The evolution of Harvey Cushing's surgical approach to pituitary tumors from transsphenoidal to transfrontal

The evolution of transsphenoidal surgery represents a special chapter in the progress of neurosurgery. Although Cushing initially advocated a transsphenoidal approach to pituitary tumors, he became disenchanted with this approach, ultimately favoring the subfrontal or "transfrontal" route late in his career. Other neurosurgeons followed Cushing's example, and the fate of transsphenoidal surgery entered a dark era in 1929. A review of Cushing's patients' records reveals that his abandonment of the transsphenoidal route was primarily related to the limitations of this approach in providing effective resection of large pituitary lesions-the symptomatic tumor recurrence rate after this procedure was substantial. Furthermore, given the preoperative uncertainty about the suprasellar extension of pituitary tumors prior to modern neuroimaging, the transfrontal route assured Cushing an adequate decompression of the optic chiasm. By 1927, Cushing's mastery of intracranial surgery was accompanied by the use of electrosurgical methods that enabled him to remove sellar lesions through the transfrontal route safely and with timely and effective restoration of visual loss. Transsphenoidal surgery remained relatively dormant, awaiting the efforts and enthusiasm of Norman Dott who bridged the gap between Cushing and Gerard Guiot, the surgeon who revitalized transsphenoidal adenomectomy for future generations of pituitary surgeons.