Optimally invasive skull base surgery

摘要

Skull Base Surgery (SBS) is a relatively recent development in neurosurgery. Though sporadic attempts at SBS were made in the 20th century and initiation of interdisciplinary co-operation was done in the 1960s, it was in the 80s that SBS became an established neurosurgical discipline. The initial enthusiasm of achieving eradication of a seemingly ‘inoperable’ lesion by novel skull base approaches led many neurosurgeons to employ radical surgery. The accompanying high morbidity was accepted as inevitable. Over the years, however, many started questioning this philosophy and the new millennium saw the pendulum swing to the other extreme with increasing popularity of endoscopic surgery and radiosurgery. Thus, minimally invasive neurosurgery became the fashion. However, it is important to remember that inadequate treatment through a less invasive approach is maximally invasive. Realization has now dawned that endoscopic surgery, endovascular treatment and radiosurgery cannot replace but should complement skull base surgery. A judicious use of skull base approaches, with appropriate adjuncts and radiosurgery is the best way forward in dealing with various skull base lesions. Measures preventing neurovascular damage during surgery, adequate closure to prevent cerebrospinal fluid (CSF) leaks, the bug bear of skull base surgery, and quick remedial measures to prevent and treat complications will go a long way to achieve optimal results. Our philosophy is that of Optimally Invasive Skull Base Surgery (OISBS), individualizing the approach to suit the given patient with a goal to achieve maximal result with minimal damage. Neuroendoscope, image guidance, endovascular therapy and radiosurgery are all utilized as pillars on the foundation of microsurgery. OISBS may be defined as skull base surgery which is as minimally invasive as possible to achieve maximum efficiency, because inadequate treatment through a small approach is maximally invasive and adequate treatment through avoidable large approach is undesirable. When faced with a neurosurgical problem, particularly a skull base lesion, one is often faced with various dilemmas: 1. to treat or not, 2. microsurgery, radiosurgery or endovascular therapy, 3. which surgical approach, and 4. eradication or modification.