DEBATE: is tractography accurate enough to be used to inform surgery?

The integration of diffusion MRI tractography into neurosurgical practice raises an essential question: is this technology accurate enough to be used to inform surgery? This short communication summarizes the key points of a debate held at the 2024 Tract-Anat Retreat on the clinical utility and limitations of tractography in neurosurgery. While tractography in neurosurgery offers unique insights into patient-specific white matter anatomy and has proven value for surgical planning, risk stratification and patient counselling, we identified limitations, challenges, and areas for improvement. These include variability in reconstruction methods, the importance of multimodal integration, false negative results and intrinsic limitations at surgery, such as brain shift during navigation. These perspectives highlight the need for standardized protocols, functional validation, and enhanced surgeon training to ensure the cautious and effective use of tractography in the operative setting.