Key points

Introduction

Throughout the past several decades, the neurosurgery publishing community has undertaken an active role in improving the quality of the neurosurgery literature. Notably, in recent years, neurosurgery journals have provided the main conduit through which the techniques of evidence-based medicine, originating outside the field, have illuminated the data produced by neurosurgery researchers. In particular, journals have promoted improvements in patient care by endorsing an evidence-based view of neurosurgery practice and actively safeguarding the quality of the review process.

In the early twentieth century, as neurosurgery matured, Osler’s “medico-chirurgical neurologists” split from general surgery to form their own discipline. The Society of Neurologic Surgeons was founded in 1920, followed by the Harvey Cushing Society (now the American Association of Neurologic Surgeons [AANS]) in 1931. With these professional accretions, a gradual awareness of the need for neurosurgery-specific journals dawned on that burgeoning community. The Journal of Neurosurgery (1944), Surgical Neurology (1975), and Neurosurgery (1977) were among the earliest and most influential journals devoted to neurosurgery in North America. The emergence of such periodicals stemmed from the recognition that despite sharing subject matter with related fields, such as neurology and general surgery, the peculiar complexities of neurosurgical care and its reliance on new science demanded discipline-focused venues for publication. Harvey Cushing, writing in 1929, famously recognized the binding influence of scientific publications in cultivating disciplinary consensus. The promulgation of independent neurosurgery journals over the course of the twentieth century reflects, in microcosm, the evolution of neurosurgery itself as a self-governing specialty with its own set of professional mores and standards.

Over the past century, the quantity of scientific information available to neurosurgeons has expanded dramatically. Neurosurgery journals have proliferated at an exponential rate, reflecting a trend seen across all scientific disciplines. This has been accompanied by a concomitant increase in the number of published articles, and increased pressures to organize that knowledge into useful forms for the clinical practitioner. At the same time, as the sea change of evidence-based medicine swept through the medical world in the 1990s, exhortations for achieving an “evidence-based neurosurgery” resulted from convincing arguments that the insistence on evidence-based patient care is applicable to neurologic surgery. Quality and quantity of the data have become paramount.

Organizing the ever-expanding mass of research data into the kind of knowledge that can guide clinical practice has proved a demanding feat. On this front, neurosurgery journals have been responsible for spearheading or facilitating many of the key initiatives. With assistance from professional societies, such as the AANS and Congress of Neurologic Surgeons (CNS), journals have improved the quality of neurosurgical knowledge by enforcing reporting standards, promoting meta-analysis, disseminating evidence-based clinical practice guidelines, and governing the process of peer review.

Introduction

Throughout the past several decades, the neurosurgery publishing community has undertaken an active role in improving the quality of the neurosurgery literature. Notably, in recent years, neurosurgery journals have provided the main conduit through which the techniques of evidence-based medicine, originating outside the field, have illuminated the data produced by neurosurgery researchers. In particular, journals have promoted improvements in patient care by endorsing an evidence-based view of neurosurgery practice and actively safeguarding the quality of the review process.

In the early twentieth century, as neurosurgery matured, Osler’s “medico-chirurgical neurologists” split from general surgery to form their own discipline. The Society of Neurologic Surgeons was founded in 1920, followed by the Harvey Cushing Society (now the American Association of Neurologic Surgeons [AANS]) in 1931. With these professional accretions, a gradual awareness of the need for neurosurgery-specific journals dawned on that burgeoning community. The Journal of Neurosurgery (1944), Surgical Neurology (1975), and Neurosurgery (1977) were among the earliest and most influential journals devoted to neurosurgery in North America. The emergence of such periodicals stemmed from the recognition that despite sharing subject matter with related fields, such as neurology and general surgery, the peculiar complexities of neurosurgical care and its reliance on new science demanded discipline-focused venues for publication. Harvey Cushing, writing in 1929, famously recognized the binding influence of scientific publications in cultivating disciplinary consensus. The promulgation of independent neurosurgery journals over the course of the twentieth century reflects, in microcosm, the evolution of neurosurgery itself as a self-governing specialty with its own set of professional mores and standards.

Over the past century, the quantity of scientific information available to neurosurgeons has expanded dramatically. Neurosurgery journals have proliferated at an exponential rate, reflecting a trend seen across all scientific disciplines. This has been accompanied by a concomitant increase in the number of published articles, and increased pressures to organize that knowledge into useful forms for the clinical practitioner. At the same time, as the sea change of evidence-based medicine swept through the medical world in the 1990s, exhortations for achieving an “evidence-based neurosurgery” resulted from convincing arguments that the insistence on evidence-based patient care is applicable to neurologic surgery. Quality and quantity of the data have become paramount.

