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Tomasz A. Dziedzic, Vijay K. Anand and Theodore H. Schwartz

cadaver study. Here, we describe the first case performed in a living patient. 8 The choice of surgical approach to the orbit is generally determined by location, extension, and the type of lesion. As a rule, cosmetics and accessibility are both considered. The open surgical approaches have been divided into transorbital or extraorbital. Lesions that are located in the anterior two-thirds of the orbit are usually managed with a transorbital approach and those located in the posterior one-third with an extraorbital approach. 3 , 4 More commonly, the endoscopic

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Edward D. McCoul, Vijay K. Anand and Theodore H. Schwartz

E ndoscopic skull base surgery has gained popularity over the past decade as an excellent alternative to microscope-assisted and open surgical approaches for selected cases. 21 Among the potential benefits of this surgery are a quicker recovery time, better wound healing, increased illumination and visualization of the operative field, and the ability to look around anatomical corners. Previous assessments of the efficacy of ESBS have generally focused on parameters such as the extent of resection and complications and have used these measures to compare

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Osaama H. Khan, M.Sc., Vijay K. Anand and Theodore H. Schwartz

details of the surgical approaches have been described previously. 2 , 32–34 , 43 However, there are certain specifics that are worth discussing with respect to patient selection and technique that inform our results. Meningiomas are given 3 antibiotics preoperatively: vancomycin, ceftriaxone, and metronidazole. Intraoperative cranial nerve or somatosensory monitoring was used intermittently depending on the location of the pathology and the patient’s preoperative examination. A lumbar drain was placed at the start of the operation if a large dural opening was

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Lessons learned in the evolution of endoscopic skull base surgery

JNSPG 75th Anniversary Invited Review Article

Theodore H. Schwartz, Peter F. Morgenstern and Vijay K. Anand

surgical approach for these lesions. Importantly, skull base meningiomas are subject to limitations that may prevent the wide marginal resections afforded to convexity meningiomas. Furthermore, recent literature has suggested that the Simpson grading scale traditionally used for extent of resection may be less relevant for skull base meningiomas than for convexity lesions, particularly because adjuvant radiotherapy for residual or recurrent tumor has been shown to be effective. 76 As is the case for other anterior cranial base pathology, PS/TS and OG meningiomas present

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Ilya Laufer, Vijay K. Anand and Theodore H. Schwartz

cyst (Case 10) because a fat graft was placed, which could be mistaken for residual tumor. The postoperative images obtained in patients with craniopharyngiomas (Cases 6–9) were all Gd-enhanced to demonstrate the absence of residual tumor after surgery. A postoperative iohexol-enhanced CT scan is featured for the patient in Case 8, who was too obese for MR imaging after surgery. RCC = Rathke cleft cyst. Surgical Procedure The surgical approach was similar in all cases ( Fig. 2 ). General anesthesia was induced, and the patient was given antibiotics

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Tony Goldschlager, Roger Härtl, Jeffrey P. Greenfield, Vijay K. Anand and Theodore H. Schwartz

OBJECT

The gold-standard surgical approach to the odontoid is via the transoral route. This approach necessitates opening of the oropharynx and is associated with risks of infection, and swallowing and breathing complications. The endoscopic endonasal approach has the potential to reduce these complications as the oral cavity is avoided. There are fewer than 25 such cases reported to date. The authors present a consecutive, single-institution series of 9 patients who underwent the endonasal endoscopic approach to the odontoid.

METHODS

The charts of 9 patients who underwent endonasal endoscopic surgery to the odontoid between January 2005 and August 2013 were reviewed. The clinical presentation, radiographic findings, surgical management, complications, and outcome, particularly with respect to time to extubation and feeding, were analyzed. Radiographic measurements of the distance between the back of the odontoid and the front of the cervicomedullary junction (CMJ) were calculated, as well as the location of any residual bone fragments.

RESULTS

There were 7 adult and 2 pediatric patients in this series. The mean age of the adults was 54.8 years; the pediatric patients were 7 and 14 years. There were 5 females and 4 males. The mean follow-up was 42.9 months. Symptoms were resolved or improved in all but 1 patient, who had concurrent polyneuropathy. The distance between the odontoid and CMJ increased by 2.34 ± 0.43 mm (p = 0.03). A small, clinically insignificant fragment remained after surgery, always on the left side, in 57% of patients. Mean times to extubation and oral feeding were on postoperative Days 0.3 and 1, respectively. There was one posterior cervical wound infection; there were 2 cases of epistaxis requiring repacking of the nose and no instances of breathing or swallowing complications or velopharyngeal insufficiency.

CONCLUSIONS

This series of 9 cases of endonasal endoscopic odontoidectomy highlights the advantages of the approach in permitting early extubation and early feeding and minimizing complications compared with transoral surgery. Special attention must be given to bone on the left side of the odontoid if the surgeon is standing on the right side.

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Edward D. McCoul, Jeffrey C. Bedrosian, Olga Akselrod, Vijay K. Anand and Theodore H. Schwartz

. MRI of the brain with gadolinium was performed to assess tumor size using volumetrics, to identify tumor extension, and to assist in planning the surgical approach. Patients with lesions involving the optic chiasm or optic tract were referred for neuro-ophthalmological evaluation and visual field testing. To assess for endocrine derangements, all patients underwent pre- and postoperative endocrinological evaluation of free cortisol, adrenocorticotropic hormone, free thyroxine, thyroid-stimulating hormone, prolactin, growth hormone (GH), insulin-like growth factor

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Justin F. Fraser, Gurston G. Nyquist, Nicholas Moore, Vijay K. Anand and Theodore H. Schwartz

C hordomas are rare, pathologically benign tumors that arise from the notochord remnant. Although ~ 35% occur in the skull base, they represent only 0.1% of all skull base tumors. 10 , 13 , 28 In addition to being rare, they are also challenging to treat due to their location, ventral to the brainstem, and their aggressive locally invasive nature. 1 , 20 The natural history of chordomas entails a relatively poor survival of 0.9 years without treatment. 19 The current therapeutic algorithm entails an aggressive surgical approach to attempt a radical

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Jeffrey C. Bedrosian, Victor Garcia-Navarro, Edward D. McCoul, Vijay K. Anand and Theodore H. Schwartz

possible because of the location of the lesion. The choice of surgical approach is based on preoperative hearing status, lesion location, extent of the lesion, relationship with neurovascular structures, and anatomical variations. 19 Traditional approaches for petrous apicectomy include transtemporal approaches that may or may not spare the otic capsule, middle fossa craniotomy, and open infratemporal fossa approaches to the skull base. 10 Image-guided transsphenoidal endoscopic drainage has been recently described as well. 8 This approach may be particularly useful

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Mario Francesco Fraioli and Laura Moschettoni

an area of hypointensity inside the remnant itself (arrow) . We believed that eventual intrasellar descent of the tumor was possible, thus we chose not to perform a second transsphenoidal surgical approach and wait to obtain the next control MR image. D: Image obtained 2 months after surgery demonstrating an eventual intrasellar descent of the tumoral remnant, with total decompression of suprasellar structures. The patient underwent postoperative stereotactic hypofractionated radiotherapy and showed no tumoral regrowth after 4.2 years of follow-up. The authors