic DDD, is potentially more pernicious because of the narrower thoracic spinal canal compared with the lumbar spine and the risk of thoracic myelopathy.[ 5 ] DDD, in general, is a leading disorder necessitating care in Nigeria and globally.[ 4 , 6 – 9 ] The surgical treatment of thoracic and lumbar DDD has evolved over the years from decompression to instrumented fusion of various kinds, with minimally invasive techniques recently added to the surgical repertoire.[ 10 , 11 ] Minimally invasive spine surgery (MISS) has gained traction since its introduction into the spine surgery armamentarium.[ 12 ] It is designed to result in reduced collateral tissue damage and morbidity, and a faster functional recovery compared to the traditional open approaches, all with the same surgical goal.[ 13 ] True to design, the tissue damage that results from open posterior spine approaches, particularly in the multifidus muscle,[ 14 – 17 ] is statistically lower in MISS.[ 18 ] Surgery duration, estimated blood loss, length of hospital stay, and complication rate are also reduced in comparison.[ 19 – 22 ] Given this improved outcome, it is no wonder that MISS is increasingly employed in many parts of the world,[ 23 , 24 ] despite its steep learning curve[ 25 – 27 ] and the need for more advanced equipment than required for the open approaches.[ 28 , 29 ] The story appears different in some regions, however. In a global survey of spine surgeons, only half (the lowest proportion in the study) of the 16 respondents in the Africa and Middle East region thought that MISS was considered mainstream in their areas and practice settings,[ 30 ] while its utilization for fusion in the region was one of the lowest in another worldwide survey.[ 31 ] MISS has been reported for the treatment of spine trauma, tuberculosis, and degenerative disease in Tanzania and South Africa (both African countries),[ 32 – 34 ] and has also been used in Haiti.[ 35 ] Tanzania and Haiti, like Nigeria, are classified as lower-middle-income economies, while South Africa is an upper-middle-income economy.[ 36 ] We did not find a report of MISS from Nigeria, where, based on anecdata, it is both new and rare. In the bid to improve access to state-of-the-art neurosurgical services in his home country, the lead author (OARS), having practiced MISS in the United States (U.S.), started performing it in Nigeria in 2017. This study aims to describe the authors’ MISS experience in Nigeria and present the associated perioperative parameters, complications, and patient-reported outcomes. Materials and methods The lead author maintained a prospective database of the patients in his practice at RNZ Clinic/Euracare Multi-Specialist Hospital, Victoria Island, Lagos, Nigeria. The data includes patient demographics, diagnoses, and perioperative parameters, including the surgeries performed, the number of spinal levels (NOL) operated on, surgery duration (SDn), estimated blood loss (EBL), length of hospital stay (LOS), perioperative complications, patient-reported outcomes (PRO), and discharge destination. For this study, we performed a retrospective review of the listed data in patients who had minimally invasive spine procedures for degenerative spine disease (DSD) involving the thoracic, lumbar, and lumbosacral spine regions from April 2017 to May 2022. The database was accessed for the research on January 31, 2024, and only one author, one of the physicians in the practice, had access to information that could identify individual participants during data collection. Patient consent was obtained for all procedures, and the Nigerian Institute of Medical Research’s Institutional Review Board granted ethical approval for the study. We made the diagnosis of thoracic, lumbar, and lumbosacral DSD from a combination of clinical features of mechanical back pain, radiculopathy, and/or neurogenic claudication, with magnetic resonance imaging findings of spondylosis, spondylolisthesis, spinal canal stenosis, and/or neural foraminal stenosis. Following six weeks of unsuccessful non-operative treatment, we recommended surgery. SDn and EBL were determined from operating room records and LOS from admission records. The perioperative complications that were considered for the study are dura tear, early surgical site infection (based on the Centers for Disease Control and Prevention, USA criteria and within 30 days of surgery),[ 37 ] malpositioned implants, venous thromboembolism, and nerve injury. A dura tear was recorded when observed during surgery or if postoperative cerebrospinal fluid (CSF) leakage was observed. We evaluated the surgical wounds per practice protocol—as needed during admission, on the seventh postoperative day, and one month after surgery, with instructions for features of wound infection given to the patient and caregivers at discharge. Malpositioned implants were diagnosed using postoperative computed tomography confirmation with or without dermatomal pain. Pulmonary embolism (PE) diagnosis was made using clinical and electrocardiogram parameters, with a computed tomography pulmonary angiogram, when the patient’s poor clinical status did not obviate one. Nerve injury was recorded when observed during the surgery and when the patient developed new weakness after surgery. The patient-reported outcomes that we evaluated were low back pain and leg pain, using the 11-point (from 0 for no pain to 10 for the worst imaginable pain) Numeric Rating Scale (NRS),[ 38 ] and disability, using the Oswestry Disability Index (ODI).