Global disparities in neurosurgery simulation: a 22-year bibliometric analysis (2003–2025)

Abstract

Abstract Background and objective Simulation training is increasingly adopted to complement traditional neurosurgical training worldwide. However, uptake remains uneven, especially in low-income countries (LICs) with disproportionately high neurosurgical burden. Using bibliometric methods, we identified global disparities between disease burden and research output in simulation-based neurosurgery. We also examined research trends to highlight delayed adoption and feasibility concerns in LIC literature. Materials and methods We retrieved 763 neurosurgical simulation articles (2003–2025) from Web of Science using predefined criteria. Data were exported as plain text and analyzed using the bibliometrix R package. Author countries were classified by 2023 World Bank income groups for additional analysis. Results There was a stark mismatch between neurosurgical burden and scientific production. Despite a high neurosurgical burden in Lower Middle-Income Countries (LMIC) and Low-Income (LIC), these groups contributed to a mere 28.1% of share in literature and often failed to meet the 1/100,000 neurosurgeon density target. Research trends show HIC focusing on technology adaptation like segmentation, cerebral aneurysm, improving resection skill and assessing the overall impact of simulation training on residents training. UMICs, including Mexico and Brazil, focused on feasibility of low-cost models in teaching hospitals and their educational benefit. India was the only country from the LMIC group to feature in top 10 contributors list. Indian and other LMIC literature focused on cost-effective indigenously developed models like SimSpine and their use in quantification of hand movements as objective markers of trainee feedback. The LIC literature was sparse ( n = 5) and was often conducted in collaboration with HIC institutions. LIC studies focused on topics relevant to addressing local disease burdens—such as endoscopic third ventriculostomy for hydrocephalus and, spina bifida repair suggesting simulation is being leveraged to overcome limited access to real-life surgical exposure. Conclusion To the authors’ knowledge, this is the first bibliometric analysis to examine neurosurgery simulation research by income group. Despite having a relatively lower neurosurgical burden, HICs dominate simulation-based research. Given the inverse relationship between income level and neurosurgical disease burden, increased representation from LMICs and LICs is essential. Cross-national collaboration and targeted investment are needed to develop context-appropriate, scalable simulation systems for low-resource settings to improve training and bridge skill gaps.

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