Editorial: Proposed Surgical Trigeminal Neuralgia Score checklist

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. (http://thejns.org/doi/abs/10.3171/2013.7.FOCUS13276)