====== Best practices in neurosurgery ====== {{rss>https://pubmed.ncbi.nlm.nih.gov/rss/search/1NAkULqPpWyRevvLnrJDTeq-yxegmNETw3KPKHEFF4ipODBgIQ/?limit=15&utm_campaign=pubmed-2&fc=20250402004219}} ===== 🧠 1. Preoperative Evaluation and Surgical Planning ===== Detailed [[neuroimaging]] analysis (MRI with contrast, tractography, CT, angio when needed). [[Multidisciplinar]]y [[case discussion]] in [[tumor board]]s or vascular [[meeting]]s, when appropriate. Use of [[navigation system]]s, [[intraoperative monitoring]], and [[functional mapping]] for eloquent areas. Patient-specific [[neurosurgical plan]]s based on comorbidities, functional status (KPS), and prognosis. ===== 🛠️ 2. Intraoperative Best Practices ===== Surgical [[checklist]]s and timeouts (WHO Surgical Safety Checklist). Meticulous microsurgical technique: Respect for neural and vascular structures. [[Hemostasis]] and clean dissection planes: reduce risk of infection, edema, or reoperation. Minimally invasive approaches when safe and appropriate. ==== 🧬 3. Postoperative Management and Follow-up ==== Early postoperative imaging when indicated (e.g., within 24–72h for tumor resection). Close neurological monitoring in the ICU/step-down for high-risk cases. Clear [[criteria]] for escalation of care: worsening deficits, hydrocephalus, CSF leak, etc. Structured follow-up schedule with imaging and functional assessment. ==== 📋 4. Documentation and Communication ==== Structured operative notes: approach, findings, complications, implants, resection extent. [[Daily progress note]]s with focused neuro exam. Clear handoffs using SBAR or similar protocols. Timely discharge summaries ensure continuity of care. ==== 📚 5. Education, Mentorship, and Simulation ==== Teach step-by-step [[decision making]], not just techniques. Promote anatomical lab dissection and simulation training (esp. for junior residents). Encourage question-driven learning, case-based discussions, and morbidity/mortality sessions. Use intraoperative teaching moments wisely — without compromising safety. ==== 🧑‍⚕️🤝 6. Patient-Centered and Ethical Practice ==== Transparent risk–benefit discussion with patients and families, especially for high-risk or palliative cases. Avoid “indication creep”: operate only when the benefit clearly outweighs the risk. Respect for autonomy: shared decision-making is key, even when patients choose not to operate. ==== 🧩 7. Quality Assurance and Morbidity/Mortality Review ==== Regular M&M conferences with root cause analysis, not blame. Track key metrics: infection rate, reoperation rate, readmissions, and long-term outcomes. Use complication grading systems (e.g., Clavien-Dindo adapted to neurosurgery). Actively participate in quality improvement projects. ==== 🧑‍🏫 8. Research and Lifelong Learning ==== Stay updated on [[clinical trial]]s and evolving technologies (e.g., AI, robotics, focused ultrasound). Contribute to [[publication]]s, clinical [[database]]s, or registries. Critical appraisal of literature is a core skill for surgeons, not just academics. Encourage multidisciplinary research (oncology, radiology, rehab, etc.). ==== 🧠🔗 9. Neuro-navigation and Technological Integration ==== Use intraoperative tools wisely: neuronavigation, 5-ALA, ultrasound, IOM, endoscopy. Ensure training and team familiarity with the equipment (OR staff included). Adapt technology to the patient, not the other way around. ==== 🤝 10. Teamwork and Leadership ==== Promote a culture of mutual [[respect]] in the OR and the ward. Empower nurses and scrub techs to raise safety concerns. Support residents and junior staff [[emotion]]ally and academically. Lead by example in [[humility]], precision, and continuous improvement. see [[Neurosurgical Practice Guidelines]]. ---- A best practice is a [[method]] or [[technique]] that has been generally accepted as superior to any alternatives because it produces results that are superior to those achieved by other means or because it has become a standard way of doing things, e.g., a standard way of complying with legal or ethical requirements. ---- Clinicians' trust [[level of evidence 1]] [[recommendation]]s, issued on preponderantly solid [[randomized clinical trial]]s (RCTs), to guide best practice [[decision-making]]. However, sometimes physicians following one [[clinical practice guideline]] (CPG) find themselves in a situation in which they do not follow another, issued on the same strong evidence base. The aim of Volovici et al. is to reflect on the [[consistency]] of [[recommendation]]s in different [[guideline]]s (between-guideline consistency). They also consider within-[[guideline]] consistency (or durability), defined as the number of recommendations carried over from one edition to another in consecutive editions of the same CPG. For illustration purposes, they use two examples: hypertension [[guidelines]] and [[traumatic brain injury guidelines]]. They conclude that just like research, [[CPG]]s also need to have between-guideline and within-guideline consistency (akin to the [[reproducibility]] of studies). Clinicians and researchers should take into account the lower [[consistency]] of [[guideline]]s that are not based on at least one strong [[RCT]] ((Volovici V, Steyerberg EW. Lost in translation between [[evidence]] and [[recommendation]]s: Expert opinion is needed to define "level I". World Neurosurg. 2021 Mar 25:S1878-8750(21)00465-4. doi: 10.1016/j.wneu.2021.03.095. Epub ahead of print. PMID: 33775869.)). ---- In an attempt to improve and standardize the use of [[cervical traction]] in pediatric patients, the authors have identified 49 best-practice recommendations, which were generated by reaching consensus among a multidisciplinary group of pediatric spine experts using a modified Delphi technique. Further study is required to determine if the implementation of these practices can lead to reduced complications and improved outcomes for children ((Alexiades NG, Shao B, Braga BP, Bonfield CM, Brockmeyer DL, Browd SR, DiLuna M, Groves ML, Hankinson TC, Jea A, Leonard JR, Lew SM, Limbrick DD, Mangano FT, Martin J, Pahys J, Powers A, Proctor MR, Rodriguez L, Rozzelle C, Storm PB, Anderson RCE. Development of best practices in the utilization and implementation of pediatric cervical spine traction: a modified Delphi study. J Neurosurg Pediatr. 2021 Apr 2:1-12. doi: 10.3171/2020.10.PEDS20778. Epub ahead of print. PMID: 33799292.)). ---- The majority of surgeons obtain preoperative head CTs in Patients With Craniosynostosis, whereas only 25% obtain CTs postoperatively, often to evaluate outcomes. Because outcomes may be evaluated clinically, this is a poor use of resources and exposes children to radiation. Consensus guidelines are needed to create best practices and limit unnecessary studies ((Makar KG, Garavaglia HE, Muraszko KM, Waljee JF, Vercler CJ, Buchman SR. Computed Tomography in Patients With Craniosynostosis: A Survey to Ascertain Practice Patterns Among Craniofacial Surgeons. Ann Plast Surg. 2021 Feb 12. doi: 10.1097/SAP.0000000000002751. Epub ahead of print. PMID: 33587463.))