Background: Neurosurgical care is vital for conditions such as traumatic brain injury, brain tumors, and hydrocephalus. In African low- and middle-income countries (LMICs), access remains limited due to systemic and structural challenges. Despite bearing 15% of the global neurosurgical burden, the region faces a massive workforce deficit and underdeveloped infrastructure. Objective: To synthesize existing evidence on barriers impeding and facilitators improving access to neurosurgical care in African LMICs. Methods: A narrative review was conducted through a targeted search of PubMed, African Journals Online (AJOL), and Google Scholar for English-language studies published between 2014 and 2024. Studies were included if they focused on African LMICs and addressed access-related barriers or facilitators. In total, 48 studies were selected and analyzed thematically. Results: Barriers to access include an acute workforce shortage (0.15 neurosurgeons per million people), with only 32 of 54 countries offering neurosurgical training. Infrastructure deficits, such as a lack of Intensive Care Units beds, operating microscopes, and anesthesia services, compound these challenges. Financial constraints are significant, with some families in Eastern Africa paying over 130% of their annual income for surgery. Long travel distances (averaging 144 km), cultural stigma, reliance on traditional healers, and political instability further restrict access. Conversely, facilitators include successful international collaborations (e.g., Duke East Africa Neurosurgery Program, WFNS Rabat Training Centre), adoption of telemedicine and teleradiology, and growth in local research capacity, including disease registries and training exchanges. Conclusion: Transforming neurosurgical access in African LMICs demands bold investment in rural services, specialist training, and full integration into national health financing.