Research Questions in Neuroendoscopy

The modern era of neuroendoscopy encapsulates some of the lessons to be learnt about the introduction of new technology, especially when it is suggested that it may replace existing methods. The natural enthusiasm of the surgeon to be amongst the first to offer the patient an alternative that may be 'better' runs hard on the commercial keenness of the salespeople to sell new and expensive kit. In some cultures and health systems, the ability to provide the latest facility may impact upon the income of the surgeon. In other societies, those who fund the purchase of new equipment may hide behind a pretend shield of "Where's the proof?" as a means of preventing progress. Meanwhile, those who are in a position to introduce the new technology do so, accumulate and present results, and begin to assume fixed positions regarding the value of the "new way". By this time it is probably too late in practical, though not in ethical, economic or scientific terms to run the studies that would be needed to seek the evidence in favor, or against. This is particularly so when existing methods are less than perfect, as is the case with hydrocephalus shunts.

So, is NTV "better" than a shunt? There are many who think so, including the present author, based simply upon the premise that shunts are vicarious, and that to be without the risk, or the actuality, of the misery of their complications is a better position in which to live one's life. Whether NTV is a better treatment per se for the hydrocephalic brain, complications of therapy aside, is not known.

One non-randomized, retrospective study comparing 30 children treated by NTV with 38 treated by ventriculo-peritoneal shunts found no difference between the two groups in neurological, endocrine, behavioral or social outcome [7]. As our aspirations for our patients become greater, it is appropriate that studies should be established to identify which method of treatment is better for the young brain in terms of neurodevelopment, and for the adult brain in terms of neuropsychological function.

For some categories of very young patient the success rate for NTV is low, but the complication rate of shunts is also high; a randomized study here would also be appropriate.

It is not known whether the apparently good results published from centers in which there are acknowledged experts in neuroendoscopy can extend to a whole population of neurosurgeons and their patients, yet this is a crucial point if advice is to be given on a national or international basis. A prospective study capturing all patients treated by NTV needs to look at this wider picture. With the concerns regarding complications, this could be matched with a central registry of adverse events. It is noteworthy, as an observation only, albeit not capable of analysis, that in Nottingham in an early study of 47 children and young people undergoing 51 secondary NTVs, there were only three significant complications (6%) [1]; yet in a series extending into a later epoch, of 63 adults undergoing 66 NTVs, there was a total complication rate of 17.5%, with an 11% serious complication rate [11].

Without any imputation, one operational change that occurred between the earlier study and the one including later patients was that the number of surgeons performing NTV rose from three consultants to six consultants plus a number of supervised trainees. This may mean nothing, but the question still needs to be asked as to whether this is a technique that can be pursued safely by all surgeons, or whether it should be subject to sub-specialization.

There are certain specific applications of NTV that could be addressed in prospective studies, e.g. the value of "routine" NTV in children with posterior fossa tumors, or the efficacy of NTV in treating syringomyelia when that condition is associated with ventriculomegaly.

With regards to other neuroendoscopic procedures, there is a clear place for a randomized

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