[ 39 , 40 ] These were assessed preoperatively and at six weeks, six months, and one year after surgery, using questionnaires. Apart from surgical site infection (SSI) and the PROs, observation of the variables, because of their nature, was limited to the admission period. The lead author performed all the minimally invasive (MIS) procedures—minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF), minimally invasive laminectomy (MIS-laminectomy), and minimally invasive microdiscectomy (MIS- microdiscectomy)—using a similar technique to that employed in a previous publication,[ 19 ] assisted in some by the co-authors. MIS-laminectomy and MIS- microdiscectomy were grouped into minimally invasive decompression (MIS- decompression) for ease of analysis. We irrigated all wounds copiously and closed them in layers. All the patients had similar postoperative care using standardized postoperative order sets, and the care for each procedure type was nearly identical for the patients who underwent it. Patients were sent for physical therapy two to four days after surgery as needed, and they returned to work as soon as they could. The postoperative management is also similar to the lead author’s method in the U.S.[ 19 ] Statistical analysis and study reporting The patients’ demographics, DDD data, and surgery types were the independent variables, while SDn, EBL, LOS, complication rates, disposition data, and PROs constituted the dependent variables. The data were evaluated using the Shapiro-Wilk test for normality, to determine whether to use parametric and nonparametric tests, and described using counts, percentages, and medians. We used the two-tailed Mann-Whitney U test to compare variables with nonparametric continuous data, while for categorical data, the chi-squared test was used to evaluate associations and goodness of fit. Where the conditions of the chi-squared test were not met, Fisher’s exact test was used. Non-parametric repeated measures analysis of variance was used to compare the baseline patient-reported outcomes with the follow-up values. We set statistical significance at p < 0.05[ 41 , 42 ] and missing data were addressed using the available-case analysis.[ 43 ] We performed the statistical analysis with jamovi (The jamovi project, Sydney, Australia)[ 44 ] and implemented the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guideline in reporting this work.[ 45 ] Study environment Nigeria had a low Human Development Index (HDI) of 0.535 and ranked 163 of 191 nations in the 2021/22 United Nations Development Programme Human Development Report.[ 46 , 47 ] Lagos, the state in Nigeria where our practice is located, was reported over multiple years to have the highest HDI in the country.[ 47 , 48 ] With an HDI of 0.681 in the 2021/22 report, which is better than the national HDI, Lagos falls into the medium human development range, but lags behind Western countries with very high development indices, and even some African countries in the high development range.[ 46 , 47 ] When told through another metric, the World Bank’s Human Capital Index (HCI) of 2020, which scores the country an index of 0.36 (the HCI ranges between 0 and 1), Nigeria’s story remains one of poor development.[ 49 ] The underdevelopment translates into the people’s pockets, affecting their purchasing power and healthcare. With a population of about 220 million people,[ 50 ] Nigeria has 40.1% of its population living below the national poverty line and 39.1% living below the international poverty line of $1.90 a day.[ 46 ] This is further worsened by poor healthcare access that is connected to poor social health insurance coverage, which was recently reported to be less than 5% of the population, with most people paying out-of-pocket for healthcare.[ 51 ] This out-of-pocket health expenditure contributes to impoverishment in the country.[ 52 ] On the backdrop of this socioeconomic scenario, and even with neurological diseases and injuries being major causes of death and disability globally,[ 53 , 54 ] neurosurgery suffers healthcare disparities between developed and developing countries, with low-income countries (LIC) and lower-middle-income countries (including Nigeria) having poor access to neurosurgical care.[ 55 ] Degenerative spine disease is one of the leading conditions requiring such care globally, including in Nigeria.[ 4 , 6 – 9 ] Despite the stark realities of healthcare in Nigeria, efforts to provide safe and affordable neurosurgical care in the country are being made, especially by individuals and through private institutions, including the lead author, who moved his practice completely from the U.S. to Nigeria in 2019.