The middle path, the beaten path, or the uncharted path: Is neurosurgical decision making at a crossroad?
Correspondence Address: Source of Support: None, Conflict of Interest: None DOI: 10.4103/0028-3886.190244
Source of Support: None, Conflict of Interest: None
The concept of surgical equipoise without compromising skill, bravado, and innovation, elucidated by Professor BS Sharma in an article  on the philosophy of the middle path, was a fascinating read. It provoked further thinking on whether neurosurgical decision making is at a philosophical crossroad, with the choice between the Beaten Path, the Middle Path, and the Uncharted Path lying before us [Figure 1] and [Table 1].
Neurosurgical decision making: Complex yet conscientious
Every neurosurgical decision is made “in good faith” with the greater goal of curing the ailment and alleviating suffering. However, decision making is unconsciously biased by the decision maker's cognitive skills, surgical expertise and past experiences, as well as the patient's expectations, institutional culture, resources, and ethical and medicolegal propriety. Decision making is, thus, a complex and unpredictable phenomenon, even though it rests on the cornerstone of primum non nocere ( first do no harm).
The surgical decision making process has been scientifically explained by the dual process theory, wherein every treatment decision has two aspects, an analytical/explicit aspect and a nonanalytical/implicit aspect. The explicit system is a higher order process based on conscious reasoning, judgement, and scientific evidence.
A young man with a large clival chordoma and unilateral 6th nerve paresis managed with the “theoretically sound” decision of a transbasal approach and radical resection risking fresh deficits.
The implicit system is intuition and unconscious impulse based and hence, heavily influenced by past experiences and memories.
A tendency to be conservative with a benign, large skull base lesion just because a few earlier patients with radical resections had a morbid course.
In reality, most neurosurgical decisions involve a close interplay between both the implicit and explicit decision making processes, that is, a balance between theory and pragmatism. A paradigm shift in the goals of neurosurgical care from the earlier “preservation of life” to the present “quality of life” also influences the care of ailments.
The beaten path of surgical bravado
To set things right, neurosurgeons most often trust the surgical scalpel much more than wonder drug molecules. Radical surgical efforts were considered scientifically and conceptually appropriate since time immemorial. Traditionally, the emphasis has been on “radiological cures,” that is, the postoperative imaging being devoid of the tumor or showing the deformity corrected. If every radical surgical effort translates into a disease-free and disability-free survival, then it is worth every ounce of blood lost and the hours of surgical toil. However, unfortunately, outcomes may not be commensurate with the effort. Paraphrasing James Ausman, ”Skull base surgeons seem more interested in the surgery itself than the patients.” The technicality of the procedure often takes an upper hand over the quality of life outcome measure. We are often swept away by the awe around the technique, thereby paying less heed to the life behind it.
The middle path of clinical equipoise
As the natural history of many neurosurgical illnesses is now well known, many neurosurgeons with a lifetime of experience choose a “middle path philosophy.” There is less emphasis on radical procedures and “radiological cures.” Every neurosurgical endeavour is balanced by the standard of care, available skills, resources, and the treating neurosurgeon's philosophy. Cure, with preservation of the quality of life, without compromise in skill and bravado, is the hallmark of the optimum care.
The uncharted path of unexplored pursuits
Smooth seas don't make skilful sailors. If it doesn't challenge you, it doesn't change you. Hence, the incurable aspect of every neurosurgical ailment offers scope for an uncharted path. It is a window of opportunity to evaluate new treatment modalities, innovate surgical techniques, and challenge the limits of medical science. Investigational yet scientifically sound therapies, randomized control trials with new molecules, and surgical renovations could bring about an earth-shattering metamorphosis in conquering new frontiers. The fine line between palliating an incurable brain tumor and curing it maybe perhaps just a “eureka moment” away.
The “integrated diagnosis” concept
Current evidence favors the “integrated diagnosis” concept for CNS tumors, which incorporates the histology, grade, molecular features, symptomatology and response to therapy.
The 2016 central nervous system World Health Organisation (WHO) classification  suggests conceptual and practical advances in our understanding of brain tumors. It brings about a major overhauling of the classification of diffuse gliomas, medulloblastomas and other embryonal tumors, and incorporates new entities that are defined by both histology and molecular features, including a glioblastoma, isocitrate dehydrogenase (IDH)-wild type and glioblastoma, IDH-mutant; diffuse midline glioma, H3 K27M–mutant; V-Rel Avian Reticuloendotheliosis Viral Oncogene Homolog A (RELA) fusion–positive ependymoma; medulloblastoma, Wingless-type (WNT)-activated and medulloblastoma, sonic hedgehog (SHH)-activated; and embryonal tumour with multi-layered rosettes, C19MC-altered. Terms like gliomatosis cerebri and even the primitive neuroectodermal tumor (PNET) have become archaic and obsolete.
However, in “resource challenged” nations like India, where many centres lack resources and access to molecular techniques and immunostains, making an “integrated diagnosis” still remains a challenge.
To each his own: Bespoke neurosurgical care
The recent focus of neuropathological tumour diagnoses (WHO,2016 classification) has been to avoid “umbrella” terms and “waste basket” categorisation because there is a certain uniqueness in every tumor. Heisenberg's uncertainty principle cites limits to the precision with which physical properties of a particle can be simultaneously known. Humans, an “amalgamation of uncertain particles,” aren't different. Disease 'X' managed by the theoretically sound and evidence based surgical treatment 'Y', need not always have the best outcome 'Z'. Thus, despite being scientifically appropriate and surgically skilful, treatment outcomes may not always achieve the intended best and have an element of inexplicable uncertainty and unpredictability.
To sum up the philosophy, neurosurgical treatment decisions have to be “tailor-made”(bespoke) for each individual and cannot be a “one-size-fits-all” generic formula. Care, based on a particular disease or diagnosis and its survival data isn't enough to get the best outcome for a particular patient. A certain man's glioma is different from another man's and has its own unique molecular signature. So would be its symptomatology, treatment response, prognosis, and survival.
Thus, the management of every ailment needs to be balanced by the natural history of the disease, the surgical expertise available, the quality of life outcome measures, the patient's and caregiver's expectations, etc., At times, a cognitively and functionally preserved independent existence, though shortlived, could mean much more than a prolonged survival dependent on others.
Sometimes there is a conflict between emotion and science, philosophy, and standard of care. When facing difficult moments in neurosurgical decision making, our path is sometimes lit up by these words of anonymous authorship,
“It's impossible,” said pride,
“It's risky,” said experience,
“It's pointless,” said reason
“Give it a try,” whispered the heart,”
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Conflicts of interest
There are no conflicts of interest.