Dr. Witcher was interviewing Dr. Adhikari for his residency at Virginia Tech when he first mentioned that he was from Nepal, and wanted to return one day. Most comfortable outdoors and in the mountains, Dr. Witcher had always wanted to go to the Himalayas. The two began discussing a trip to Nepal, and how to help out the Nepalese population while there.

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Dr. Adhikari’s father, still based in Nepal, was instrumental in helping make their plans a reality. He communicated widely through his networks at home, eventually connecting them with Professor Jha and Dr. Khadka at Bir Hospital. 

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Travel restrictions related to the COVID-19 outbreak delayed the trip for several years, but eventually Dr. Adhikari was able to travel to Nepal in 2023 for initial scoping. The following year Dr. Witcher joined him, and the two began meeting with the Ministry of Health and the heads of neurosurgical units at various hospitals, presenting their research and starting to build partnerships. These meetings helped build a picture of the tools and trainings that their Nepali colleagues needed to enhance the services they were able to offer. 

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Drs. Witcher and Adhikari identified that functional neurosurgery was a critical need in Nepal. The doctors at Bir Hospital had experience in stereotactic technique – the root of all functional brain surgery – but no access to training or functional work. All that was missing was equipment. The idea of VTC Nepal Neurosurgery was born.

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Over the course of the next year, Dr. Witcher began piecing together equipment to take to Nepal – building some in his workshop and buying secondhand what he couldn’t make himself from medical distributors or the Home Depot. When they returned, he and Dr. Adhikari planned to start working on cases. Performing neurosurgery requires having backup plans in case something goes wrong, knowing that some things may fail at the beginning. Looking at the equipment they would bring, they had to work through similar scenarios. Would their 50 hertz power circuit work with their 60 hertz equipment? Did they need transformers?

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Like a hiking trip or any outdoor adventure, if you don’t pack a piece of equipment in when performing neurosurgery, you can’t find it when you’re there. Reflecting on the preparations for that second trip, Dr. Witcher said “what terrified me the most was being halfway into someone’s brain and not being able to serve them, after making them go through all that.” 

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When you’re teaching neurosurgery, it’s not only the patient you need to be worried about. It’s also the surgeons, nurses, anesthesiologists and other hospital staff. Having only recently built these networks on the first visit to Nepal, Dr. Witcher knew these relationships were also on the line during the training. In the end, the preparation and planning for the trip paid off. After countless tests of the systems they built, they packed them into Pelican cases and took them to the airport. 

For the past several years, Drs. Witcher and Adhikari, along with selected faculty, residents and students, have been conducting on-site training in Nepal. This consists of didactic subject-specific seminars hosted at Bir Hospital in Kathmandu, typically co-sponsored by the Nepalese Society of Neurosurgeons (NESON). These are paired with hands-on demonstrations using supplies donated by Carilion Clinic, Dr. Witcher and NESON, including complex spine and functional neurosurgery workshops. 

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They then lead operations at Bir Hospital, along with senior and junior Nepali faculty, to demonstrate the technique and directly serve the selected patients. In these surgeries, patient costs are partially sponsored, though implant costs (for example deep brain stimulation hardware) are the patient’s individual responsibility. 

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As this is an indigent care facility, many of the patients cannot afford this treatment and must be turned away. Dr. Witcher wishes to expand the treatment option though direct sponsorship of hardware costs, so that, as more patients are directly served, local faculty develop expertise associated with repetition. This skill can then be taught to trainees, thus transferring the knowledge base to rising faculty and practitioners.

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According to Dr. Adhikari, they are already seeing the results of their work to strengthen capacity. “We’ve been there for four years, and it’s very nice to see the transformation. The doctors are independently doing procedures they were not capable of doing before – so it’s kind of surreal to watch. It’s very humbling and meaningful.”

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Additionally, Dr Witcher and faculty see a high volume of clinic patients (Parkinson's Disease and complex spinal deformity) and select patients for operative intervention. Nepal’s age-standardized prevalence rate of Parkinson's is between 50 and 60 per 100,000 population, and with an aging population the incidence is expected to increase (source). There is also a high prevalence of young onset Parkinson’s in Nepal; 35.8% of those admitted at one hospital had young onset Parkinson’s with an average age of onset of 42.3 years old (source).

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Doctors in Nepal have also called for an increase in specialized centers. One article developed by Nepali doctors calls for a public-owned neurological institute with provincial satellite centers. Noting that the rural population has difficulties accessing hospitals, the authors recommend that in addition to enhancement and upgrade of service provision in Kathmandu, there is a need for increased care in rural areas (source).