Neurosurgery, as with any other medical specialty, is at a crossroad-of increased technological capability and biological uncertainty. Neurosurgeon, today, can visualize and diagnose with precision and intervene with sophistication. This has enhanced one of the biggest dilemmas in surgical practice—when to intervene and when to exercise restraint. A 72-year-old retired schoolteacher presented to me recently, with an incidentally detected large ophthalmic segment aneurysm picked up during work up of early dementia. The counselling session with the patient and her family focused on the natural history of incidental aneurysms, the risks of rupture, the morbidity or mortality associated with rupture and the available microsurgical and endovascular strategies. Risk stratification using the PHASES score estimated an annual rupture risk of approximately 1%–2% that to the family represented an existential threat and made them opt for intervention. The postoperative course was complicated, and despite maximal care, the patient did not survive. In another similar case, few years ago, a large, cavernous segment carotid artery aneurysm was detected in an elderly lady during evaluation for minor trauma. Following similar counselling and risk assessment, her family chose conservative management. One year later, she succumbed following catastrophic epistaxis. The two patients described represent opposing decisions for similar pathologies and embody the core ethical paradox of incidental pathology. Neither decision was wrong. Both were rational, evidence-based, and ethically defensible. The tragedy lies not in the choices, but in the limits of medical ability.1,2 To intervene or to watch ?. Intervention carries risk, non-intervention carries uncertainty, and the outcome retrospectively causes guilt and regret. Modern medicine has transitioned from treating disease to managing risks. Incidental findings transform healthy individuals into patients, and probabilities into pathologies. All unbled aneurysms become a future catastrophe-in-waiting. Contemporary neurosurgical practice increasingly relies on predictive tools such as PHASES, UIATS, and population-based rupture risk models. These offer clarity on probabilities but not on certainties.1,2 A 1%–2% risk of rupture when extrapolated across remaining life expectancy, becomes persuasive but when weighed against procedural morbidity and mortality becomes ethically ambiguous. The asymptomatic lesion becomes a psychological burden. Ignorance is bliss, knowledge is torture! My mentor Prof Suresh Nair, during our residency days, offered two simple aphorisms which he never got tired of repeating almost every day. “If it ain’t broke, don’t fix it” and “never treat a scan, treat the patient.” This advice explains that biological systems possess their own equilibrium, and that intervention disrupts as often as it heals. Most of his trainees adopted this principle—as a posture of humility before complexity. I have over the years not only practiced it, but preached it to all my residents. As a neurosurgeon, both, a catastrophic rupture of an unbled aneurysm and a surgical complication is unforgettable and remains a haunting nightmare. Evidence increasingly supports this restraint. Large natural history studies, including ISUIA and subsequent population-based cohorts, demonstrate that many unruptured aneurysms—particularly in elderly patients carry rupture risks that may not exceed treatment-related morbidity. Advances in endovascular therapy have reduced procedural risk but not eliminated it. Morbidity, cognitive decline, loss of independence, deterioration in quality-of-life remain underrepresented endpoints in outcome reporting. Every intervention trades one risk for another. Every non-intervention accepts a future unknown. The ethical challenge is choosing which uncertainty a patient must live with. This ethical tension is compounded by modern medico-legal climates, patient expectations shaped by technological optimism, and the pressure to “do something.” Yet, medicine’s highest virtue is not action, but judgment. Restraint in neurosurgery is therapeutic maturity. It recognizes that not all detectable pathology requires correction, that not all risks demand elimination, and that sometimes the most responsible act is non-action. “If it ain’t broke, don’t fix it” is not a rejection of progress. It is a reminder that the most sophisticated intervention remains clinical wisdom and that sometimes, the bravest act in neurosurgery is to leave well enough alone. Let us practice with data but decide with conscience. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.
Girish Ramachandra Menon (Sun,) studied this question.