Editorial: Proposed Surgical Trigeminal Neuralgia Score checklist

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The authors merit congratulations for their ambitious efforts to assess the quality of surgical literature regarding the management of trigeminal neuralgia (TN).1 In the presented literature review and in the Surgical Trigeminal Neuralgia Score (STNS)–based evaluation of study rigor they attempt to 1) provide a checklist to guide future journal editorial decisions; 2) standardize patient-centered outcome measures in the TN literature; and 3) guide clinical practitioners in the application of study results to patient care situations.

The authors' creation and use of the proposed STNS scale falls short of their presented methodological standard. A single author scored most

The authors merit congratulations for their ambitious efforts to assess the quality of surgical literature regarding the management of trigeminal neuralgia (TN).1 In the presented literature review and in the Surgical Trigeminal Neuralgia Score (STNS)–based evaluation of study rigor they attempt to 1) provide a checklist to guide future journal editorial decisions; 2) standardize patient-centered outcome measures in the TN literature; and 3) guide clinical practitioners in the application of study results to patient care situations.

The authors' creation and use of the proposed STNS scale falls short of their presented methodological standard. A single author scored most TN manuscripts; only 10% were randomly subjected to multiple reviewers to assess interobserver variability of the STNS checklist. The authors do not disclose their rate of scoring discordance, and they only note that scoring differences were reconciled by discussion. This method fails to account for potential bias in the overwhelming majority of papers that only benefited from a single STNS review.

The STNS elements presented in Table 1 of this paper arbitrarily weigh clinical factors surrounding diagnosis, treatment, and complications comparably to manuscript organization, methods presentation, and Kaplan-Meier curve construction. More beta testing of the individual components of the list will be needed to be able to rank in order the elements of manuscript format and clinical data points in terms of their contribution to the model. As yet, the STNS checklist itself is not a validated tool, and great care must be taken in the introduction of any method that may shape the literature on a grand scale and carry unintended reporting bias.

Naturally, use of the checklist by editorial boards in publication decisions would prompt publication of manuscripts that score higher by the STNS checklist standard. This self-fulfilling prophecy notwithstanding, the authors presume that a higher STNS corresponds with a greater ascertainment of clinical reality, and that subjective STNS checklist application will improve our understanding of TN treatment. This premise is tantalizingly intuitive, but remains unproven.

As is common to many neurosurgical procedures, patient selection based on clinical presentation, past treatment, and imaging findings remains crucial to clinical success. Few randomized trials exist for surgical modalities because technical equipoise rarely exists. We would argue that this is clearly the case with microvascular decompression versus the nerve-injuring methodologies. The high STNSs reported by the authors for studies in the neurosurgical literature probably correspond with strong performance of these manuscripts in the clinical elements of the STNS scale; that is, treating neurosurgeons ask the right clinical questions.

Conversely, journals with a high impact factor that emphasize aspects of the STrengthening the Reporting of OBservational studies in Epidemiology (STROBE) formula may perform well on the STNS methodological elements, but fail to capture the TN population of interest. From this perspective, which set of papers carries greater clinical application? Despite admirable efforts toward meta-analysis, there remains a clear role for surgical expertise and discretion in the selection of patients with TN; study data further this process by offering clear-eyed understanding of benefit durability and complication profiles in the relevant study population. Although we dispute the authors' contention that the existing literature fails to offer surgeons this information, we remain mindful of opportunities for ongoing improvements in methodological studies in the neurosurgical literature.

Overall, we stand in full agreement that the standardization of outcomes assessment in TN, be it the Brief Pain Inventory–Facial favored by the authors or another metric such as the 36-Item Short Form Health Survey, offers broad benefits for the field and should be carried forward. We further agree about the benefits of standard outcome tools for disease states to foster improved metaanalysis. We applaud the authors for empirically demonstrating the greater detail in the selection of patients with TN that is evident in the neurosurgical literature, and the correspondingly strong STNS for these manuscripts. Checklists such as the STNS may evolve as guides for future editorial decisions, and the resulting literature may inform but not dictate the application of study data to an individual patient care situation.