[ 56 ] This practice is in a private hospital with a single operating room equipped with a Jackson table, Wilson frame, operating microscope, and fluoroscopy machine, which were used as standard items for MISS. Retraction was maintained during the MISS procedures using a 22 mm tubular retractor (METRx System, Medtronic, Memphis, TN, USA), while pedicle screw instrumentation was performed percutaneously. Some of the other neurosurgical conditions treated in the practice include brain and spine tumors, chronic subdural hematomas, brain and spine trauma, and peripheral nerve injuries and entrapments. Results A total of 261 patients had spine surgery during the 62-month study period, 143 of whom had minimally invasive spine procedures for DSD involving the thoracic, lumbar, and sacral spine regions. This constitutes 54.8% of our spine surgery practice and 65.0% of the 220 patients operated on for DSD during the period. The excluded patients had open spine surgeries and/or surgery for non-degenerative spine conditions. When tested for normality, the data were not normally distributed. The median age was 62 years, with an interquartile range (IQR) of 15 years, and males comprised 55.9% (80/143). About half (73, 51.0%) of the patients had MIS- laminectomy, while 65 (45.5%) and five (3.5%) patients had MIS-TLIF and MIS- microdiscectomy, respectively. Overall, 105 (73.4%) of the surgeries were performed in the lumbar spine, while 36 (25.2%) involved the lumbosacral junction and the remaining two were in the thoracic spine ( Fig 1 ). All the MISS were performed in one (82, 57.3%) or two (61, 42.7%) spinal levels. Download figure Open in new tab Fig 1. Spinal regions operated on—comparison of minimally invasive transforaminal interbody fusion (MIS-TLIF) with minimally invasive decompression (MIS-decompression), which comprises minimally invasive laminectomy and minimally invasive microdiscectomy. The median (IQR) SDn, EBL, and LOS were 112 (121) min, 50 (70) cubic centimeters (cc), and 3 (0) days, respectively. There were three dura tears (2.1%), two incidents each of PE and malpositioned screws (1.4% each), and one SSI and nerve injury each (0.7% each), with complications directly related to surgery occurring in 4.9% and an overall complication rate of 6.3%. A subanalysis of the patients into MIS-TLIF and the MIS-decompression is shown in the table. With age (p = 0.334) and NOL (p = 0.354) operated on being similar in both groups (see Table ), MIS-TLIF had higher SDn, EBL, and LOS values (all p < 0.001), and complication rate (p = 0.011). View this table: View inline View popup Table. Comparison of minimally invasive transforaminal interbody fusion with minimally invasive decompression, which comprises minimally invasive laminectomy and minimally invasive microdiscectomy. Each malpositioned screw required an additional procedure for revision in the two affected patients. The patient who developed SSI had undergone MIS-TLIF and was one of those who had a dura tear, which led to postoperative CSF leakage, for which he had a second procedure for dura repair. The SSI was a deep one, which caused prolonged admission and required an additional procedure for wound debridement and washout. The nerve injury, with an associated dura tear, occurred intraoperatively during MIS-TLIF, and this resulted in a right-sided foot drop, which improved with physiotherapy. The third dura tear occurred during an MIS-laminectomy, being the only complication in that group. The latter two dura tears were repaired in the same surgery with no postoperative CSF leakage. The two patients who suffered PE had undergone MIS-TLIF, and one of them was a morbidly obese woman who died on the seventh postoperative day after developing sudden severe PE symptoms and rapid clinical deterioration. The other patient’s symptoms were insidious, and she did well with anticoagulation therapy. There were no complications in the patients who had MIS-microdiscectomy. Most (76, 59.8%) of the patients were discharged to inpatient physical therapy, while 39.4% (50) were discharged home with no skilled care (see Table for comparison between MIS-TLIF and MIS-decompression). A statistically higher proportion of patients less than 65 years of age were discharged home compared to patients greater than/equal to 65 years of age (p = .01). The median NRS score was 8.0 preoperatively, while postoperatively, the median scores were 4.0, 5.0, and 3.5 at six weeks, six months, and one year, respectively. There was a statistical difference between the baseline NRS score and the follow-up values (each p < 0.001) during pair-wise comparison. The preoperative median ODI was 56%, while it was 38%, 36%, and 26%, respectively, six weeks, six months, and one year after surgery. There was also a statistical difference between the baseline ODI and the follow-up values (p = 0.048, p = 0.008, and p < 0.001, respectively) during pairwise comparison. The NRS and ODI results are further illustrated in Figs 2 and 3 . Download figure Open in new tab Fig 2. Median Numeric Rating Scale scores at preoperative and follow-up evaluations. Download figure Open in new tab Fig 3. Median Oswestry Disability Index at preoperative and follow-up evaluations. Discussion The results of this study describe the patients, indications, practice, perioperative parameters, complications, and patient-reported outcomes of MISS performed by the authors in Nigeria. Though the data were prospectively collected, some were missing. They were assumed to be missing completely at random (MCAR) since they were not observed to be related to other variables.[ 57 ] We believe that applying the available-case analysis to the missing data helped keep the data as robust as possible.[ 43 ] These missing data are likely due to omissions in records. This study’s perioperative parameters and complication (overall and specific) rates are comparable to those obtained from previous work on MIS lumbar decompression and MIS-TLIF.[ 19 , 58 – 69 ] While there is much similarity in surgical techniques and outcome evaluation between these reports and our work, there are a few differences we wish to highlight. In contrast to this study and the work of Sulaiman et al.,[ 19 ] where bilateral percutaneous screw fixation was performed, Nandyala et al.