When Theodore Schwartz, MD, a neurosurgeon specializing in minimally invasive treatments for brain tumors and epilepsy at NewYork-Presbyterian/
Dr. Theodore Schwartz
That didn’t stop him from pursuing his interest in the field, which has since led NewYork-Presbyterian/
The Difference of a Minimally Invasive Approach
Historically, neurosurgeons accessed skull base tumors through an open, invasive craniotomy, a complex surgery with a significant risk of complications. “If you have a tumor at the top of your head, it's relatively straightforward to perform a craniotomy to access it,” says Dr. Schwartz. “But if the tumor is under the brain and you open up the top of the head, the brain is in the way.”
Neurosurgeons needed a better way to access tumors under the brain, and the evolution of endoscopes and neuroendoscopy provided the missing piece required to pursue these alternative treatment approaches. Among the types of tumors Dr. Schwartz and his team treat with minimally invasive techniques are meningiomas, pituitary adenomas, craniopharyngiomas, chordomas and schwannomas. “Patients recover faster, they get out of the hospital more quickly,” says Dr. Schwartz. “We retract the brain less, which leads to better outcomes.”
Patients recover faster, they get out of the hospital more quickly. We retract the brain less, which leads to better outcomes.
— Dr. Theodore Schwartz
The first approach to be adopted was the supraorbital approach, done through a small incision in the eyebrow, in the 1990s. “There were only a handful of surgeons who saw where the field was going and had the ability to take the risk to try something new, and the foresight to adopt this before anybody else did,” says Dr. Schwartz.
The adoption of the endonasal approach, one which accesses the brain through the nostrils, followed about 15 years later. Finally, the transorbital approach was adopted in 2015. As each approach was developed and modified at NewYork-Presbyterian/
Dr. Schwartz notes that, despite the wide adaptation and success of these minimally invasive approaches, open surgery is still sometimes necessary. “Not every tumor lends itself to a minimally invasive approach,” he says. “What's critical is choosing the right case for the approach. We’re constantly evaluating patients as they come in and finding new and different indications to use these techniques. Because we can treat a wide range of conditions with a variety of different methods, this allows us to provide precision treatment to each individual patient.”
Collaborating for Success in the Present and Future
The success of these approaches is a result of the multidisciplinary collaboration that is a hallmark of NewYork-Presbyterian/
The reason we were so successful in adopting minimally invasive approaches is that we were able to collaborate with surgeons in other departments. [NewYork-Presbyterian] has so many great surgeons in other departments that we can work with that allows us to leapfrog ahead of our peers.
— Dr. Theodore H. Schwartz
Dr. Schwartz credits his work with Vijay Anand, MD, an otorhinolaryngologist at NewYork-Presbyterian/
The more traditional orbitozygomatic approach to the anterior skull base shown on the left is contrasted with the endoscopic endonasal and transorbital approaches shown on the right.
These approaches are ever evolving, and Dr. Schwartz is committed to continue pursuing new and better ways to treat skull base tumors. “Neurosurgery is technically demanding and there are many inherent risks in so many of our procedures that we’re always trying to figure out ways to do these procedures better and use technology to improve upon them,” he says. “I’m always thinking, ‘How can I do this better? How can I get a better result? How can I have a smaller footprint on the patient? How can I reduce my risk of complications?’”
Dr. Schwartz and Dr. Godfrey collaborated recently on developing a lateral transorbital approach (LTOA) suited for addressing paramedian pathology of the anterior and middle fossa. In a paper published in the Journal of Neurosurgery, they reported results from a retrospective analysis of 20 consecutive LTOA patients, which showed that LTOA provides a “safe minimal access approach to a variety of paramedian anterior skull base pathologies in several locations.” In another 2023 study published in Operative Neurosurgery, Drs. Schwartz and Godfrey also explored LTOA for lesions in the cavernous sinus with successful results.
Additionally, Dr. Schwartz and Dr. Anand closely collaborated to invent a new technique called the gasket seal for closing the skull base during endoscopic skull base surgery. “When taking out tumors through the nose, one of the biggest problems we had is that the fluid in the brain, the cerebrospinal fluid, would leak into the nose at the end of the operations,” says Dr. Schwartz. “It was very difficult to create a watertight closure in the back of the nose to prevent the fluid from the brain from leaking into the nose. So, we developed a technique where we would place an overlay of soft tissue and then wedge in a rigid substance to create a gasket. It creates a rubber-like seal around this piece of bone that we replaced to prevent the fluid from leaking from the brain into the nose.”
This unique procedure has been adopted by many other centers around the world. Dr. Schwartz notes that this novel work has resulted in NewYork-Presbyterian/
Training the Next Generation of Skull Base Surgeons
In addition to working to find new and better ways to apply these minimally invasive techniques, Dr. Schwartz is also deeply committed to training the next generation of neurosurgeons. “At many of the top academic programs in the United States, you might not learn these approaches,” he says. “Now we’re training our residents to do these procedures, so they come out of our program ahead of the curve.”
Dr. Schwartz has taken what he has learned and published several books and hundreds of papers to help others learn his methods. In collaboration with Dr. Anand, he wrote and published the first textbook on endoscopic skull base surgery – Practical Endoscopic Skull Base Surgery – which describes and demonstrates endoscopic techniques and provides a practical guide to these techniques. He’s also been an author and editor on subsequent books, Endoscopic Skull Base and Pituitary Approaches: A Step-By-Step Guide for Cadaveric Dissection and Surgical Instruction (2007); Endoscopic Skull Base and Pituitary Approaches: A Step-By-Step Guide for Cadaveric Dissection and Surgical Instruction (2010); Endoscopic Pituitary Surgery. A Comprehensive Guide Instruction (2011); Transsphenoidal Surgery: Techniques Including Complication Avoidance and Management (2017); and Pediatric Endoscopic Skull Base Surgery (2020). Dr. Schwartz is currently in the process of writing the first textbook on transorbital skull base surgery with Doo-Sik Kong, MD, from Samsung Medical Center in Seoul, and Kris Moe, MD, from the University of Washington in Seattle.
When surgeons train, we learn to perform our operations in a particular way. We learn from our teachers how to do the surgeries that we will do for the rest of our lives. When you develop a new approach and a new way of doing things, you build upon what you were previously taught but also must unlearn what you thought was dogma. You need to change your philosophical approach to what neurosurgery is and how neurosurgery is done, which is not so easy to do.
— Dr. Theodore Schwartz
In addition to hands-on teaching and writing, Dr. Schwartz is an in-demand speaker and educator on these new minimally invasive techniques. He directed the first continuing medical education course in North America on transorbital and supraorbital approaches in 2021. To further educate his peers, Dr. Schwartz, along with colleagues at other institutions, published a paper in 2022 in the Journal of Neurosurgery outlining the accumulation of skills for surgeons interested in the minimally invasive transorbital approach to skull base surgery.
The five stages of performing minimally invasive transorbital skull base surgery. (Image: Glia Media)
“When surgeons train, we learn to perform our operations in a particular way. We learn from our teachers how to do the surgeries that we will do for the rest of our lives,” Dr. Schwartz says. “When you develop a new approach and a new way of doing things, you build upon what you were previously taught but also must unlearn what you thought was dogma. You need to change your philosophical approach to what neurosurgery is and how neurosurgery is done, which is not so easy to do. You change the way you think and change your philosophy on taking care of these diseases, using completely new and different approaches, new corridors, and new instruments.”
