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Neurology India, Vol. 54, No. 4, October-December, 2006, pp. 352 Invited Commentaries Stereotaxy: The paradigm changes towards image-guided frameless procedures Gunther Kleinpeter Neurochirurgische Abteilung, Rudolfstiftung, Juchgasse 25, A-1030 Wien Code Number: ni06126 This is a study which examines the accuracy and reliability of three different brain biopsy procedures:[1] frame-based stereotactic biopsy, frameless image-guided biopsy and US-guided biopsy. Technique, outcome, complications and cost of the procedures were not the focus of the investigation. The investigators have validated the three methods in a larger clinical series. In the current cohort of 130 patients the three groups were not equally distributed. If we start from the assumption that the analysis was planned without prejudice to any null hypothesis, then the fact that the majority of the cases (95/130) were represented in the frame-based stereotactic biopsy group corrupts the results with an implied bias in favor of a "gold standard procedure". Thus the newer methods tested (frameless biopsy and US-guided biopsy) are only represented with relative low case numbers (15/ 130 and 20/130 respectively), weakening any resultant conclusion. One could argue that the underlying alternative hypothesis in this comparative study was to find out whether these two methods could reach the same accuracy as the "gold standard". And in fact, that is the result of this study; there were no major differences in the accuracy of brain tumor biopsy of standard frame-based (84%), frameless (87%) and US-guided (80%) methods. Thus this data does not meet statistical criteria, but it matches the recent literature and the impression of neurosurgeons working in this field.[2],[3],[4],[5],[6] Neurosurgery is currently undergoing a paradigm change in the direction of the modern image-guided techniques which have become available in the majority of departments. However, for a reliable scientific statement the presented data is too weak. This would require a prospective study in which the three patient series are concurrent and the choice of the procedure would be randomized. This comparison study strongly suggests that the new procedures are safe and accurate and the results are comparable to or better than the gold standard frame-based method. The principles are discussed in the light of the available literature. The wasteful, time-consuming classical stereotactic procedure, which is cumbersome and inconvenient for both patient and doctor, will surely give way to the new methods described in this investigation. However, beyond empirical practice, we shall rely on scientific support for this change. References
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