[ 59 ] used a unilateral approach, which may explain the lower SDn and EBL they found, particularly in the second arm of their study. Another difference is the much higher complication rates of Ahn et al.[ 58 ] and Nandyala et al.[ 59 ] This is likely due to their inclusion of longer-term complications, like pseudoarthrosis, which we did not set out to evaluate. Patients’ home discharge rates vary across studies, given that the patient populations and techniques in these studies differ.[ 65 – 69 ] Our patient disposition data compare well with those from a “spine naïve” community hospital in the U.S., also reporting initial cases.[ 66 ] The dearth of skilled home care in our environment markedly hampered our ability to discharge patients needing skilled care to their homes. Our finding that the discharge to inpatient physical therapy rate was statistically higher for older patients compares with the work of Altshuler et al.,[ 69 ] though they used 60 years as their threshold. Most of the patients with missing disposition data in our study were less than 65 years of age. A mock analysis of a scenario where all the patients below 65 years of age who had missing data were discharged home still yielded a statistically higher inpatient physical therapy discharge rate for older patients. TLIF, whether open or minimally invasive, is more invasive, destructive, and technically demanding than laminectomy and microdiscectomy. It is, therefore, not surprising that MIS-TLIF resulted in statistically higher SDn, EBL, and LOS than the MIS-decompressions as also observed by Chan et al.[ 65 ] in their study. In the same vein, it is also not surprising that patients who underwent MIS-TLIF had statistically higher discharge to inpatient physical therapy rates and lower discharge home rates than those who had MIS-decompression. The higher incidence of complications in MIS-TLIF compared with MIS-decompressions is also not unexpected because the instrumentation involved in MIS-TLIF increases the risk of dura and nerve injuries. Furthermore, implants increase SSI risk and may be misplaced intraoperatively.[ 70 ] The only SSI in this study occurred in a patient who had MIS-TLIF. Though both PEs occurred in MIS-TLIF patients, there is no indication that MIS-TLIF is an independent risk factor for PE. Patient-reported outcomes are important and are increasingly used in spine surgery, particularly regarding minimal important difference (MID), which is the smallest change perceived by patients as clinically important.[ 71 , 72 ] In our study, the improvement between median scores at the preoperative evaluation and one year after surgery were either comparable to or exceeded MIDs found by other researchers—a two-point change for NRS and 5.9–20 for ODI[ 72 ]—and the difference was statistical. Improved access to safe and affordable surgical care is both a major need in lower-middle-income countries (LMIC) and a 2030 Global Surgery target.[ 73 ] The healthcare disparities between developed and developing nations that affect neurosurgery[ 55 ] will also need to be addressed if this need/target must be met. The neurosurgical workforce is an area of disparity, with few neurosurgeons dealing with huge loads of essential consultations and surgical cases in these developing countries, and the workforce need is projected to worsen towards 2030.[ 55 , 74 ] While capacity-building efforts like twinning and training are helpful, these methods face challenges,[ 75 ] some of which are likely to be mitigated by the continuous presence of the capacity builders in the countries of need, as is the case in our practice. The benefit is seen in neurosurgical care generally, but where the capacity for beneficial cutting-edge care can be deployed, developed, and maintained in LICs and LMICs, we believe it is expedient to offer such care to the people in these nations, while not neglecting the ‘stock’ procedures. This informed our efforts to introduce MISS as part of our practice in Nigeria. Despite the advantages of MISS (reduced complication profile and increased safety compared to open approaches), its resource-intensiveness has made it generally prohibitive in developing countries, leaving its availability there to the episodic interventions of practitioners from countries in the Global North.[ 32 , 35 , 76 ] The pitfalls of this approach, despite the good intentions, possibilities, and successes, have been described.[ 76 ] The feasibility of MISS as a continuous practice in the Global South rather than as isolated occurrences[ 32 – 35 ] is shown in this study. Though it started as monthly visits, the lead author’s MISS practice in Nigeria has morphed into a steady practice, with patient numbers approaching those of his previous practice in the U.S. If there are reports of more consistent MISS practice in the region, we have yet to find such, despite the reported acceptance and utilization in the Africa and Middle East region in the cited global surveys.