The Learning Curve in Skull Base Surgery Part 1­ From Historical-Philosophical Concepts to Microsurgical Lab Training

The learning curve reflects surgeons' experience in managing several patients with the same disease. In skull base surgery, the professional's place on the curve could be related to the number of times the same procedure was performed. Where does curve begin? What amount of training is necessary prior to its application in surgical settings? What were the results of the first few skull base tumor surgeries performed by a surgeon who goes on to produce excellent results, and how is reflected in the start of their learning curve? The only way for neurosurgeons to improve their results from the start is with prior training in the microsurgery laboratory. This learning technique is essential to maximize the chance of success of a neurosurgical procedures, minimizing the morbidity rate to which patients are subjected by less experienced neurosurgeons. This article is divided in two parts, and its purpose is to show how training in the microsurgical laboratory fits into the construction of knowledge about skull base surgery, based on authors' experience and reflections. This first part discusses the technical, psychological, and philosophical aspects of medical knowledge, primarily addressing those training in skull base surgery, the principles of some selected philosophical currents, and their influence on the development of current medical knowledge.

The Learning Curve in Skullbase Surgery Part 2­From the Microsurgical Lab Training to the Operative Room / A Curva de Aprendizado em Cirurgia de Base do Crânio - Do laboratório de microcirurgia à sala cirúrgica

In this second part, the authors review and suggest a methodology for studies in skull base surgery and training inmicrosurgical laboratory, based on their experiences and reflections. Not only are the foundations for the acquisition of microsurgical skills presented, but also what is needed to be an effective skullbase surgeon with good results. The present article reflects in particular the philosophy of professor Evandro de Oliveira and also serves to present to the neurosurgical community a new state-of-the-art laboratory for hands-on courses in Brazil, at the Faculdade Evangélica Mackenzie do Paraná.

Nesta segunda parte, os autores revisam e sugerem uma metodologia para o estudo em cirurgia de base de crânio e treinamento em laboratório de microcirurgia baseado em suas experiencias e reflexões. Não apenas os fundamentos para a aquisição de habilidades microcirúrgicas estão presentes, como também, o que é necessário para ser um eficiente cirurgião de base de crânio com bons resultados. Este artigo reflete, em particular, a filosofia do Professor Evandro de Oliveira, além de servir para apresentar a comunidade neurocirúrgica o novo "estado da arte" em laboratórios de cursos "hands-on" no Brasil, na Faculdade Evangélica Mackenzie do Paraná.

Plasmocitoma solitario intracraneal: una presentación inusual / Intracranial solitary plasmacytoma: an unusual presentation

Background: Intracranial solitary plasmacytoma is extremely rare and its location in the clivus is unusual; its clinical presentation is very varied and the diagnostic images are similar to the other tumors in skull-base. Case presentation: 47-year-old woman with initial diagnosis of pituitary macroadenoma, attended with headache, nausea, vomiting, diplopia in the right eye and paralysis of her abducent nerve. She was reoperated by transsphenoidal endoscopic approach, concluding in solitary clivus plasmacytoma by biopsy and immunohistochemistry. Conclusions: Clivus is an unusual location for intracranial plasmacytoma. Early diagnosis, complete study and careful follow-up are required due to its high progression to multiple myeloma(AU)

Introducción: El plasmocitoma solitario intracraneal es extremadamente raro y su localización en el clivus es inusual; su presentación clínica es muy variada y las imágenes diagnósticas son similares a las de otros tumores de la base del cráneo. Reporte de caso: Se presenta el caso de una mujer de 47 años con diagnóstico inicial de macroadenoma hipofisiario, que cursó con cefalea, náuseas, vómitos, diplopía en ojo derecho y parálisis de su nervio abducente. Fue reintervenida por vía transesfenoidal endoscópica, concluyendo en plasmocitoma solitario del clivus por biopsia e inmunohistoquímica. Conclusiones: El clivus es una localización inusual para plasmocitoma intracraneal, se requiere un diagnóstico precoz, estudio completo y seguimiento cuidadoso por su alta progresión a mieloma múltiple(AU)

Clinical experience of resection for nasal skull-base tumors by microsurgical-assisted technique / 临床耳鼻咽喉头颈外科杂志

OBJECTIVES@#To investigate the application of the microsurgical treatment in nasal skull-base tumors resection.@*METHODS@#In a retrospective study, totally 15 cases with tumors in the nasal skull-base received microsurgical-assisted treatment in our department from February 2012 to June 2017 were analysed. Lateral rhinotomy approach was carried out in 11 patients and posterior wall of the maxillary sinus approach in 4 patients.@*RESULTS@#Tumors of all cases were completely resected under the microscope. Postoperative bleeding, cerebrospinal fluid leakage, infection and meningo-encephalocele did not occur in this series. The postoperative follow-up time were 6 months to 5 years. One case lost follow-up, seven cases were survivor of tumor-free. Seven cases had recurrence or metastasis, with one case died and other six alive with tumor.@*CONCLUSIONS@#Microsurgical-assisted resection for nasal skull-base tumors can obtain clear vision, with high surgical precision and security.

