Neurological Society of India Guest Lecture: optimally invasive skull base surgery.

Skull base surgery has been an established neurosurgical discipline since the late 1980s. The initial enthusiasm of achieving eradication of a seemingly inoperable lesion by novel skull base approaches led many neurosurgeons to use radical surgery. The accompanying high morbidity was accepted as inevitable. Over the years, however, many started questioning this philosophy, and the last decade saw the pendulum swing to the other extreme with the increasing popularity of endoscopic surgery and radiosurgery. Thus, minimally invasive neurosurgery became the fashion. However, it is important to remember ‘‘the pearl’’ that inadequate treatment through a less invasive approach is maximally invasive. Realization has now dawned that endoscopic surgery, endovascular treatment, and radiosurgery cannot replace but should complement skull base surgery. A judicious use of skull base approaches with appropriate adjuncts and radiosurgery is the best way forward in dealing with various skull base lesions. Measures preventing neurovascular damage during surgery, adequate closure to prevent cerebrospinal fluid leaks, the nemesis of skull base surgery, and quick remedial measures to prevent and treat complications will go a long way toward achieving optimal results. Some examples of skull base tumors and complex aneurysms are shown here to answer some questions neurosurgeons face almost daily: whether to treat or not, whether to use microsurgery or radiosurgery, which surgical approach to use, and whether to attempt total or subtotal excision. Our philosophy is that of optimally invasive skull base surgery, individualizing the approach to suit the given patient with a goal of achieving maximal result with minimal damage. Neuroendoscope, image guidance, endovascular therapy, and radiosurgery are used as pillars on the foundation of microsurgery.