[ 30 , 31 ] Since both ‘subregions’ were combined in the surveys, perhaps the acceptance and utilization were recorded more in the Middle East than in Africa. Our study’s limitations include its retrospective nature with its inherent challenges and the associated missing data that has been discussed. In addition, it is a single surgeon and single center experience, which is not implausible since MISS is just burgeoning in Nigeria. Nonetheless, we believe it is important to highlight this work to explore the possibilities of MISS in the country. As the practice of MISS spreads in Nigeria, multicenter studies may corroborate our findings, making our results generalizable. One of our study’s strengths is that the patient numbers approach those of multiple studies from the developed world over similar periods. There is also strength in the evaluation of the parameters using sources free of surgeon bias, such as anesthesia and nursing records, as well as patient-filled questionnaires. Conclusions MISS is available in Nigeria, and it is characterized in our practice by satisfactory patient-reported outcomes and comparable perioperative parameters and complication rates to those obtained from MISS performed in countries with higher incomes than Nigeria, where MISS is a staple of spine surgery practice. This underscores the role that diaspora medical experts can play in the development of modern surgical care in Sub-Saharan African countries. A reversal of the “brain drain” to “brain gain” is slowly happening in many medical fields in Nigeria, whereby U.S.- and U.K.-trained specialists are returning to Nigeria to provide state-of-the-art healthcare to Nigerian patients. Data Availability An accession number and/or DOI will be made available after acceptance. Footnotes ↵ ¶ OARS is the Senior Author. References 1. ↵ Mattiuzzi C , Lippi G , Bovo C . Current epidemiology of low back pain . J Hosp Manag Health Policy 2020 ; 4 : 15 – 15 . OpenUrl 2. Wu A , March L , Zheng X , Huang J , Wang X , Zhao J , et al. Global low back pain prevalence and years lived with disability from 1990 to 2017: estimates from the Global Burden of Disease Study 2017 . Ann Transl Med 2020 ; 8 : 299 . OpenUrl CrossRef PubMed 3. ↵ Hoy D , March L , Brooks P , Blyth F , Woolf A , Bain C , et al. The global burden of low back pain: Estimates from the Global Burden of Disease 2010 study . Ann Rheum Dis 2014 ; 73 : 968 – 74 . OpenUrl Abstract / FREE Full Text 4. ↵ Ravindra VM , Senglaub SS , Rattani A , Dewan MC , Härtl R , Bisson E , et al. Degenerative Lumbar Spine Disease: Estimating Global Incidence and Worldwide Volume . Global Spine J 2018 ; 8 : 784 – 94 . OpenUrl PubMed 5. ↵ McInerney J , Ball PA . The pathophysiology of thoracic disc disease . Neurosurg Focus 2000 ; 9 : 1 – 8 . OpenUrl CrossRef 6. ↵ Dewan MC , Rattani A , Baticulon RE , Faruque S , Johnson WD , Dempsey RJ , et al. Operative and consultative proportions of neurosurgical disease worldwide: Estimation from the surgeon perspective . J Neurosurg 2019 ; 130 : 1098 – 106 . OpenUrl PubMed 7. Oyemolade TA , Balogun JA , Akinkunmi MA , Ogunyileka OC , Arogundade FM , Olusola AJ . The Burden of Neurosurgical Diseases in a Rural Southwestern Nigeria Setting . World Neurosurg 2020 ; 140 : e148 – 52 . OpenUrl PubMed 8. Komolafe MA , Owagbemi OF , Alimi TI . The distribution and pattern of neurological disease in a neurology clinic in Ile-Ife, Nigeria . Niger J Clin Pract 2018 ; 21 : 1520 – 4 . OpenUrl PubMed 9. ↵ Rabiu T , Komolafe E . Neurosurgery in rural Nigeria: A prospective study . J Neurosci Rural Pract 2016 ; 7 : 485 – 8 . OpenUrl PubMed 10. ↵ Castro I de , Santos DP dos , Christoph D de H , Landeiro JA. The history of spinal surgery for disc disease: an illustrated timeline . Arq Neuropsiquiatr 2005 ; 63 : 701 – 6 . OpenUrl PubMed 11. ↵ Jaikumar S , Kim DH , Kam AC . History of minimally invasive spine surgery . Neurosurgery 2002 ; 51 : S1 – 14 . OpenUrl CrossRef PubMed 12. ↵ Thongtrangan I , Le H , Park J , Kim DH . Minimally invasive spinal surgery: a historical perspective . Neurosurg Focus 2004 ; 16 : 1 – 10 . OpenUrl PubMed 13. ↵ McAfee PC , Phillips FM , Andersson G , Buvenenadran A , Kim CW , Lauryssen C , et al. Minimally Invasive Spine Surgery . Spine (Phila Pa 1976) 2010 ; 35 : S271 – 3 . OpenUrl 14. ↵ Rantanen J , Hurme M , Falck B , Alaranta H , Nykvist F , Lehto M , et al. The Lumbar Multifidus Muscle Five Years After Surgery for a Lumbar Intervertebral Disc Herniation . Spine (Phila Pa 1976) 1993 ; 18 : 568 – 74 . OpenUrl 15. Gejo R , Matsui H , Kawaguchi Y , Ishihara H , Tsuji H . Serial Changes in Trunk Muscle Performance After Posterior Lumbar Surgery . Spine (Phila Pa 1976) 1999 ; 24 : 1023 – 8 . OpenUrl 16. Kim CW . Scientific basis of minimally invasive spine surgery: Prevention of multifidus muscle injury during posterior lumbar surgery . Spine (Phila Pa 1976) 2010 ; 35 : 281 – 6 . OpenUrl 17. ↵ Kim KT , Lee SH , Suk KS , Bae SC . The quantitative analysis of tissue injury markers after mini-open lumbar fusion . Spine (Phila Pa 1976) 2006 ; 31 : 712 – 6 . OpenUrl 18. ↵ Fan S , Hu Z , Zhao F , Zhao X , Huang Y , Fang X . Multifidus muscle changes and clinical effects of one-level posterior lumbar interbody fusion: Minimally invasive procedure versus conventional open approach . European Spine Journal 2010 ; 19 : 316 – 24 . OpenUrl CrossRef PubMed 19. ↵ Sulaiman WAR , Singh M . Minimally invasive versus open transforaminal lumbar interbody fusion for degenerative spondylolisthesis grades 1-2: patient-reported clinical outcomes and cost-utility analysis . Ochsner J 2014 ; 14 : 32 – 7 . OpenUrl Abstract / FREE Full Text 20. Mcgirt MJ , Parker SL , Lerner J , Engelhart L , Knight T , Wang MY . Comparative analysis of perioperative surgical site infection after minimally invasive versus open posterior/transforaminal lumbar interbody fusion: Analysis of hospital billing and discharge data from 5170 