The Concept of Medical Reversal in Neurosurgery

Sir, The concept of medical reversal, introduced by Prasad et al.,[1] refers to the phenomenon where new, methodologically robust, and conclusive evidence contradicts previously accepted practices. Medical reversal has tremendous implications in neurosurgical practice. Patients may undergo unnecessary interventions that lead to adverse effects, potentially harming their health and adversely impacting healthcare systems due to increased costs and resource utilization. Neurosurgeons must provide care based on evidence which is the most recent. One of the advantages of evidence-based medicine (EBM) is the contribution of well-conducted randomized controlled trials that feature improved blinding, better controls, greater statistical power, well-defined endpoints, and reduced bias. Ioannidis[2] explained why most published research findings are false in six corollaries. The less likely the research findings are to be true when smaller the studies conducted and the smaller the effect sizes in a scientific field; when there is a more significant number and a lesser selection of tested relationships in a scientific field; when there is greater flexibility in designs, definitions, outcomes, and analytical models in a scientific field; when there is more significant financial and other interests and prejudices involved in a scientific field; and finally when the hotter a scientific field (with more scientific teams involved), the research findings are less likely to be true.[3] It is a well-known fact that much of what is being done in medicine persists because of the simple reason: “That is how it has always been done,” or “That is how it was taught,” along with a reluctance to change practices that seem to work, even when evidence suggests otherwise. A pivotal aspect of making medical practice and clinical research impactful in our healthcare system is identifying and eliminating low-value medical practices. Medical reversal occurs because therapeutic approaches are often based on a reductionist view, focusing solely on one perspective – whether it be pathophysiological, epidemiological, historical, or even rooted in EBM. This happens when decisions are made using flawed information, often derived from methodologically weak randomized trials or meta-analyses that include inconclusive studies with significant heterogeneity.[3] As a result, interventions that seem effective may later be disproved by more robust evidence. In addition, the lower the current standard of any treatment’s acceptance, the higher the chances of its future reversal. Management of intracerebral hemorrhage (ICH) is one potential area of medical reversal in the context of neurosurgical practice, and this trial demonstrated that early intervention in patients with ICH did not improve prognosis in those affected by the condition. One of the studies that can help us understand the context of medical reversal is the analysis of the Surgical Trial in ICH (STICH) trials.[4,5] Mendelow et al. published the results of STICH and STICH II trials in 2005 and 2013, respectively.[4,5] Results of STICH confirmed that 26% of all those randomized to early surgery had a favorable outcome compared with 24% of those randomized to initial conservative treatment with odds ratio (OR) of 0·89 [95% confidence interval (CI) 0·66–1·19], (P = 0.414); absolute benefit 2·3% (–3·2–7·7), relative benefit 10% (–13–33).[5] Therefore, it concluded that patients with spontaneous supratentorial ICH show no overall benefit from early surgery when compared with initial conservative treatment.[5] The results and their interpretation of the STICH II trial, published in 2013, present a significantly different perspective. Fifty-nine percent of patients in the early surgery group had an unfavorable outcome versus 62% of patients in the initial conservative treatment group (absolute difference 3·7% [95% CI –4·3 to 11·6], OR 0·86 [0·62 to 1·20]; P = 0·367).[5] The STICH II results confirm that early surgery does not increase the rate of death or disability at 6 months and might have a small but clinically relevant survival advantage for patients with spontaneous superficial ICH without intraventricular hemorrhage. Medicine, in general, and Neurosurgery, in particular, are fields that are characterized by overwhelming progress that occurs every day, with the development of new techniques and diagnostic imaging modalities becoming a regular part of our practice. In this context, medical reversal is a critical phenomenon in which newer techniques do not surpass their predecessors. This highlights the importance of continually evaluating the effectiveness and safety of interventions, ensuring that older methods may still provide better outcomes than newly introduced practices. Emphasizing EBM is essential to avoid unnecessary medical reversals and to provide the best possible care for our patients. Understanding the concepts of replacement and reversal is relevant, Prasad and Cifu highlight that replacement occurs when a superior treatment supplants an older one, such as low molecular weight heparins replacing Coumadin. A reversal happens when a commonplace practice is abandoned because it is found to be ineffective or harmful despite its previous acceptance. Examples include Avandia, ezetimibe, atenolol, and hormone replacement therapy, which were later criticized due to new evidence revealing their limitations or risks.[6] Looking at these results, the naïve neurosurgical units between 2005 and 2013, after reading and following the 2005 study (but before the publication of 2013), would prefer initial conservative management over early surgery. However, after 2013, the same team may manage similar patients with a preference to decompress and remove hematoma over initial conservative management, leading to a reversal of medical management of supratentorial ICH without Intraventricular extension. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.