Editorial

Abstract

The approach of 2020 invites a retrospective of the last few years. We have seen a number of trials relevant to neurosurgery published and interpreted with conclusions that have in general been neutral. A considerable international research effort went into the question of decompressive craniectomy for conditions associated with raised intracranial pressure, specifically traumatic brain injury and stroke. The results did not prove to be revolutionary. Rather they placed existing views and practice on a more reliable evidentiary footing. This observation is not unique to the current age. Previous decades have also seen practices and opinions within neurosurgery remain fairly constant while the evidence base that supports those views evolved to become more generalizable and more rigorous. Spinal surgery has also seen an evolving evidence base but the primary advance in recent years seems to have been a rethinking of the surgical approach to what is probably that field’s economically most significant area of uncertainty: fusion surgery for back pain. It is now over 10 years since the publication of trials from both the UK and Sweden that appeared to demonstrate a significant benefit for fusion surgery when compared to conservative measures, however more recent results and measured meta-analysis of multiple outcome metrics told a different story. NICE looked into the issue and in November 2016 agreed (guideline NG 59) saying “Do not offer spinal fusion for people with low back pain unless as part of a randomised controlled trial”. That may not sound like progress but there is no more effective way of improving cost effectiveness then to stop doing expensive, dangerous, and counterproductive things. Notwithstanding that, the number of operations conducted per capita in Western populations in neurosurgery has continued its steady rise, mainly driven by spinal surgery. This is was not prompted by randomized trial results, but rather by ever increasing options of surgical implants. Technological advance has been part of retrospectives for as long as anybody can remember but recent years have brought incremental improvements rather than revolutionary change to neurosurgery. Intraoperative MRI, once hailed as the future, has remained esoteric in application, and that is in part due to the improvements in ultrasound technology and image navigation, usability. Technology such as digital microscopes and robotics remain just around the corner, as they have been since we were all trainees. In what I will loosely called health politics there have been major changes that have altered out working lives. The last decade in particular has seen a rapid rise in legal indemnity costs in neurosurgery, and this has made private practice uneconomic for all but a small number of practitioners working in major cities. The number of neurosurgeons participating in private practice form my own unit of Newcastle has fallen over the past 10 years from 5 to 1, while the number of consultants employed in the department has risen from 6 to 11. The eternal balancing act between ready access to local services and the economies of scale afforded by larger centres located far from much of their catchment will be a political football for as long as there are healthcare systems. Right now we’re seeing this play out in stroke medicine, which peripherally affects us in neurosurgery because that elusive 24 hours mechanical thrombectomy service will be provided by our radiological neurovascular colleagues. Closer to home were the questions of paediatric, functional and epilepsy surgery. That access v scale balance is intimately dependent on the time available for planning and carrying out treatment. It is therefore no surprise that the areas where consolidation has been successfully achieved are restricted to those narrow fields where ample time for planning and travel is permitted by the condition: craniosynostosis and epilepsy surgery. In the much larger field of paediatric services in general, no such consolidation was successful. Instead, attempts in that direction resulted in dedicated paediatric neurosurgical rotors that in turn necessitated an expansion in surgeon numbers to staff them. The number of surgeons currently doing paediatric neurosurgical operations in the UK is very similar to what it was a decade ago, and those surgeon’s case mix between paediatric and adult work is also probably pretty similar to what it was then. An irony in this question of paediatric neurosurgery is that there are areas in the country where the balance between access and the economies of scale could be improved upon, but the idea was derailed by launching a one size fits all approach to planning rather than optimisation of services region by region. A change that was not specific to neurosurgery but was bookmarked by the last 10 years was the introduction of the World Health Organization safe surgery checklist, and this has been something of a disappointment. This was introduced in 2009/10 in the wake of a pilot study published in 2009 that found improvements in mortality that were surprisingly good. It was conducted in 8 hospitals around the world in different economic settings and of different sizes. The three months preceding the introduction of the checklist were compared with the three months following. A total of just under 8,000 operations were observed. Just under 4,000 before and about 4,000 after the introduction. Inpatient mortality fell from 1.5 to 0.8%. Inpatient complications fell for 11 to 7%. These impressive results were the primary driving force for the implementation of the checklist and in the years following a flurry of other reports on its effectiveness appeared. Overall, the checklist seemed to help, but no one managed to match the 46% mortality improvement of the pilot study, they weren’t even close. Many of the following reports did not focus on the same parameters of postoperative inpatient mortality or surgical complications. But those that did generally found improvements of the order of 10%. Further, these modest improvements spanned time periods during which operative mortality was falling for multiple reasons, reducing the benefits ascribable to the checklist. This has been disappointing and the reasons suggested for it are many. One of these is regression to the mean.