Disclosure

The authors report no conflict of interest.

Reference

1

Akram HMirza BKitchen NZakrzewska JM: Proposal for evaluating the quality of reports of surgical interventions in the treatment of trigeminal neuralgia: the Surgical Trigeminal Neuralgia Score. Neurosurg Focus 35:3Advances in the Neurosurgical Treatment of Intractable PainE32013

Response

We would like to kindly thank Drs. Khalessi and Giannotta for their informative and constructively critical letter. We strongly agree with their notion that the standardization of outcome reporting in the field of TN is of great benefit to the scientific community and ultimately to patient care, and we would like to add that it is also essential—especially in the scarcity of evidence available from randomized controlled trials for the obvious reasons that their editorial highlights.

Drs. Khalessi and Giannotta raise a relevant point; we are not in a position to rule out bias introduced due to interobserver variation. We would like to take this opportunity, however, to reiterate that most of the STNS elements can be scored by a simple yes/no answer to determine whether a certain item has been included in the manuscript; other items look at reported variables such as the duration of follow-up and the number of patients in the study, and therefore are unlikely to be incorrectly scored. Although we believe that this leaves very little space for interobserver variability, we agree that a Cronbach analysis would have shown this in a more robust fashion.

The only discrepancy between the coauthors was when scoring a single item reporting on the baseline measure of pain; following a discussion an agreement was reached to credit only papers reporting the actual baseline measure of pain and not just stating that it was measured. We believed that this was an important point to make. There were no other discrepancies between the 3 authors when scoring the remaining 29 items. It was therefore not considered necessary to rescore more than 10% of the sample.

Drs. Khalessi and Giannotta mention that journals with high impact factors that follow the STROBE formula “may perform well on the STNS methodological elements, but fail to capture the TN population of interest.” Our analysis has shown that this is simply not the case, and there was no significant correlation between the impact factor of a journal and the STNS. This was not the case when we examined the correlation between the scores and the type of journal (mainstream neurosurgery vs other), which is consistent with Drs. Khalessi and Giannotta's remark that surgical expertise is invaluable when it comes to asking the right questions. Journals that use reviewers who work in this area are more likely to identify missing key factors. Reports need to contain sufficient similar data that will enable meta-analysis to be performed, because results can vary dramatically when reporting larger series, as has been shown by Rughani et al.1 Those investigators analyzed 3273 procedures and showed that age per se was not a predictor of poor outcome in the elderly, whereas other small series had suggested the opposite.

We agree with Drs. Khalessi and Giannotta that the STNS checklist is not a validated tool, and we have never made the claim for it to be one. We are simply putting forward a suggested method that we would like others to test. We would therefore welcome responses from a wide readership so that it can be further improved, especially in connection with ranking the importance of the various criteria. We hope, however, that the reviewers agree with us that speaking the same language is essential when reporting on the outcomes of surgical intervention, and that by following the example of the STROBE criteria we are making progress in achieving this goal.

Reference

1

Rughani AIDumont TMLin CT: Safety of microvascular decompression for trigeminal neuralgia in the elderly. Clinical article. J Neurosurg 115:2022092011

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Article Information

Please include this information when citing this paper: DOI: 10.3171/2013.7.FOCUS13276.

© AANS, except where prohibited by US copyright law.

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References

1

Akram HMirza BKitchen NZakrzewska JM: Proposal for evaluating the quality of reports of surgical interventions in the treatment of trigeminal neuralgia: the Surgical Trigeminal Neuralgia Score. Neurosurg Focus 35:3Advances in the Neurosurgical Treatment of Intractable PainE32013

1

Rughani AIDumont TMLin CT: Safety of microvascular decompression for trigeminal neuralgia in the elderly. Clinical article. J Neurosurg 115:2022092011

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