CC BY-NC-ND 4.0 · IJNS 2019; 08(01): 001-005
DOI: 10.1055/s-0039-1688729
Neurological Surgeons' Society of India

Evidence-Based Medicine in Neurosurgery—Other Side of the Coin?

Abrar Ahad Wani
1  Department of Neurosurgery, Sher-i-Kashmir Institute of Medical Sciences, Soura, Srinagar, J&K, India
Arif Hussain Sarmast
1  Department of Neurosurgery, Sher-i-Kashmir Institute of Medical Sciences, Soura, Srinagar, J&K, India
› Author Affiliations
Further Information

Publication History

Publication Date:
30 April 2019 (online)


The concept evidence-based medicine (EBM), although in vogue since long, has been gradually making its space in the neurosurgical practice for the past four decades. The proponents propose it as a new paradigm of health care on which every treatment modality must be based, and on the other extreme, there is skepticism in EBM taking a significant role in management of neurosurgical ailments. The debate will vary from deception to the final truth. Nevertheless, this concept will evolve with days to come, but it needs to be understood in all aspects, including its pros and cons with a need to improve it in many aspects. In this article, we focus on unique problems of universal application of this concept in neurosurgery.

Evidence-based medicine is commonly defined as “the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients.”[1] The term is loosely used and can refer to anything from conducting a statistical meta-analysis of accumulated research, promoting randomized clinical trials (RCTs), supporting uniform reporting styles for research, and formulating a personal orientation toward critical self-evaluation. EBM was initially defined in opposition to clinical experience, but later definitions have emphasized its complementary character and have aimed to improve clinical experience with better evidence. It was in the late 1970s when a group of researchers in Canada's McMaster University authored a group of manuscripts on how to critically appraise scientific information and the term “evidence-based medicine” made first appearance in 1990 at the same university. The term subsequently appeared in print in the American College of Physicians (ACP) journal club in 1991.[2] In contrast to EBM, comparative effectiveness research (CER) is defined as “The generation and synthesis of evidence that compares the benefits and harms of alternate methods to prevent, diagnose, treat and monitor a clinical condition or to improve the delivery of care.”[3] All definitions of EBM involve three overlapping processes: systemic review of the available scientific studies, integration of such data with clinical experience, and patient participation in decision making.[4] [5] One common implementation of EBM involves the use of clinical practice guidelines during medical decision making to encourage effective care. The Institute of Medicine (IOM) defines clinical guidelines as “systematically developed statements to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances.”[3]

It is difficult to exaggerate the resonance of EBM in contemporary health care. Many observers have elevated EBM to a new international health care “paradigm.”[6] Many parties have jumped into this subject, and many clinical practice guidelines are being framed by individuals, professional organizations, insurers, and others that the benefits of uniformity may disappear when there are so many overlapping, conflicting, and poorly constructed guidelines. With more than 1,000 guidelines created annually, calls for “guidelines for clinical guidelines” have been issued.[7] [8] This is perhaps what Arthur Doyle in his work stated “There is nothing more deceptive than an obvious fact.” The work on EBM was motivated, in part, as a response to the accusations made by Archibald Cochrane in his book, Effectiveness and Efficiency, which Hill describes as a “a biting scientific critique of medical practice.” In it, Cochrane accuses that many of the treatments, interventions, tests, and procedures used in medicine had no evidence to demonstrate their effectiveness and may, in fact, be doing more harm than good.[9] Cochrane promoted the use of RCTs as the best means of demonstrating the efficacy of a therapy or an intervention, as well as the concept of “efficient health care,” that is, using the available health care resources to “maximize the delivery of effective interventions.”[10] A large group of researchers based in Canada and the United States formed the first international EBM working group and published “The User's Guide to the Medical Literature,” in JAMA between 1993 and 2000, as a 25-part series that still resonates today. These papers were later turned into a textbook on EBM.[2] [10] At the same time, when there was tremendous change in EBM, a need was felt for the applicability of the same to the neurologic surgery.[11]

Evidence-based medicine is informed by hierarchical evidence, and this hierarchy informs clinical decision making. The descending order of evidentiary weight is (1) systemic reviews of multiple high-quality randomized trials, (2) a single high-quality randomized trial, (3) systemic review of observational studies addressing patient important outcome, (4) single observational studies addressing patient important outcome; (5) physiologic studies, and (6) unsystematic clinical observations. It is important to recognize that if treatment effects are sufficiently large and consistent, observational studies may prove compelling evidence than RCTs, particularly in situation where RCTs are not feasible.[10]