Understanding how to move from dogmatic to outcome-based neurosurgical care: Lessons from past surgical studies on...

The role research can play in neurosurgical care is poorly understood. The result is that inappropriate methods are frequently used in clinical research, and unverifiable neurosurgical care is widely practised.

We review the research questions and the methods used in two landmark studies on the surgical treatment of ruptured aneurysms. We then compare the explanatory approach with the more appropriate pragmatic approach, and explain the difference by analogy with the ancient medical dispute between dogmatists and empiricists.

The International Cooperative study on the timing of aneurysm surgery was dogmatic or rationalistic: medical care is based on reason; research aims to gain theoretical knowledge, explanations and generalizations to be used as reasons to act in practice. But practice based on case-by-case reasoning is haphazard and unverifiable. The Finnish randomized trial was more empirical in spirit: reliable knowledge is to be found in repeated clinical experience. A reliable treatment is one proven to provide verifiably better outcomes in a trial integrated into practice.

Verifiable outcome-based neurosurgical care will be possible with the integration of pragmatic trials into everyday practice.