CORRESPONDENCE
Letter: Machine Learning and Artificial
Intelligence in Neurosurgery: Status,
Prospects, and Challenges
To the Editor:
I read with great interest the article by Dagi and colleagues.1 I
would like to congratulate the authors on introducing artificial
intelligence (AI) to neurosurgeons and presenting a compre-
hensive overview of AI concepts, applications, and challenges to
the adoption of AI algorithms in clinical practice.
AI has the potential to revolutionize diagnostics, clinical
decision making, prognostication, and operative interventions in
neurosurgery and has an important role to play in advancing
precision medicine for neurosurgery in the future.2-6 Dagi et al
highlighted that as of 2018, only 23 neurosurgical studies
reported using machine learning (ML) or AI in the neurosurgical
literature,7 although this number may be under-represented and
may be closer to the order of 70 to 155 studies in recent years.8,9
Despite the exponential increase in the number of publications on
the use of AI in medicine and neurosurgery,10,11 actual clinical
applications and medical devices using AI algorithms remain
limited.12,13 There is still a large gap between expectations of AI
and the reality of applying AI in neurosurgical clinical practice.
In their article, Dagi et al1 had introduced the need for
validation and verification of AI algorithms, and highlighted
the regulatory challenges of translating AI algorithms into real-
world applications. In order to bridge the translational gap
for AI algorithms to be used in neurosurgery, I would like
to emphasize that, first, the development of accurate and
unbiased AI algorithms is needed.14 This allows the neurosur-
gical community to trust the use of AI algorithms in clinical
practice, and to mitigate the risks of unintended and negative
consequences in using AI in neurosurgery.5 These concerns are
real, and existing reviews on AI algorithms in neurosurgery
have highlighted methodological issues related to using biased
data for AI model development and applying models outside
of populations intended for clinical use.7,15,16 Furthermore, the
risks of widespread implementation of inaccurate AI algorithms
have been illustrated in a recent example of a proprietary sepsis
prediction model that was shown to have poor discrimination and
calibration in predicting the onset of sepsis, raising fundamental
concerns about its use nationally.17 Thus, for AI algorithms to be
translated into real-world applications in neurosurgery, challenges
related to algorithm development and ML science would need to
be addressed.18
In order to facilitate the development of AI algorithms for
use in neurosurgery, the neurosurgical community would need
to better understand the algorithm development pipeline,19
AI performance metrics,20,21 and potential bias in AI model
development,22 and collaborate with data scientists to address
NEUROSURGERY
problems suited for AI solutions in neurosurgery. As neurosur-
geons best understand the myriad clinical problems related to the
management of neurosurgical diseases, they play a pivotal role in
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guiding the development of AI algorithms for clinical application
in neurosurgery. Importantly, before widespread adoption and
translation into clinical practice may occur, AI algorithms would
also need to be understood and trusted by neurosurgeons.18 Thus,
the perceived opacity of AI algorithms, described by Dagi et al as
“a black box whose internal logic may be elusive” is a barrier to
the translation of AI algorithms into neurosurgical practice.23,24
To enable the neurosurgical community to better understand
how AI algorithms work and to reach a minimum level of trust
that allows AI algorithms to be applied and used in neurosur-
gical practice, I would like to introduce the concept of explainable
AI.25-27 Explainable AI is focused on the understanding and inter-
pretation of the behavior of AI algorithms, which aims to create
insight into how and why these algorithms produce predictions,
while maintaining high predictive performance levels.28,29 Thus,
an AI algorithm is explainable if neurosurgeons are able to under-
stand how these algorithms make their predictions. Methods
used to develop explainable AI may be classified into explainable
modeling and post-hoc explanations, and these methods are able
to provide global or local explanations of the AI algorithms
being used.28 Examples of explainable AI have been reported in
the medical literature,30-32 and in neurosurgery, an explainable
deep-learning algorithm was developed for the detection of acute
intracranial hemorrhage on noncontrast computed tomography
scans.33 Further developments in the field of explainable AI may
allow both neurosurgeons and neurosurgical patients to better
understand how AI algorithms work, and enable the translation
of these algorithms into neurosurgical practice.
Lastly, the true test of clinical applicability for AI algorithms
may occur in the form of robust clinical evaluation using real-
world randomized controlled trials (RCTs).18,34 Such RCTs for
AI are an invaluable tool to demonstrate causal inference and
the effectiveness of AI algorithms in improving clinical outcomes
in neurosurgical practice.34 Data scientists cannot conduct such
RCTs in neurosurgical practice. Neurosurgeons are thus best
positioned to lead the development of AI solutions in neuro-
surgery, to ensure that the neurosurgical community understand
the intended use of these algorithms, and to translate these
algorithms into real-world neurosurgical applications.
I hope that this letter would be complementary to Dr Dagi’s
article1 to highlight further challenges to the clinical application
of AI algorithms in neurosurgery, introduce explainable AI to
neurosurgeons, and encourage the development of AI algorithms
for neurosurgical practice in the future.
Funding
This study did not receive any funding or financial support.
VOLUME 0 | NUMBER 0 | 2021 | 1
CORRESPONDENCE
Disclosures
The author has no personal, financial, or institutional interest in any of the
drugs, materials, or devices described in this article.
Mervyn J. R. Lim, MBBS, MPH
Division of Neurosurgery
University Surgical Centre
National University Hospital
Singapore
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