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Return to Skull Base Techniques Offer Brain Tumor Patients Less Invasive Options Overview

More on Skull Base Techniques Offer Brain Tumor Patients Less Invasive Options

Skull Base Techniques Offer Brain Tumor Patients Less Invasive Options

New York (Mar 21, 2011)

surgery in large operating room

Tumors and other disorders at the base of the skull – the sloping area of the brain behind the eyes and nasal passages – are notoriously difficult to reach. Traditionally, surgeons have had to perform a craniotomy, opening the skull and moving tissue out of the way to get to the bottom of the brain. The procedure could be risky, causing the brain to swell and exposing patients who may already be in diminished health to a lengthy recovery period. Now novel minimally invasive techniques make it possible to get to this area through smaller incisions, and sometimes through an unlikely orifice – the nostrils – greatly facilitating the removal of skull base tumors and the repair of other disorders in this area.

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"When tumors arise along the base of the skull, they may grow around nerves and blood vessels, which are fragile and soft," explained Jeffrey Bruce, M.D., a neurosurgeon who performs skull base surgery at NewYork-Presbyterian/Columbia University Medical Center. "Minimally invasive techniques enable us to see the tumor more clearly and remove as much of it as we can without damaging these delicate nearby structures."

Over the past 30 years, skull base surgery has evolved through various stages to avoid retracting (moving aside) the brain and manipulating nerves and blood vessels. The first major advances came from collaborations between neurosurgeons, head and neck surgeons, and plastic surgeons. They learned to reach the skull base from the top or sides of the head by removing bone, inserting a surgical microscope, and using microsurgical techniques to delicately remove tumor tissue from intervening arteries and nerves. During microsurgery, Dr. Bruce looks through the binocular eyepieces of the surgical microscope and uses slender instruments to perform this procedure. These approaches are particularly useful for larger tumors near the sides of the brain.

Jeffrey N. Bruce, M.D., F.A.C.S.
Jeffrey N. Bruce, M.D.

With endoscopic surgery, surgeons navigate an endoscope – a stalk-like instrument with a camera at the tip – into a nostril, through the sinuses, and into the brain. No incisions are required, which is why it is also called "minimal access neurosurgery." Endoscopic minimally invasive techniques, which also include the use of an eyebrow incision, offer patients benefits such as less blood loss, smaller incisions (and in the case of nasal surgery, invisible incisions), less post-operative pain, and little or no brain swelling, resulting in a speedier recovery and quicker return to normal activities.

"One of the great advantages of the centers at New York-Presbyterian is that we can combine all of the techniques – from microsurgery to endoscopy, along with other modalities such as radiosurgery – to individualize treatment and achieve the best possible outcomes for patients who need skull base surgery," said Dr. Bruce.

"The sinuses offer a huge gateway to the skull base," said Theodore H. Schwartz, M.D., who performs endoscopic skull base surgery at NewYork-Presbyterian/Weill Cornell Medical Center. The approach is particularly useful for removing midline tumors, although combinations of endonasal and more traditional transcranial (through the skull) approaches can be performed for larger tumors that extend to the sides.

Theodore H. Schwartz, M.D., F.A.C.S.
Theodore H. Schwartz, M.D.

Before he enters the brain, Dr. Schwartz's colleague, Vijay Anand, M.D., an otolaryngologist (ear-nose-and-throat surgeon), performs sinus surgery to open this gateway. Then Dr. Schwartz peers into the depths of the brain and inserts the narrow instruments alongside the endoscope to remove tumor tissue or fix an anatomic problem.

Endoscopy is especially useful for removing difficult-to-reach skull base tumors, including pituitary adenoma (which grows on the hormone-producing pituitary gland); chordoma (which arises from embryonic tissue); angiofibroma (a non-cancerous growth at the back of the nose or upper throat); chondrosarcoma (a tumor comprised of cartilage); craniopharyngioma (a tumor arising from embryonic tissue that grows near the pituitary gland and optic nerve); and esthesioneuroblastoma (a tumor of the nerves regulating the sense of smell). Neurosurgeons are also evaluating endoscopic surgery to remove other types of brain tumors, such as gliomas.

