The emerging discipline of outcomes analysis has spawned an industry and a literature of its own. It is deemed an invaluable tool to assess the value of new medications, management practices, and technologies.
The dawn of modern neurosurgery in the late 19th century is recorded in the form characteristic of the time — mostly sporadic case reports announcing the successful localization of an intracranial lesion.
Case reports predominated for the first several decades of neurosurgery, although in 1893 the Glaswegian pioneer Sir William Macewen published his classic book, Pyogenic Diseases of the Brain and Spinal Cord. He summarized the results of his surgical series, using survival as his “endpoint” and percentage as his statistical analysis. Of 25 patients with brain abscesses, 18 of the 19 who had surgery survived while all of the nonsurgical patients died. With Scottish understatement Macewen wrote, “One might conclude that in uncomplicated abscesses of the brain, operated on at a fairly early period, recovery ought to be the rule.”
Some 12 years later, when Harvey Cushing began to operate on patients with “tumors of the nervus acusticus,” the published experience of this surgery reported a mortality rate of about 80 percent. Four of his first 11 patients died shortly after surgery. Had Cushing stopped there, discouraged, the results likewise would have spoken for themselves. But no internal review board or outcomes panel stepped in, and by 1917 he reported that mortality after acoustic neuroma surgery had dropped to 11 percent.
The drama of those early days is long past and will be hard to match. Most neurosurgical discoveries and refinements today yield incremental improvements in patient survival or function — or not. Modern outcomes analysis may be necessary to parse out these important but small changes. But it gives one pause to consider that if today’s standards had been applied to neurosurgery’s pioneers, the neurosurgical specialty might never have come into being. It is unlikely that many of the Bulletin’s readers believe the world would be better off for that.
Michael Schulder, MD, is associate professor in the Department of Neurological Surgery and director of image-guided neurosurgery at UMDNJ-New Jersey Medical School.