Introduction

Decades into the era of evidence-based medicine, most neurosurgeons are aware that the vast majority of our day-to-day patient care decisions are not guided by class I evidence, especially those related to surgical procedures. We rely on common sense, personal bias based on our residency training and personal experience (based largely on time in practice and the nature of our practice), personal comfort and “gut feeling”.

Case report

A 35-year-old man presented with a 6-month history of visual loss, cognitive decline and endocrine dysfunction. Imaging showed the culprit lesion to be a cystic suprasellar tumour with a mural nodule (Fig. 1). The senior neurosurgeon responsible was challenged by this case and sought opinions regarding the optimal surgical approach from 40 colleagues in his own hospital and other centres in North America, Europe and Asia. Over 90% of those canvassed responded. The breakdown of the 37 approaches suggested was:

  • Pterional craniotomy for cyst drainage and resection of the nodule (18)

  • Interhemispheric low frontal (4)

  • Interhemispheric high frontal transcallosal (3)

  • Subfrontal (3)

  • Transcortical transventricular (2)

  • Transcortical, but not through the ventricle (2)

  • Cyst aspiration followed by radiosurgery to the nodule (2)

  • Cyst aspiration followed by second stage subfrontal resection of the nodule (1)

  • Subtemporal (1)

  • Transsphenoidal (1)

Fig. 1
figure 1

a Axial, b coronal and c sagittal T1 gadolinium-enhanced MRI of the patient showing a suprasellar cystic lesion with a mural nodule

Full size image

A right pterional image-guided craniotomy successfully allowed for drainage of the cyst and resection of the nodule. The pathology was adamantinomatous craniopharyngioma. The patient had an excellent surgical recovery and a good outcome with normalisation of his neurological, endocrine and imaging abnormalities.

Discussion

A literature review confirms the wide variability in treatment approach among surgeons, partly due to surgeon-specific factors such as age [2], experience [3] and training background [2, 3]. Variability in decision-making between generalists and specialists [1] reflects the influence of training, whereas the influence of experience is seen when the same surgeon’s management changes over time [4].

Almost 50% of respondents recommended the same approach, but this case highlights how diverse the potential surgical approaches were in this particular case, and presumably countless cases dealt with every day by neurosurgeons all over the globe. This is distinct from other professionals such as airline pilots whose practices are guided by set standards. Assuming that the majority of neurosurgical approaches are not and will never be amenable to exploration by randomised studies, is there any other way to help standardise the management of challenging neurosurgical problems?

We humbly suggest that there may be too much individualism in neurosurgical decision-making and that more conformality in surgical approach may be beneficial to our profession. Perhaps a simplistic way to start this initiative would be to submit difficult cases to the Virtual Tumour Board, similar to what was done here. Some surgeons probably do this on an informal and/or occasional basis. The persona of surgeons as independent individualists is still prevalent, and may be an obstacle to forward progress in this area. Perhaps asking the advice of our colleagues in a safe and constructive arena should be a more commonly employed tool used to benefit patients.