Editorial

Welcome to the fourth issue of the year. This year the journal continues to enjoy a healthy series of submissions. As a consequence there is a backlog for inclusion into the print version of the journal, though I remind authors that once the article is published online it can be cited, and is effectively in publication from that date.

There is the usual mix of articles in the journal – perhaps a little sparse on the neurovascular side, but this will be rebalanced in the next issue. See also reference to abstracts from the recent 3^rd International CNS germ cell Symposium which we are happy to host online. In the print journal (and online) can be found the abstracts of the recent British Society for Stereotactic & Functional Neurosurgery meeting.

The topic of the moment that I presume is on everyone's mind is the issue of publication of surgeon-specific outcomes. I've highlighted this issue in earlier editorials as I consider it both important and a huge opportunity, although there are also dangers as shown by a recent paper. ¹ Clearly the patient had better not have a rare disease else the surgeon outcome cannot be addressed! Alternatively, a closer examination of the denominator is needed, and perhaps this process would be able in time to inform us as to what degree would sub-specialisation be advantageous, compared to the benefits from a more broad knowledge base.

It is a huge opportunity as we can get into practice meaningful outcomes. Recently I was asked to provide representative outcome data for microvascular decompression for trigeminal neuralgia – the requester suggesting infections, length of stay, revisions, re-admissions and mortality would be likely to be important variables to record. Of course, whilst “not unimportant” (which, by the way, I always feel is a dreadful double negative) the key issue is the 5- and 10-year pain-free off-medication rate! Mortality is so unusual as to be worthless as a useful discriminator unless there was a complete catastrophe – see again Walker et al.¹ Also important and often neglected is the fate of the cases not accepted for treatment for whatever reason. How then do we bring to notice a circumstance where a policy to accept elderly patients for microvascular decompression might have as a consequence a less good outcome in respect of a foramen ovale method, as all the frail patients with co-morbidity go in this direction? Differential diagnosis could be relevant; if the case is not trigeminal neuralgia then the pain-free outcome will very likely not be good, but this data is presumably not included in the surgeon-specific outcomes for microvascular decompression for trigeminal neuralgia.

So, is publication of surgeon-specific data a good thing? Definitely, but in order not to appear fools we will have to make sure the data is of good quality – accurate and complete, and relevant. The good thing about this imperative is that it will by necessity force us to achieve this goal. The surgeon by the way should be the consultant performing or directly supervising the person doing the primary intervention for that patient's condition. The importance of this to neurosurgery is in particular for interventional neuroradiology, where open surgery for aneurysms is now virtually non-existent.

I hope that the open publication of this kind of data will mean that all will have to address such problems. I would note a number of issues to be taken on:

• Effect of case mix – we must understand and have made transparent any algorithm used to adjust for this, especially if volume considerations mean a wide variety of different types of cases need to be summated – each with its own case mix algorithm.

• Multidisciplinary working

• The effect of training and perhaps experience – differentiating between case numbers required for a “learning curve” and case volume for reasonable outcomes – although it is fashionable to parade case volume as an argument for many political agendas, how robust is the evidence? Is there in fact any “level 1” evidence? Does surgeon specific data include cases done by a trainee? Could a surgeon “improve” outcomes by not training?

• The situation where there is more than one treatment available for a given circumstance – this is referred to above in selection of patients with trigeminal neuralgia between medical management, radiosurgery, foramen ovale techniques and microvascular decompression.

• The issue of the differential diagnosis – as above, consider not trigeminal neuralgia, but the outcome for management of facial pain? As a more general point, how is the denominator for case volume defined?

This list of points is not by any means exhaustive, and will require resource. One powerful lever to obtain such resource might be that commissioners insist on the collection and publication of such data, and perhaps they could “demand” true population statistics. Difficult, of course, but valuable, unquestionably. When examining in the commissioning process the different cases for different treatments, agreement could also be reached as to the clinically relevant outcome measures. If such data could be collected in a comprehensive fashion it would provide an excellent substrate for clinical research, and create economies for running trials as outcome data collection processes would be in place for all conditions.