Global disparities in neurosurgical literature: a narrative review of underrepresentation of low- and middle-income countries and pathways to research equity.

The global neurosurgical literature is dominated by high-income countries, with low- and middle-income countries (LMICs) contributing minimally despite bearing the most significant share of the neurosurgical disease burden. Underrepresentation limits equitable knowledge dissemination and the relevance of guidelines. The objective of this review was to assess neurosurgical publication disparities, identify deterrents to LMIC participation, and outline initiatives that foster equity and inclusion in research. This narrative review synthesized evidence on global disparities in neurosurgical literature through a structured search of PubMed, Scopus, and Google Scholar (2010-2025). Eligible studies examined research output, authorship trends, publication barriers, or equity initiatives. Findings mapped bibliometric patterns, highlighted structural barriers, and synthesized strategies to promote equitable neurosurgical scholarship. More than two-thirds of neurosurgical reviews come from North America and Europe, whereas less than 10% come from Africa and South-East Asia. Barriers to publication include limited funding, high article processing charges, lack of mentorship, and weak institutional infrastructure. LMIC authors are often relegated to middle authorship, which decreases exposure and hinders academic advancement. Case studies from Africa, South Asia, and Latin America highlight progress in expanding the workforce and in training for specific areas, but persistent research inequities remain. Recent initiatives, such as AuthorAID, HINARI, African Neurosurgical Research Collaborative, and open-access waiver programs, have demonstrated measurable improvements in LMIC research output and authorial independence. Significant inequities persist in neurosurgical research. For sustainable solutions, there is an important need for structural reforms: expanded mentorship, equitable funding, inclusive editorial policies, and strengthened regional collaborations that ensure global neurosurgical research reflects diverse contexts and meaningfully contributes to worldwide patient care.