Organizing the ever-expanding mass of research data into the kind of knowledge that can guide clinical practice has proved a demanding feat. On this front, neurosurgery journals have been responsible for spearheading or facilitating many of the key initiatives. With assistance from professional societies, such as the AANS and Congress of Neurologic Surgeons (CNS), journals have improved the quality of neurosurgical knowledge by enforcing reporting standards, promoting meta-analysis, disseminating evidence-based clinical practice guidelines, and governing the process of peer review.

Neurosurgery journals and proliferation of scientific information

The proliferation of neurosurgery journals and their quantitative impact over time is not well described in the primary literature, in part because categorizing scientific periodicals by discipline can be a deceptively difficult task. However, irrespective of which method is applied, it is clear that over several decades the number of neurosurgery journals has increased dramatically. In the mid-1970s, three major journals dominated the field. Today, there are dozens in the English language alone. One popular neurosurgery community World Wide Web portal lists 35 neurosurgical journals, rank-ordered by impact factor, in its resources section. Another source identified 182 neurosurgery-related journals and found 2522 distinct journals cited by neurosurgical literature during a 3-month period. New neurosurgery journals have been incepted de novo from professional interest groups, by evolution from pre-existing journals (eg, the continuation of Surgical Neurology as World Neurosurgery ), or by splitting from a parent journal. The latter mechanism is represented, for example, by the recent spinoff of Operative Neurosurgery from its parent journal, Neurosurgery .

The importance of a periodical within its field is classically measured by metrics based on citation analysis. For example, the impact factor is defined as the average number of citations per paper published in that journal over the preceding 2 years. The h index reflects number of publications and citations; a journal with an h index of N has published N papers that have each been cited a minimum of N times. Both the impact factor and the h index have been applied to individual authors and to journals, although their dominance as metrics of scientific importance has been debated. Citations in neurosurgical literature have been described as following a clear clustering pattern, with a recent analysis identifying the six “core” neurosurgery journals, in order of citations for a given time period, as Journal of Neurosurgery , Neurosurgery , Spine , Acta Neurochirurgica , Stroke , and Journal of Neurotrauma .

In modern neurosurgery publishing, several safeguards are put in place to ensure the quality of research publications and, by consequence, the contribution of literature to the quality of patient care.

Reporting guidelines as a tool for literature quality

Around the turn of the twenty-first century, there emerged a growing awareness of the poor quality of reporting in medical research literature. Selective reporting of data, incomplete listing of interventions, problematic conclusions, and unclear methodologies plagued many papers. In neurosurgery, these deficiencies were particularly profound. Despite the well-known preeminence of randomized controlled trials (RCTs), these were scarce in the neurosurgery literature even when compared with general surgery or other surgical subspecialties. Moreover, under close examination, neurosurgical RCTs as a group showed many flaws. In a survey of 108 RCTs on neurosurgery procedures during a 36-year span, underpowered trials and inadequate design reporting were widespread. Another survey of 159 neurosurgical RCTs found, among other pitfalls, that nearly half of trials had inadequate reporting of allocation concealment, a core feature of proper RCT design.

Beginning in the 1990s, the advent of consensus reporting guidelines from internationally recognized working groups has revolutionized the ability to objectively qualify clinical studies. The most widely accepted of these, introduced in 1996 and last revised in 2010, is known as the CONSORT statement (Consolidated Standards of Reporting Trials) and centers on a 25-item checklist for RCT reporting. CONSORT has been recognized as an important tool for ensuring the quality RCTs in the literature. Because RCTs are uncommon in neurosurgery, the variety of guidelines developed for other study designs are of considerable importance. Prominent examples include GRADE (2004) for formal grading of evidence, AMSTAR (2007) for systematic reviews, PRISMA (2009) for systematic reviews and meta-analyses, and MOOSE for meta-analyses that include observational studies. Collectively, these reporting guidelines have standardized and strengthened the organization of clinical knowledge.

The first publicized effort by a major neurosurgical journal to improve the quality of its literature by applying internationally recognized guidelines took place in 2011, when Neurosurgery endorsed and began requiring several of these guidelines. This followed comparable initiatives by top-tier journals in other biomedical disciplines, and endorsements of CONSORT by the International Committee of Medical Journal Editors ( www.icjme.org ) and other associations.

