Endoscopic versus open approaches to the skull base: A comprehensive literature review

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The surgical approach to the skull base has traditionally been transcranial, often involving extensive bone drilling, brain retraction, and nerve manipulation to expose pathology. The endoscopic endonasal approach represents a minimal access, maximally aggressive alternative that provides a direct route to the area of interest. Few data exist that can be used to compare these 2 surgical strategies. We conducted a systematic review of case series and case reports in hope of furthering our understanding of the role of endoscopy in the management of difficult cranial base lesions. We found that the endonasal endoscopic technique generates equivalent or greater rates of gross total resection than open approaches for craniopharyngiomas, clivalchordomas, odontoid resection, and tuberculumsellaemeningiomas. The rate of cerebrospinal fluid (CSF) leaks is greater for patients undergoing endoscopic surgery for anterior skull base meningiomas and craniopharyngiomas. There was no difference in the rate of CSF leak between approaches for clival chordoma resection or after odontoidectomy. Despite the increased risk of CSF leak, the risk of postoperative meningitis does not appear to be increased. Our systematic review supports the endonasal endoscopic approach as a safe and effective alternative for the treatment of a wide variety of skull base pathology, particularly small midline tumors. Careful patient selection and meticulous multilayer closure are critical to obtaining maximal resection and acceptably low CSF leak rates.

Section snippets

Study selection

We performed a literature search by using the Ovid gateway of the MEDLINE database between the years of 1950 and 2010. Eligibility criteria were limited by the nature of existing literature on this topic, which consists of only case series and case reports. All publications in which the authors examined outcomes after surgery of the skull base were selected, whereas editorials, commentaries, and review articles were not because they did not include original data. To avoid duplication of

Meningiomas

A total of 75 series and 1847 patients were included, which described outcomes for tuberculum sellae and olfactory groove meningiomas. For olfactory-groove meningiomas, there were 568 patients in the open group and 19 patients in the endoscopic group. There was a significantly greater rate of GTR in the open group (92.9% vs 63.2%, P < 0.001) and a significantly greater rate of partial resection in the endoscopic group (0.4% vs 26.3%, P < 0.001; Figure 1). There was a greater rate of CSF leak in

Discussion

For tumors of the midline anterior cranial fossa, a ventral surgical approach, that is, passing through the sinuses and nasal cavity, is logical, assuming the tumors do not have significant lateral extension beyond the carotid arteries and lamina papyracea. Before the development of endonasal endoscopic cranial-base approaches, open cranial-base approaches were frequently used to reach even small midline tumors, to provide enough light from the microscope to visualize the full extent of the

Conclusions

Our systematic review supports the conclusion that the endoscopic endonasal approach may be an alternative to traditional open cranial-base surgery or transsphenoidal microscopic approaches for the treatment of certain tumors of the anterior skull base, particularly small midline tumors. For some pathologies such as tuberculum sellae meningiomas, clivalchordomas, or odontoidectomy, endonasal approaches may offer equivalent rates of total removal with significantly lower morbidity and improved

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