In recent years, the work of Drs. Schwartz and Anand has benefited from the development of a three-dimensional endoscope, called the Visionsense VSii system, which provides far greater depth perception and a clearer understanding of complex surgical anatomy. The new system is also easier to use and reduces fatigue for the neurosurgeon.

Illustration, removing a brain tumor through sinuses with endoscope and instruments
Illustration, removing a brain tumor
through sinuses with endoscope
and instruments.

[Enlarge this image]

With the 3D system, the surgeon wears special glasses (much like those used to view 3D movies in theaters) and views the surgical field on a monitor next to the operating table. Drs. Schwartz and Anand and their colleagues helped evaluate the device for Visionsense. They also published the first paper on 3D neuroendoscopy in 2008, showing that compared with the conventional 2D approach, it improved the surgeon's depth perception, speed, and efficiency.

The endoscopic approach is also useful for repairing a cerebrospinal fluid leak – a tear or hole in the membrane that surrounds the brain and spinal cord. Patients with rheumatoid arthritis affecting the cervical vertebrae (upper spine) may benefit from this approach, too, because the surgeon can use it to remove bone that may be pushing on the spinal cord.

NewYork-Presbyterian neurosurgeons have taught both microsurgical and endoscopic skull base surgical techniques to hundreds of surgeons at centers across the country and around the world, including courses sponsored by the North American Skull Base Society, the Congress of Neurosurgeons, and the American Association of Neurological Surgeons. Drs. Schwartz and Anand taught a course in Mumbai, India in February for a hundred neurosurgeons and otolaryngologists.

Head scan before and after surgery
Head scan before and after surgery. The red
arrow points at a brain tumor.

[Enlarge this image]

NewYork-Presbyterian also hosts an annual two-day continuing medical education course (this year, June 10-11) in New York and a second one in Florida. New York-Presbyterian/Weill Cornell recently began a three-month fellowship in endoscopic skull base surgery which has attracted neurosurgeons from countries such as Saudi Arabia, Israel, Iraq, and Mexico, to name a few.

Sometimes minimally invasive neurosurgery is not sufficient to remove all tumor tissue safely. In those cases, the addition of the Gamma knife (a highly targeted form of radiation therapy called radiosurgery) may complement the surgery. "Sometimes the tumor embeds itself in the carotid artery (which supplies blood to the brain) and cannot be removed," explained Dr. Bruce. "When the tumor tissue is in a critical area like this, we may deliberately leave that tissue behind because we know we can destroy it afterward using the Gamma knife."

Patients fare much better following skull base surgery today than they once did. "There was once less understanding of the impact of tumors on blood vessels and nerves and how to protect these vital structures, and surgeons accepted a higher level of post-operative complications," said Dr. Bruce. "Today, with more experience and minimally invasive techniques, the acceptable level of complications is much lower. Patients are doing far better and living with a better quality of life."

Contributing faculty for this article:

Jeffrey N. Bruce, M.D., F.A.C.S. is the Director of the Bartoli Brain Tumor Research Laboratory and Co-Director of the Brain Tumor Center at NewYork-Presbyterian/Columbia University Medical Center, and the Edgar M. Housepian Professor of Neurological Surgery and Vice Chairman of Academic Affairs at Columbia University College of Physicians and Surgeons.

Theodore H. Schwartz, M.D., F.A.C.S. is Co-Director of the Institute for Minimally Invasive Skull Base and Pituitary Surgery at NewYork-Presbyterian/Weill Cornell Medical Center, and a Professor of Neurological Surgery, Associate Professor of Neurological Surgery in Neurology, and Professor of Neurological Surgery in Otorhinolaryngology at Weill Cornell Medical College.

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