Difficulty in Diagnosing a Case of Severe Headache Caused by Lung Cancer Metastasis to Base of Skull Due to Lack of Imaging Evidence

<p>Introduction: We report a case of severe headache caused by lung cancer metastasis to the base of the skull that was difficult to diagnose due to a lack of imaging evidence. Case: A 70-year-old man diagnosed with advanced lung cancer experienced sudden, severe headache. He was diagnosed as having a tension-type headache because magnetic resonance imaging of his head failed to detect any pathology. He was prescribed various drugs, which except for strong opioids failed to treat his headache. He referred to our palliative care unit to treat the pain. Re-evaluation of his head CT revealed metastasis to the clivas. His pain was treated with rapid titration of subcutaneous oxycodone injection. Conclusion: Even if radiographic investigations fail to identify the metastasis, the patient should be re-evaluated if the headache worsens and/or is accompanied with cranial nerve dysfunction.</p>

Temporomandibular joint disorder from skull-base osteomyelitis: a case report / 대한악안면성형재건외과학회지

Skull-base osteomyelitis is a rare disease affecting the medulla of the temporal, sphenoid, and occipital bones. In general, it occurs due to external ear canal infections caused by malignant external otitis. Skull-base osteomyelitis usually affects elderly diabetic patients. The patient, a 58-year-old man, was referred for evaluation and management of the left jaw. Clinical examination of the patient revealed pain in the left jaw and mouth-opening deflection to the left. The maximum active mouth opening was measured to about 27 mm. Panoramic, CT, and CBCT revealed bone resorption patterns in the left condyle. Through control of diabetes, continued pharmacological treatment, arthrocentesis, and occlusal stabilization appliance therapy were carried out. The extent of active mouth opening was increased to 45 mm, and pain in the left jaw joint was alleviated. This was a case wherein complications caused by failure to control diabetes induced skull-base osteomyelitis. There is a need for continued discussion about the advantages and disadvantages of arthrocentesis with lavage for patients with skull-base osteomyelitis and other treatment options.

Prognostic Analysis of Skull-base Invasion of Nasopharyngeal Carcinoma Based on Magnetic Resonance Imaging / 中山大学学报(医学科学版)

[Objective]To evaluate the prognostic value of skull-base invasion of nasopharyngeal carcinoma(NPC)based on magnetic resonance imaging(MRI).[Methods]A total of 924 patients who were diagnosed with NPC between 2003 and 2004,had undergone MRI scan and received mdiothempy as their primary treatment,and had no distant metastasis were included in this study.MRI images and medical records were analyzed retrospectively.All the 924 eases.patients who developed skull-base invasions based on MRI,315 patients with T3 disease and 227 patients with T2 disease were selected for analysis.The staging was according to the sixth edition of the American Joint Commission on Cancer(AJCC)staging system.[Results]Incidence of skullbase invasion according to MRI was 55.4%.Of 924 cases.skull-base invasion on MRI was not an independent prognostic factor for overall survival(OS)and distant metastasis-free survival(DMFS),but was a marginally significant independent prognostic factor for local relapse-free survival(LRFS),P=0.068.Grading of MRI-detected skull-base erosion according to the site of invasion was an independent prognostic factor for OS(P=0.002 and P=0.005)and DMFS(P=0.001 for both)in the 512 patients with skull-base invasions and 315 patients with T3 disease.Severe-grade of skull-base invasion on MRI was an independent prognostic factor for OS and DMFS in the 924 patients(P ＜ 0.001 for both).No significant differences were observed on OS,LRFS,and DMFS between T2a patients and T3 patients with low-grade of MRI-deteeted skull-base involvement.[Conclusions]Skull-base invasion based on MRI is not an independent prognostic factor for NPC.However,severe-grade of invasion according to the site of involvement has positive prognostic value.

Microsurgical resection for orbital or orbitocranial neoplnsma / 中国医师进修杂志

Objective To find out a sesirable approach through which orbital or orbitocranial neoplasma can be resected more effectively. Methods A retrospective study was made on microsurgical resection of 32 cases orbital or orbitocranial neoplasma treated. All patients showed malfunction of optic organs.Microsurgical techniques and different approaches were used to remove neoplasmas. Results Twenty-sevencases received total removal,4 cases subtotal resection, 1 case no resection and 15 cases' skull bases were reconstructed.No postoperative morbidity was found. Conclusions Microsurgical techniques as well as disirable or combined approaches may increase the possibility to resect the total neoplasma and improve clinical results.The reconstruction of skull base should be much emphasized on preventing complications.