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This review of neurosurgical conditions at the University Teaching Hospital of Butare highlights the challenges faced by the nascent field of neurosurgery in Rwanda. The reader will appreciate that neurosurgery is not a privilege of "five star hospitals" that can afford state-of-the-art technologies and that a lot can be achieved with little means and yet with acceptable results. Neurosurgery trainees and teachers alike in Africa will learn from this experience that the practice of neurosurgery is possible without over emphasized reliance on expensive equipment. However it is recommended to effectively train future neurosurgeons and to create working conditions that are appealing enough to attract medical students and young doctors to the specialty.