Department of Neurosurgery

Minimally Invasive Cranial Base

By: J. D. Day, M.D.


What is Minimally Invasive Neurosurgery?

Minimally invasive neurosurgery mostly refers to those procedures that can be safely performed through a small opening utilizing the endoscope or microscope for viewing.  Minimally invasive neurosurgical procedures differ from more traditional approaches by avoiding unnecessary damage or manipulation to adjacent tissues.  Minimally invasive approaches have been devised for nearly every facet of brain and spine surgery.  Every effort is made by the neurosurgeons of the UT Cranial Base Surgery Program to design a surgical treatment plan that is the least invasive.


Keyhole/Endoscopic Microvascular Decompression for Trigeminal Neuralgia and other Cranial Nerve Vascular Compression Syndromes

Vascular Compression Syndromes affect the function of several cranial nerves (nerves arising from the brain stem).  Compression of the Trigeminal nerve causes lancinating paroxysmal facial pain, known as Tic Doloureaux or Trigeminal Neuralgia.  Compression of the facial nerve leads to uncontrollable twitching of the face and eyelids.  This condition is known as Hemifacial Spasm.  Patients may also suffer dizziness from a vessel pressing against the balance nerve.  Finally, some patients experience severe pain in the throat, which comes and goes, due to pressure on the glossopharyngeal nerve.  This causes glossopharyngeal neuralgia.
All of these conditions can be treated by moving the offending blood vessel away from the nerve  which serves as a permanent solution to the  problem in the majority of cases.  Surgeons of the practice surgical techniques for these problems that result in a minimum of tissue manipulation.  Vessels are moved through openings about the size of a dime, visualizing the area either with an endoscope or microscope.  Patients normally spend no more than three days in the hospital, including the day of surgery.

Case Study:

A 64 year-old woman was seen by Dr. Day who had been suffering from Trigeminal Neuralgia for 6 years.  She had been undergoing medical treatment by a neurologist with only partial relief of her symptoms.  The pain had changed her life, causing her to be withdrawn and not willing to participate in activities that she enjoyed.  All due to the fear and apprehension of the pain which was triggered by any stimulation to the face or mouth on the right side.  An MRI of the brain revealed the offending vessel pressing on the trigeminal nerve on the right side.  A keyhole microvascular decompression was offered as a way to cure her pain.
The patient underwent the surgery by Dr. Day who made a dime sized opening in the skull behind the ear and moved the offending vessel away from the nerve.  The patient was immediately free of pain after surgery and was discharged from the hospital less than 48 hours after surgery.  The patient had a wonderful response to treatment, with no further pain.  She returned to her normal activities.  The words of her daughter, “Thank you for giving me my mother back!”, are the best description of the success that can be realized from this treatment for trigeminal neuralgia.


Endoscopic Pituitary Tumor Surgery

Patients with benign tumors of the pituitary gland, pituitary adenomas, have traditionally been treated by removing the tumor by opening the skull from above (craniotomy) or by an approach that accessed the tumor by making an incision under the lip and dissected the patients nose to reach the sinuses and pituitary tumor.  Now,  such a complicated and potentially uncomfortable approach is unnecessary.  Patients at our center are treated by removing the tumor via an Endoscopic approach through the nose that requires no incisions on the head or in the mouth.  The pituitary tumor is removed by working through the nasal passageway, typically in about one hour.  The vast majority of patients are discharged home within one to three days after surgery.  Patients do not require packing in the nose and have minimal discomfort as a consequence of this procedure.

Case Study:

A 56 year-old man was referred from his ophthalmologist to Dr. Day with a history of headaches and blurred vision.  A brain MRI revealed a large mass in the area of the pituitary gland, consistent with a pituitary tumor.  The patient was apprehensive about undergoing surgery, mainly because his daughter was to be married in the coming weeks and he did not want to be recovering from an operation.  His fears were allayed by the description of the Endoscopic procedure and the track record of Dr. Day in this arena.  He was scheduled for surgery.
The tumor was removed completely via the Endoscopic approach.  The patient had no significant discomfort and was discharged from the hospital the morning following his operation.  At his two week follow-up visit he said he felt “perfect” and was looking forward to dancing with his newly wed daughter at her wedding the following week.


Minimally Invasive Brain Aneurysm Repair

Brain Aneurysm repair is now performed mostly from inside the artery, referred to as endovascular techniques.  Not all aneurysms, however, are appropriate for such treatment and require an open surgical method of closing the aneurysm.  Many aneurysms that require surgery can be safely approached via a minimally invasive technique that results in far less manipulation and disruption of tissue.  Limited, precise procedures are performed to reach the aneurysm, resulting in less discomfort after the procedure and improved cosmetic outcomes.

Case Study:

This case study is being rewritten, please check back soon!


Endoscopic Surgery for Arachnoid Cysts

This portion of the article is being rewritten, please check back soon!


Endoscope-assisted Microsurgery for Brain Tumors and Aneurysms

This portion of the article is being rewritten, please check back soon!


Endoscopic Surgery for Petrous Apex Cholesterol Cyst

Cholesterol cysts are hemorrhagic, inflammatory cysts that form in bone.  Neurosurgeons occasionally encounter a patient with such a cyst in the petrous bone, one of the central bones of the skull.  The cyst can cause a number of symptoms, including head or ear pain, double vision, dizziness, hearing loss, and facial numbness.  These cysts require drainage to relieve these symptoms, which was accomplished in the past by a craniotomy to reach the cyst and drain it.  This procedure has historically had a high risk of recurrence of the cyst owing to the fact that complete removal of the cyst wall is very difficult, and a permanent drainage tract is hard to establish.

This limitation in traditional treatment has largely been overcome in some patients by a fully endoscopic transnasal approach to the petrous bone to drain the cyst.  This approach has resulted in not only drainage of the cyst, but the ability to establish a permanent drainage tract into the sinuses and pharynx, which reduces the likelihood of recurrence of the cyst.  This procedure allows for a quicker recovery from surgery and discharge from the hospital is typically the day after surgery.

Case Study:

A 56 year-old airline captain presented to Dr. Day with recurrent symptoms of headache and trouble equalizing pressure in his right ear after an eight year hiatus from these symptoms.  He was initially treated eight years prior by Dr. Day via a craniotomy and drainage of a cholesterol cyst working under the temporal lobe of the brain.  The patient had a recurrence of the cyst demonstrated on MRI of the brain and skull base.  A transnasal endoscopic approach was recommended for drainage. (Video coming soon)

The patient underwent an uncomplicated endoscopic procedure to drain the cyst and establish a permanent drainage route into the back of the nose and throat.  He was discharged the following day without pain and was feeling very well.  He returned to flying in 2 weeks for a major U.S. airline.