patients - Clinical article . J Neurosurg Spine 2011 ; 14 : 771 – 8 . OpenUrl CrossRef PubMed 21. Schizas C , Tzinieris N , Tsiridis E , Kosmopoulos V . Minimally invasive versus open transforaminal lumbar interbody fusion: Evaluating initial experience . Int Orthop 2009 ; 33 : 1683 – 8 . OpenUrl PubMed 22. ↵ Park Y , Ha JW . Comparison of One-Level Posterior Lumbar Interbody Fusion Performed With a Minimally Invasive Approach or a Traditional Open Approach . Spine (Phila Pa 1976) 2007 ; 32 : 537 – 43 . OpenUrl 23. ↵ Kobayashi K , Ando K , Nishida Y , Ishiguro N , Imagama S . Epidemiological trends in spine surgery over 10 years in a multicenter database . European Spine Journal 2018 ; 27 : 1698 – 703 . OpenUrl CrossRef PubMed 24. ↵ McCabe FJ , Jadaan MM , Byrne F , Devitt AT , McCabe JP . Spinal metastasis: The rise of minimally invasive surgery . Surgeon 2022 ; 20 : 328 – 33 . OpenUrl PubMed 25. ↵ Sclafani JA , Kim CW . Complications Associated With the Initial Learning Curve of Minimally Invasive Spine Surgery: A Systematic Review . Clin Orthop Relat Res 2014 ; 472 : 1711 – 7 . OpenUrl CrossRef PubMed 26. Epstein NE . Learning curves for minimally invasive spine surgeries: Are they worth it? Surg Neurol Int 2017 ; 8 : 61 . 27. ↵ Sharif S , Afsar A . Learning Curve and Minimally Invasive Spine Surgery . World Neurosurg 2018 ; 119 : 472 – 8 . OpenUrl CrossRef PubMed 28. ↵ Vaishnav AS , Othman YA , Virk SS , Gang CH , Qureshi SA . Current state of minimally invasive spine surgery . J Spine Surg 2019 ; 5 : 2 – 10 . OpenUrl 29. ↵ Lener S , Wipplinger C , Hernandez RN , Hussain I , Kirnaz S , Navarro-Ramirez R , et al. Defining the MIS-TLIF: A Systematic Review of Techniques and Technologies Used by Surgeons Worldwide . Global Spine J 2020 ; 10 : 151S – 167S . OpenUrl PubMed 30. ↵ Lewandrowski KU , Soriano-Sánchez JA , Zhang X , Ramírez León JF , Soriano Solis S , Rugeles Ortíz JG , et al. Regional variations in acceptance, and utilization of minimally invasive spinal surgery techniques among spine surgeons: results of a global survey . Journal of Spine Surgery 2020 ; 6 : S260 – 74 . OpenUrl 31. ↵ Härtl R , Lam KS , Wang J , Korge A , Kandziora F , Audigé L . Worldwide Survey on the Use of Navigation in Spine Surgery . World Neurosurg 2013 ; 79 : 162 – 72 . OpenUrl CrossRef PubMed 32. ↵ Njoku I , Wanin O , Assey A , Shabani H , Ngerageza JG , Berlin CD , et al. Minimally Invasive 2D Navigation-Assisted Treatment of Thoracolumbar Spinal Fractures in East Africa: A Case Report . Cureus 2016 ; 8 : e507 . OpenUrl 33. Kelly A , Younus A , Lekgwara P . Minimally invasive spinal surgery in spinal tuberculosis – A case report series . Interdisciplinary Neurosurgery 2021 ; 23 : 101010 . OpenUrl 34. ↵ Younus A , Kelly A , Lekgwara P . Full-endoscopic lumbar foraminoplasty and discectomy to manage a recurrent disc in a patient with previous percutaneous lumbo-sacral stabilization - A case report and literature review . Interdisciplinary Neurosurgery 2020 ; 22 : 100812 . OpenUrl 35. ↵ Wang MY . Devastation after the Haiti Earthquake: A Neurosurgeon’s Journal . World Neurosurg 2010 ; 73 : 438 – 41 . OpenUrl PubMed 36. ↵ World Bank Country and Lending Groups – World Bank Data Help Desk [Internet] . [cited 2022 Jun 26];Available from: https://datahelpdesk.worldbank.org/knowledgebase/articles/906519-world-bank-country-and-lending-groups 37. ↵ Horan TC , Gaynes RP , Martone WJ , Jarvis WR , Emori TG. CDC definitions of nosocomial surgical site infections, 1992: a modification of CDC definitions of surgical wound infections . Infect Control Hosp Epidemiol 1992 ; 13 : 606 – 8 . OpenUrl CrossRef PubMed Web of Science 38. ↵ Hjermstad MJ , Fayers PM , Haugen DF , Caraceni A , Hanks GW , Loge JH , et al. Studies comparing numerical rating scales, verbal rating scales, and visual analogue scales for assessment of pain intensity in adults: A systematic literature review . J Pain Symptom Manage 2011 ; 41 : 1073 – 93 . OpenUrl CrossRef PubMed Web of Science 39. ↵ Fairbank JC , Couper J , Davies JB , O’Brien JP . The Oswestry low back pain disability questionnaire . Physiotherapy 1980 ; 66 : 271 – 3 . OpenUrl PubMed Web of Science 40. ↵ Fairbank JC , Pynsent PB . The Oswestry Disability Index . Spine (Phila Pa 1976) 2000 ; 25 : 2940 – 52 ; discussion 2952. OpenUrl CrossRef 41. ↵ Dwivedi AK . How to write statistical analysis section in medical research . Journal of Investigative Medicine 2022 ; 70 : 1759 – 70 . OpenUrl Abstract / FREE Full Text 42. ↵ Du Prel JB , Röhrig B , Hommel G , Blettner M . Auswahl statistischer testverfahren - Teil 12 der serie zur bewertung wissenschaftlicher publikationen . Dtsch Arztebl 2010 ; 107 : 343 – 8 . OpenUrl 43. ↵ Kwak SK , Kim JH . Statistical data preparation: Management of missing values and outliers . Korean J Anesthesiol 2017 ; 70 : 407 – 11 . OpenUrl CrossRef PubMed 44. ↵ The jamovi project ( 2024 ). jamovi (Version 2.5) [Computer Software] [Internet] . [cited 2025 Jan 17];Available from: https://www.jamovi.org 45. ↵ Von Elm E , Altman DG , Egger M , Pocock SJ , Gøtzsche PC , Vandenbrouckef JP . The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) Statement: Guidelines for reporting observational studies . Bull World Health Organ 2007 ; 85 : 867 – 72 . OpenUrl CrossRef PubMed Web of Science 46. ↵ UNDP (United Nations Development Programme) . 2022 . Human Development Report 2021-22: Uncertain Times, Unsettled Lives: Shaping our Future in a Transforming World . New York . 