Today, Neurosurgery endorses and requires authors to adhere to several key reporting guidelines. Research articles that must be submitted according to the appropriate reporting guidelines include, but are not limited to, randomized trials, systematic reviews, meta-analyses of interventions, meta-analyses of observational studies, diagnostic accuracy studies, and observational epidemiologic studies (eg, case series, cohort, case-control, and cross-sectional studies). For manuscripts that report statistics, the journal requires that authors provide evidence of statistical consultation or expertise. As of October 2014, Neurosurgery explicitly requires the reporting guidelines listed in Table 1 .

Myriad resources exist to assist authors and reviewers in the task of understanding and meeting reporting guideline requirements. Authors are referred to the EQUATOR Network, which was established in 2006 to promote transparent and accurate reporting of research studies by providing an up-to-date list of guidelines. These include reporting guidelines for niche topics, such as neuro-oncology trials, and other nonrequired checklists and consensus statements designed to ensure research quality.

Organization of knowledge: systematic reviews and meta-analyses

In tandem with efforts to improve the reporting and methodology of primary research, such as RCTs, renewed emphasis has been placed on secondary analyses of primary data, such as systematic reviews and meta-analyses. This attention is justified by the fact that meta-analyses can represent powerful levels of evidence. Current initiatives to improve the quality of meta-analyses and systematic reviews in the neurosurgery literature have mirrored efforts in the larger world of medical publishing. The most successful of these has been the Cochrane Database of Systematic Reviews, established in 1993 as an electronic collection of “living documents” representing systematic reviews of primary research in health care and health policy. In 2011, the Cochrane Database of Systematic Reviews was recognized with a seat on the World Health Organization’s World Health Assembly. Although the Cochrane Database of Systematic Reviews contains more than 5000 reviews, a keyword search of that database for “neurosurgery” yielded only 13 reviews. This validates the need for more neurosurgery-specific efforts to organize data from clinical studies into systematic reviews.

Attempts to quantify the quality of evidence in the neurosurgical literature have yielded varying results. A recent study found that higher levels of evidence (levels I and II) represented only 1 in 10 clinical papers from the top neurosurgical journals. Publications with larger sample size were significantly associated with a higher level of evidence. The authors of that study compared their data with that obtained for the year 1999, concluding that the proportion of high-quality evidence in neurosurgery journals had not significantly changed.

In the realm of methodologic and reporting quality for neurosurgery studies, there remains significant room for improvement. By some measures, the quality of meta-analyses in the neurosurgical literature seems to be improving. However, among 72 papers in neurosurgery journals self-described as meta-analyses, one study found that on average only 53% of PRISMA items and 31% of AMSTAR items were completed. Only 15% of the papers mentioned using a content checklist, and none mentioned using a methodology checklist. According to an editorial accompanying that study, these results demonstrated that neurosurgery had one of the worst quality meta-analyses of any medical field. Concerns about literature quality have emerged not only for meta-analyses, but also for observational study designs, which are more numerous. A 2014 study found that most papers in the neurosurgical literature self-identifying as “case-control studies” are labeled incorrectly, with several attendant concerns in methodology. In evaluating those papers that met the definition as case-control studies, the authors applied the Strengthening the Reporting of Observational Studies in Epidemiology Checklist and found examples of reporting deficiencies, such as reporting of bias (28%), missing data (55%), and funding (44%). Evidence is emerging, however, that the intervention of enforcing reporting guidelines may measurably improve the quality of published literature. In at least one editorial position statement, this has been noted as a promising way forward for quality of the neurosurgery literature. For instance, comparison of RCTs published before and after the advent of CONSORT, and of RCTs in journals that do or do not endorse CONSORT reporting, supported a beneficial effect of the CONSORT statement on literature quality.

Organization of knowledge: clinical practice guidelines

Initiatives to improve the quality of primary and secondary clinical research studies have been accompanied by coordinated efforts to develop comprehensive clinical practice guidelines for specific conditions. Neurosurgery journals have often worked in conjunction with professional societies to develop and disseminate the guidelines produced via these efforts. The CNS has formalized an in-house infrastructure to curate clinical practice guidelines, which it defines as including recommendations intended to optimize patient care and informed by a systematic review of evidence along with an assessment of benefits and harms.

The most concentrated large-scale efforts to develop evidence-based clinical practice guidelines in neurosurgery have occurred over the past 15 years. In chronologic order of their date of publication, Table 2 lists clinical practice guidelines publicly endorsed by the CNS and other neurosurgery-related guidelines.

