Skull Base Surgery: Past, Present, and Future Trends
The author outlines the history of skull base surgery and describes the new paradigm emerging with increasing use of endoscopic microneurosurgery.
There is nothing more difficult, more dangerous nor moreleast likely to succeed than to initiate a new order of things.
--Niccolo Machiavelli (1469-1527)
The roots of brain and skull base surgery extend deeply into the nineteenth century. Bold and creative physicians in every decade who challenged existing practices "to initiate a new order of things" often came under intense criticism and were even ostracized by their peers. The modern era of surgery required the discovery of anesthesia, antisepsis, and cortical localization, all of which initially were controversial; not unlike innovations at the present time.
After watching many of his patients die of puerperal fever, Semmelweis (1818–1865) discovered that simple handwashing before and after each delivery markedly reduced this scourge of the birthing room. When he reported his Results to the medical society of Vienna, he and his paper were greeted with virulent attacks. Ten years after his original discoveries, the profession hardly took notice and scientists as prestigious as Virchow still opposed his ideas. He ultimately was broken by the indifference and callousness of his superiors and colleagues and was committed to an asylum where he died in 1865.
Finally, two Germans, Fritsch (1838–1927) and Hitzig (1838–1907) boldly exposed the brain of a dog on Fra Hitzig's drawing room table and used an electrical current to stimulate the exposed brain. They were roundly criticized for their experimentation despite the fact that their observations subsequently led to the modern era of brain localization.
Thus, with the discoveries of anesthesia, antisepsis, and cerebral localization the stage was finally set for the evolution of brain and skull base surgery. The earliest approaches to brain surgery were at the skull base. Francesco Durante (1845–1934) was the first to remove an olfactory groove meningioma from the skull base in a 35-year-old woman who presented with proptosis, loss of smell, and memory impairment. He induced chloroform anesthesia and applied antiseptic techniques together with cerebral localization, with a successful outcome documented 10 years later. In 1879 William Macewen (1849–1924) similarly successfully removed a brain tumor over the right eye in a 14-year-old patient by using a meticulous technique and what he referred to as antiseptic trephining. Macewen also introduced endotracheal intubation in place of tracheostomy in 1880 and modified the Lister technique by spraying carbolic acid over the wound.
Subsequent innovations in skull base surgery came relatively rapidly. Sir Victor Horsley (1857–1916) sectioned the posterior root of the trigeminal nerve for pain relief, Sir Charles Ballance (1856–1936) reported one of the earliest cases of acoustic tumor removal, and pioneers such as Fedor Krause (1857–1937) from Germany, Thierry de Martel (1875–1940) from France, and others made major contributions to posterior fossa and skull base surgery.
The author outlines the history of skull base surgery and describes the new paradigm emerging with increasing use of endoscopic microneurosurgery.
There is nothing more difficult, more dangerous nor moreleast likely to succeed than to initiate a new order of things.
--Niccolo Machiavelli (1469-1527)
The roots of brain and skull base surgery extend deeply into the nineteenth century. Bold and creative physicians in every decade who challenged existing practices "to initiate a new order of things" often came under intense criticism and were even ostracized by their peers. The modern era of surgery required the discovery of anesthesia, antisepsis, and cortical localization, all of which initially were controversial; not unlike innovations at the present time.
After watching many of his patients die of puerperal fever, Semmelweis (1818–1865) discovered that simple handwashing before and after each delivery markedly reduced this scourge of the birthing room. When he reported his Results to the medical society of Vienna, he and his paper were greeted with virulent attacks. Ten years after his original discoveries, the profession hardly took notice and scientists as prestigious as Virchow still opposed his ideas. He ultimately was broken by the indifference and callousness of his superiors and colleagues and was committed to an asylum where he died in 1865.
Finally, two Germans, Fritsch (1838–1927) and Hitzig (1838–1907) boldly exposed the brain of a dog on Fra Hitzig's drawing room table and used an electrical current to stimulate the exposed brain. They were roundly criticized for their experimentation despite the fact that their observations subsequently led to the modern era of brain localization.
Thus, with the discoveries of anesthesia, antisepsis, and cerebral localization the stage was finally set for the evolution of brain and skull base surgery. The earliest approaches to brain surgery were at the skull base. Francesco Durante (1845–1934) was the first to remove an olfactory groove meningioma from the skull base in a 35-year-old woman who presented with proptosis, loss of smell, and memory impairment. He induced chloroform anesthesia and applied antiseptic techniques together with cerebral localization, with a successful outcome documented 10 years later. In 1879 William Macewen (1849–1924) similarly successfully removed a brain tumor over the right eye in a 14-year-old patient by using a meticulous technique and what he referred to as antiseptic trephining. Macewen also introduced endotracheal intubation in place of tracheostomy in 1880 and modified the Lister technique by spraying carbolic acid over the wound.
Subsequent innovations in skull base surgery came relatively rapidly. Sir Victor Horsley (1857–1916) sectioned the posterior root of the trigeminal nerve for pain relief, Sir Charles Ballance (1856–1936) reported one of the earliest cases of acoustic tumor removal, and pioneers such as Fedor Krause (1857–1937) from Germany, Thierry de Martel (1875–1940) from France, and others made major contributions to posterior fossa and skull base surgery.
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