47. ↵ Global Data Lab, Institute for Management Research, Radboud University. Subnational Human Development Index [Internet] . [cited 2023 Aug 1];Available from: https://globaldatalab.org/shdi/shdi/?interpolation=0&extrapolation=0&nearest_real=0 48. ↵ National Bureau of Statistics . Computation of Human Development Indices for the UNDP Nigeria Human Development Report ( 2016 ) [Internet]. Nigeria Human Development Report2018 [cited 2023 Aug 1];Available from: https://nigerianstat.gov.ng/elibrary/read/830 49. ↵ World Bank . 2020 . The Human Capital Index 2020 Update: Human Capital in the Time of COVID-19 . © World Bank, Washington, DC. http://hdl.handle.net/10986/34432 License: CC BY 3.0 IGO. 50. ↵ The World Bank . Population, total - Nigeria | Data [Internet] . [cited 2023 Aug 31];Available from: https://data.worldbank.org/indicator/SP.POP.TOTL?locations=NG 51. ↵ Amoo BAG , Adenekan AT , Nagado HU . National Health Insurance Scheme (NHIS) implementation in Nigeria: issues, challenges and way forward . CBN Bullion 2017 ; 41 : 15 – 33 . OpenUrl 52. ↵ Wagstaff A , Eozenou P , Smitz M . Out-of-pocket expenditures on health: A global stocktake . World Bank Research Observer 2020 ; 35 : 123 – 57 . OpenUrl 53. ↵ Feigin VL , Nichols E , Alam T , Bannick MS , Beghi E , Blake N , et al. Global, regional, and national burden of neurological disorders, 1990–2016: a systematic analysis for the Global Burden of Disease Study 2016 . Lancet Neurol 2019 ; 18 : 459 – 80 . OpenUrl CrossRef PubMed 54. ↵ James SL , Theadom A , Ellenbogen RG , Bannick MS , Montjoy-Venning W , Lucchesi LR , et al. Global, regional, and national burden of traumatic brain injury and spinal cord injury, 1990–2016: a systematic analysis for the Global Burden of Disease Study 2016 . Lancet Neurol 2019 ; 18 : 56 – 87 . OpenUrl CrossRef PubMed 55. ↵ Dewan MC , Rattani A , Fieggen G , Arraez MA , Servadei F , Boop FA , et al. Global neurosurgery: The current capacity and deficit in the provision of essential neurosurgical care. Executive summary of the global neurosurgery initiative at the program in global surgery and social change . J Neurosurg 2019 ; 130 : 1055 – 64 . OpenUrl PubMed 56. ↵ US-based neurosurgeon returns to Nigeria every month to provide healthcare | CNN [Internet] . [cited 2023 Sep 1];Available from: https://www.cnn.com/2019/10/03/africa/dr-sulaiman-free-surgeries-intl/index.html 57. ↵ Thabane L , Mbuagbaw L , Zhang S , Samaan Z , Marcucci M , Ye C , et al. A tutorial on sensitivity analyses in clinical trials: The what, why, when and how . BMC Med Res Methodol 2013 ; 13 . 58. ↵ Ahn J , Iqbal A , Manning BT , Leblang S , Bohl DD , Mayo BC , et al. Minimally invasive lumbar decompression—the surgical learning curve . Spine Journal 2016 ; 16 : 909 – 16 . OpenUrl 59. ↵ Nandyala S V. , Fineberg SJ , Pelton M , Singh K . Minimally invasive transforaminal lumbar interbody fusion: One surgeon’s learning curve . Spine Journal 2014 ; 14 : 1460 – 5 . OpenUrl 60. Goldstein CL , Macwan K , Sundararajan K , Rampersaud YR . Comparative outcomes of minimally invasive surgery for posterior lumbar fusion: A systematic review . Clin Orthop Relat Res 2014 ; 472 : 1727 – 37 . OpenUrl CrossRef PubMed 61. Weiss H , Garcia RM , Hopkins B , Shlobin N , Dahdaleh NS . A Systematic Review of Complications Following Minimally Invasive Spine Surgery Including Transforaminal Lumbar Interbody Fusion . Curr Rev Musculoskelet Med 2019 ; 12 : 328 – 39 . OpenUrl CrossRef PubMed 62. Mueller K , Zhao D , Johnson O , Sandhu FA , Voyadzis JM . The difference in surgical site infection rates between open and minimally invasive spine surgery for degenerative lumbar pathology: A retrospective single center experience of 1442 cases . Operative Neurosurgery 2019 ; 16 : 750 – 5 . OpenUrl PubMed 63. Hussain NS , Perez-Cruet MJ . Complication management with minimally invasive spine procedures . Neurosurg Focus 2011 ; 31 . 64. Perez-Cruet MJ , Fessler RG , Perin NI . Review: Complications of minimally invasive spinal surgery . Neurosurgery 2002 ; 51 : 26 – 36 . OpenUrl 65. ↵ Chan AK , Bisson EF , Bydon M , Glassman SD , Foley KT , Potts EA , et al. A comparison of minimally invasive transforaminal lumbar interbody fusion and decompression alone for degenerative lumbar spondylolisthesis . Neurosurg Focus 2019 ; 46 . 66. ↵ Dalton JF , Oyekan A , Ridolfi D , Gannon E , Ruh E , Sharma V . Minimally Invasive Transforaminal Lumbar Interbody Fusion with Enhanced Recovery after Surgery (ERAS): Early Experience with Initial Consecutive Cases at a Spine Naïve Community Hospital . Journal of Minimally Invasive Spine Surgery and Technique 2022 ; 7 : 259 – 65 . OpenUrl 67. Carroll AH , Dowlati E , Molina E , Zhao D , Altshuler M , Mueller KB , et al. Does minimally invasive spine surgery improve outcomes in the obese population? A retrospective review of 1442 degenerative lumbar spine surgeries . J Neurosurg Spine 2021 ; 35 : 460 – 70 . OpenUrl PubMed 68. Bisson EF , Mummaneni P V. , Virk MS , Knightly J , Ali Alvi M , Goyal A , et al. Open versus minimally invasive decompression for low-grade spondylolisthesis: analysis from the Quality Outcomes Database . J Neurosurg Spine 2020 ; 33 : 349 – 59 . OpenUrl PubMed 69. ↵ Altshuler M , Mueller KB , MacConnell A , Wirth P , Sandhu FA , Voyadzis JM . Reoperation, readmission, and discharge disposition for patients with degenerative lumbar pathology treated with either open or minimally invasive techniques: A single-center retrospective review of 1435 cases . Neurosurgery 2020 ; 87 : 1199 – 205 . OpenUrl PubMed 70. ↵ Malter AD , McNeney B , Loeser JD , Deyo RA . 