Is there too much variability in technical neurosurgery decision-making? Virtual Tumour Board of a challenging case

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. 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. Opinions regarding the optimal surgical approach were sought from 40 colleagues in the senior neurosurgeon's own hospital and other centres worldwide, who suggested 37 different approaches. 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.