From the laboratory to the OR: education and innovation in skull base surgery

Over the last decade, the Endoscopic Endonasal Approach (EEA) has revolutionized skull base neurosurgery. The endonasal approach has anatomical and technical advantages over traditional skull base approaches for the treatment of selected lesions. EEA is not only minimally invasive but also maximally effective for the treatment of a wide variety of skull base lesions. Meticulous knowledge of the skull base anatomy as seen from the endoscopic perspective is critical to apply endonasal endoscopic surgery in a safe and effective manner. The Surgical Neuroanatomy Lab (SNL) at the University of Pittsburgh has a dual educational and research role aiming to improve surgical techniques and outcomes by mastering knowledge of relevant surgical neuroanatomy. At the SNL, we have pioneered anatomical work on the area of skull base endoscopy. Our goal is to continue providing landmark contributions to the skull base community. The SNL has a strong commitment in training the future generation of skull base surgeons. Over the last four years, 35 national and international neurosurgeons and ENT surgeons from 14 different countries have completed a research fellowship at the SNL devoting six months to one year of focused training in endoscopic skull base surgical anatomy. The results of the studies performed at the SNL have been published in the most prestigious journals in the field. These results have been routinely presented in an innovative and highly effective 3D format at our world-renowned endoscopic endonasal surgery course, offered three times a year at UPMC Presbyterian. More than 600 neurosurgeons and ENT surgeons from virtually every state and 25 different countries have participated in these courses. The main theme of the SNL is “From the Lab to the OR,” a reflection of a true translational effort to introduce novel anatomical concepts and innovative surgical techniques into real surgical practice. We are defining the intricate skull base anatomy required to perform gentle, accurate, and safe endoscopic skull base surgery, and have described novel approaches that allow more effective access to previously inaccessible or highly risky areas of the skull base. As an example, skull base tumors located at the region of the jugular tubercle (figure 1) and foramen magnum (figure 2) are extremely complex cases to operate, and they carry high risk of lower cranial nerves dysfunction after the operation, causing swallowing and breathing difficulties with the need for permanent and/or temporary feeding and breathing tubes. Now, the studies performed at the SNL have been key to effectively and safely removing tumors from these areas by using the EEA. Because the approach is performed from the endonasal route as opposed to the posterior route, the lower cranial nerves are not manipulated and therefore are fully preserved. Patients from around the world have been successfully treated at our institution. They have returned home with no neurological deficits and their complex tumors effectively removed, demonstrating the success of translating surgical innovation from the lab to the operating room. • Figure 1. This is the case of a 52-year-old female patient from California. She presented with difficulty walking and was found to have a tumor at the jugular tubercle region causing severe compression of the brainstem (medulla). The studies in the SNL provided an accurate description of the surgical access to this complex area, and the tumor was successfully removed with no neurological complications.