5-Year Reoperation Rates After Different Types of Lumbar Spine Surgery . Spine (Phila Pa 1976) 1998 ; 23 : 814 – 20 . OpenUrl 71. ↵ Guzman JZ , Cutler HS , Connolly J , Skovrlj B , Mroz TE , Riew KD , et al. Patient-reported outcome instruments in spine surgery . Spine (Phila Pa 1976) 2016 ; 41 : 429 – 37 . OpenUrl 72. ↵ Finkelstein JA , Schwartz CE . Patient-reported outcomes in spine surgery: Past, current, and future directions . J Neurosurg Spine 2019 ; 31 : 155 – 64 . OpenUrl CrossRef PubMed 73. ↵ Meara JG , M Leather AJ , Hagander L , Alkire BC , Alonso N , Ameh EA , et al. The Lancet Commissions Global Surgery 2030: evidence and solutions for achieving health, welfare, and economic development The Lancet Commissions . The Lancet 2015 ; 386 : 569 – 624 . OpenUrl CrossRef 74. ↵ Ukachukwu AEK , Still MEH , Seas A , von Isenburg M , Fieggen G , Malomo AO , et al. Fulfilling the specialist neurosurgical workforce needs in Africa: a systematic review and projection toward 2030 . J Neurosurg 2023 ; 138 : 1102 – 13 . OpenUrl CrossRef PubMed 75. ↵ Lu Z , Tshimbombu TN , Abu-Bonsrah N , Kanmouyne US , Hesson D , Edward A , et al. Transnational Capacity Building Efforts in Global Neurosurgery: A Review and Analysis of Their Impact and Determinants of Success . World Neurosurg 2023 ; 173 : 188 – 198 .e3. OpenUrl PubMed 76. ↵ Phillips FM , Lieberman IH , Polly Jr. DW , Wang MY Rodgers CR , Rodgers WB . The Role of MI Spine Surgery in Global Health: A Development Critique . In: Phillips FM , Lieberman IH , Polly Jr. DW , Wang MY , editors. Minimally Invasive Spine Surgery: Surgical Techniques and Disease Management . Switzerland : Springer Cham ; 2020 . page 47 – 57 . View the discussion thread. Back to top Previous Next Posted March 14, 2025. Download PDF Data/Code Email Thank you for your interest in spreading the word about medRxiv. NOTE: Your email address is requested solely to identify you as the sender of this article. Your Email * Your Name * Send To * Enter multiple addresses on separate lines or separate them with commas. You are going to email the following A cohort of minimally invasive spine surgeries in Nigeria Message Subject (Your Name) has forwarded a page to you from medRxiv Message Body (Your Name) thought you would like to see this page from the medRxiv website. Your Personal Message CAPTCHA This question is for testing whether or not you are a human visitor and to prevent automated spam submissions. Share A cohort of minimally invasive spine surgeries in Nigeria Oluwafemi F. Owagbemi , Temitayo O. Ayantayo , Olawale A.R. Sulaiman medRxiv 2025.03.14.25323958; doi: https://doi.org/10.1101/2025.03.14.25323958 Share This Article: Copy Citation Tools A cohort of minimally invasive spine surgeries in Nigeria Oluwafemi F. Owagbemi , Temitayo O. Ayantayo , Olawale A.R. Sulaiman medRxiv 2025.03.14.25323958; doi: https://doi.org/10.1101/2025.03.14.25323958 Citation Manager Formats BibTeX Bookends EasyBib EndNote (tagged) EndNote 8 (xml) Medlars Mendeley Papers RefWorks Tagged Ref Manager RIS Zotero Tweet Widget Facebook Like Google Plus One Subject Area Surgery Subject Areas All Articles Addiction Medicine (567) Allergy and Immunology (863) Anesthesia (296) Cardiovascular Medicine (4409) Dentistry and Oral Medicine (443) Dermatology (380) Emergency Medicine (606) Endocrinology (including Diabetes Mellitus and Metabolic Disease) (1505) Epidemiology (15203) Forensic Medicine (30) Gastroenterology (1119) Genetic and Genomic Medicine (6569) Geriatric Medicine (666) Health Economics (994) Health Informatics (4510) Health Policy (1365) Health Systems and Quality Improvement (1608) Hematology (537) HIV/AIDS (1263) Infectious Diseases (except HIV/AIDS) (15902) Intensive Care and Critical Care Medicine (1103) Medical Education (619) Medical Ethics (144) Nephrology (665) Neurology (6572) Nursing (345) Nutrition (998) Obstetrics and Gynecology (1139) Occupational and Environmental Health (954) Oncology (3319) Ophthalmology (967) Orthopedics (369) Otolaryngology (420) Pain Medicine (435) Palliative Medicine (129) Pathology (662) Pediatrics (1688) Pharmacology and Therapeutics (691) Primary Care Research (710) Psychiatry and Clinical Psychology (5421) Public and Global Health (9205) Radiology and Imaging (2190) Rehabilitation Medicine and Physical Therapy (1367) Respiratory Medicine (1191) Rheumatology (593) Sexual and Reproductive Health (709) Sports Medicine (529) Surgery (709) Toxicology (99) Transplantation (288) Urology (265) (function(){function c(){var b=a.contentDocument||a.contentWindow.document;if(b){var d=b.createElement('script');d.innerHTML="window.__CF$cv$params={r:'9fe7761249d641e2',t:'MTc3OTIzOTQyMQ=='};var a=document.createElement('script');a.src='/cdn-cgi/challenge-platform/scripts/jsd/main.js';document.getElementsByTagName('head')[0].appendChild(a);";b.getElementsByTagName('head')[0].appendChild(d)}}if(document.body){var a=document.createElement('iframe');a.height=1;a.width=1;a.style.position='absolute';a.style.top=0;a.style.left=0;a.style.border='none';a.style.visibility='hidden';document.body.appendChild(a);if('loading'!==document.readyState)c();else if(window.addEventListener)document.addEventListener('DOMContentLoaded',c);else{var e=document.onreadystatechange||function(){};document.onreadystatechange=function(b){e(b);'loading'!==document.readyState&&(document.onreadystatechange=e,c())}}}})();