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

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.