The influence of clinical evidence on surgical practice

Given the considerable interest in the use of evidence-based medicine to guide clinical practice, it is surprising that the results of a recent randomized controlled trial have been met with such a limited response. The DECompressive CRAniectomy study investigators have recently published the results of a landmark trial in neurosurgery, comparing early decompressive craniectomy with standard medical therapy in patients who developed intracranial hypertension after diffuse closed traumatic brain injury (TBI). This is the first ever randomized controlled trial investigating the surgical management of adult patients with severe TBI. The trial clearly demonstrated that early decompression did not provide clinical benefit; however, rather than having a significant impact on clinical practice, it has been almost uniformly criticized. While there were some problems with randomization and crossover, we feel that the trial has been somewhat misinterpreted and in this article we address some of the key issues.