Minimally Invasive Skull Base Surgery : Principles & Practice

Classically defined as the art of curing by the hand, hand intended as the organ of the possible, and positive certitude according to Paul Valery, surgery is shifting toward a scientific discipline with a very high technological valence. Neurosurgery in general, and skull base surgery in particular do not stave off this natural evolution. Obviously, technological advances have driven the tremendous progresses in both diagnosis (CT scan, MRI, angiography ) and therapeutic fields (ultrasonic aspiration, radiosurgery). This technological aspect should not hide the humanistic remnant of the modern neurosurgeon, who should propose the less invasive technique in his possession to treat most efficiently his patient, keeping in mind the quality of life above all. The compromise between the invasiveness of the surgical approach to the skull base and the main goal of the surgery has shed light on the recent concept of minimally invasive skull base surgery. This concept has been conspicuously initiated by Axel Perneczky in the late 1980''s under the descriptive "keyhole neurosurgery", especially through the renowned eyebrow supra-orbital mini-craniotomy and the implementation of endoscope-assisted microneurosurgery. A decade after, Jho and others introduced the endoscopic endonasal approaches to the skull base, with a perpetual development and an exponential rhythm of scientific publications. This recent paradigm shift toward a minimal approach-related iatrogeny coupled with a maximally efficient surgical target is not so clear cut, as pioneering neurosurgeons such as Cushing, Dandy or Dott among others already adopted this philosophy of work, limited by the technology available at that time that did not permit their minimally invasive expectations. This has been possible only with the progresses made in the fields of imaging, surgical instrumentation, illumination technologies (microscope and endoscope), radiosurgery, and neuroanesthesia.