Endoscopic Endonasal Skull Base Surgery
P re f a c e
Daniel M. Prevedello, MD Editor
centrally debulked to facilitate its extracapsular resection, which is done using standard principles of bimanual dissection and microsurgical technique. Over the last decade, as more centers are performing EEAs, we are discovering that the initial impressions of EEA’s pioneers were correct: that EEAs can offer comparable resection rates while offering, in appropriately selected cases, the potential to minimize morbidity when compared with traditional approaches. Conversely, it is clear that EEAs cannot replace traditional skull-base approaches in every instance; therefore, surgeons should strive to be facile with both open and endonasal techniques to provide the safest, most efficient means to address specific clinical situations. I thank all my colleagues who contributed articles to this work not only for their efforts hereby presented but also for all their previous contributions to establish and refine EEA for the benefit of our patients. Daniel M. Prevedello, MD Departments of Neurological Surgery, and Otolaryngology and Head & Neck Surgery Wexner Medical Center The Ohio State University Columbus, OH 43210, USA
Neurosurg Clin N Am 26 (2015) xiii http://dx.doi.org/10.1016/j.nec.2015.05.001 1042-3680/15/$ – see front matter Ó 2015 Published by Elsevier Inc.
E-mail address: [email protected]
neurosurgery.theclinics.com
Immediately following its introduction, expanded endonasal approaches to intracranial lesions faced substantial criticism due to their high risk of postoperative cerebrospinal fluid (CSF) leak and the perceived risk of intracranial infection with sinonasal flora. Progressive development of the technique, led by multiple pioneering centers around the world, reduced these pertinent concerns. We are approaching the 10th anniversary of the pedicled nasoseptal flap, which was quickly adopted worldwide and dramatically reduced postoperative CSF leak rates, making the technique reliable and reproducible. Furthermore, the apprehension regarding high rates of postoperative infection proved to be unfounded. Consequently, endoscopic endonasal approaches (EEAs) to address intracranial diseases became a viable alternative to traditional approaches. Technical feasibility should not be the only motivation to continue doing EEA skull-base surgery. Often a ventral approach to the skull base allows for direct access to pathologic abnormality, minimizing or eliminating the need for manipulation of neurovascular structures compared with open approaches. In many instances, EEAs transform skull-base tumors into “convexity tumors,” as they share the same surgical strategy. For example, in the case of a midline skull-base meningioma, the tumor origin is reached early in the surgery, and its blood supply is interrupted before the tumor is exposed. Most or even all involved dura can be removed. The nearly avascular tumor may be
P re f a c e
Daniel M. Prevedello, MD Editor
centrally debulked to facilitate its extracapsular resection, which is done using standard principles of bimanual dissection and microsurgical technique. Over the last decade, as more centers are performing EEAs, we are discovering that the initial impressions of EEA’s pioneers were correct: that EEAs can offer comparable resection rates while offering, in appropriately selected cases, the potential to minimize morbidity when compared with traditional approaches. Conversely, it is clear that EEAs cannot replace traditional skull-base approaches in every instance; therefore, surgeons should strive to be facile with both open and endonasal techniques to provide the safest, most efficient means to address specific clinical situations. I thank all my colleagues who contributed articles to this work not only for their efforts hereby presented but also for all their previous contributions to establish and refine EEA for the benefit of our patients. Daniel M. Prevedello, MD Departments of Neurological Surgery, and Otolaryngology and Head & Neck Surgery Wexner Medical Center The Ohio State University Columbus, OH 43210, USA
Neurosurg Clin N Am 26 (2015) xiii http://dx.doi.org/10.1016/j.nec.2015.05.001 1042-3680/15/$ – see front matter Ó 2015 Published by Elsevier Inc.
E-mail address: [email protected]
neurosurgery.theclinics.com
Immediately following its introduction, expanded endonasal approaches to intracranial lesions faced substantial criticism due to their high risk of postoperative cerebrospinal fluid (CSF) leak and the perceived risk of intracranial infection with sinonasal flora. Progressive development of the technique, led by multiple pioneering centers around the world, reduced these pertinent concerns. We are approaching the 10th anniversary of the pedicled nasoseptal flap, which was quickly adopted worldwide and dramatically reduced postoperative CSF leak rates, making the technique reliable and reproducible. Furthermore, the apprehension regarding high rates of postoperative infection proved to be unfounded. Consequently, endoscopic endonasal approaches (EEAs) to address intracranial diseases became a viable alternative to traditional approaches. Technical feasibility should not be the only motivation to continue doing EEA skull-base surgery. Often a ventral approach to the skull base allows for direct access to pathologic abnormality, minimizing or eliminating the need for manipulation of neurovascular structures compared with open approaches. In many instances, EEAs transform skull-base tumors into “convexity tumors,” as they share the same surgical strategy. For example, in the case of a midline skull-base meningioma, the tumor origin is reached early in the surgery, and its blood supply is interrupted before the tumor is exposed. Most or even all involved dura can be removed. The nearly avascular tumor may be