Table 2

Notable neurosurgery guidelines and consensus statements

	Year	Publisher	Sponsor
Guidelines Endorsed by CNS
Guidelines for the Management of Severe Traumatic Brain Injury (Third Edition)	2007	Journal of Neurotrauma	Brain Trauma Foundation, AANS, CNS
Guidelines for the Treatment of Newly Diagnosed Glioblastoma	2008	Journal of Neuro-Oncology	CNS/AANS Joint Section on Tumors
Clinical Guideline on the Treatment of Carpal Tunnel Syndrome	2008	American Academy of Orthopedic Surgeons	American Academy of Orthopedic Surgeons
Evidence-Based Clinical Practice Parameter Guidelines for the Treatment of Patients with Metastatic Brain Tumor	2009	Journal of Neuro-Oncology	CNS/AANS Joint Section on Tumors, in collaboration with McMaster Evidence-Based Practice Center
Guideline for the Surgical Management of Cervical Degenerative Disease	2009	Journal of Neurosurgery: Spine	CNS/AANS Joint Section on Spine
Guidelines for the Management of Spontaneous Intracerebral Hemorrhage in Adults	2010	Stroke	American Heart Association/American Stroke Association/American College of Cardiology
Guidelines for the Prevention of Stroke in Patients with Stroke and Transient Ischemic Attack (Secondary Stroke Prevention)	2011	Stroke	American Heart Association/American Stroke Association
Guideline on the Management of Patients with Extracranial Carotid and Vertebral Artery Disease	2011	Circulation	American Heart Association/American Stroke Association/American College of Cardiology and others
Guidelines for the Acute Medical Management of Severe Traumatic Brain Injury in Infants, Children, and Adolescents	2012	Pediatric Critical Care Medicine	Brain Trauma Foundation
Guidelines for the Management of Aneurysmal Subarachnoid Hemorrhage	2012	Stroke	American Heart Association/American Stroke Association/American College of Cardiology
Guidelines for the Management of Acute Cervical Spine and Spinal Cord Injuries	2013	Neurosurgery	AANS/CNS Section on Disorders of the Spine and Peripheral Nerves
Guideline Update for the Performance of Fusion Procedures for Degenerative Disease of the Lumbar Spine	2014	Journal of Neurosurgery: Spine	AANS/CNS Section on Disorders of the Spine and Peripheral Nerves
Consensus Statements Endorsed by CNS
Position Statement on Percutaneous Vertebral Augmentation	2007	Journal of Vascular and Interventional Radiology	Multiple including AANS, CNS, American Society of Interventional and Therapeutic Neuroradiology
Reporting Standards for Angioplasty and Stent-Assisted Angioplasty for Intracranial Atherosclerosis	2010	Journal of NeuroInterventional Surgery	Society of Interventional Radiology
Reporting Standards for Endovascular Repair of Saccular Intracranial Aneurysms	2010	American Journal of Neuroradiology	Society of Interventional Radiology
Diagnosis and Management of Cerebral Venous Thrombosis	2011	Stroke	American Heart Association/American Stroke Association/American College of Cardiology
Key Data Elements and Definitions for Peripheral Atherosclerotic Vascular Disease	2012	Journal of the American College of Cardiology	American College of Cardiology/American Heart Association
An Updated Definition of Stroke for the 21st Century: A Statement for Healthcare Professionals from the American Heart Association/American Stroke Association	2013	Stroke	American Heart Association/American Stroke Association
Guidelines and Statements Reviewed but not Endorsed by CNS
Occupational Medicine Practice Guidelines, Low Back Disorders	2007	American College of Occupational and Environmental Medicine	American College of Occupational and Environmental Medicine
Evaluation and Management of Adult Patients Presenting to the Emergency Department With Acute Headache	2008	Annals of Emergency Medicine	American College of Emergency Physicians
Occupational Medicine Practice Guidelines, Chronic Pain	2008	American College of Occupational and Environmental Medicine	American College of Occupational and Environmental Medicine
Occupational Medicine Practice Guidelines, Hand, Wrist, and Forearm Disorders	2009	American College of Occupational and Environmental Medicine	American College of Occupational and Environmental Medicine
Treatment of Symptomatic Osteoporotic Spinal Compression Fractures	2011	Journal of the American Academy of Orthopedic Surgeons	American Academy of Orthopedic Surgeons
Other Notable Neurosurgery-Related Guidelines a
Guidelines for Field Management of Combat-Related Head Trauma	2005	Brain Trauma Foundation	Brain Trauma Foundation
Guidelines for the Surgical Management of Traumatic Brain Injury	2006	Neurosurgery	N/A
Guidelines for Prehospital Management of Traumatic Brain Injury, Second Edition	2007	Journal of Neurotrauma	Brain Trauma Foundation, AANS/CNS Joint Section on Neurotrauma and Critical Care

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