Outcome from complex neurosurgery: An evidence based approach

Background. The aim of this study was to determine outcome, including quality of life, after surgery for petroclival meningioma using a standard skull base approach and to carry out an evidence based appraisal of the relevant literature. Method. Pre- and post-operative data including adverse events were prospectively recorded in 19 patients (15 females, age range 29-63) undergoing a transpetrous approach for a petroclival meningioma. patients were assessed using the GOS and SF-36 post operatively. Findings. 24 operations were done. 6 patients developed a new permanent neurological deficit and 10 experienced a temporary deficit or exacerbation of existing deficits. At 1 year 15 patients had made a good/moderate recovery, 3 were severely disabled and 1 died - in keeping with other studies. By contrast the SF-36 showed that in all 8 categories of the SF-36 between 39-72% of surviving patients were functioning below the accepted norms. Interpretation. After transpetrous excision of a petroclival meningioma the quality of life for the patient is worse than that indicated in surgeons' reported results. This paper represents an attempt to address the issue of evidence-based medicine and finds that such an approach is not apparent in the medical literature on this pathology. While we argue that methods for measuring outcome should be refined and carers input recognised it does raise certain philosophical considerations. It is the counsel of perfection and if achieved may lead to surgeons operating on fewer patients, more petroclival cases being viewed as inoperable because of the higher morbidity, despite there being an inescapable pathway to surgical intervention.