Combined anterior and anterolateral approaches to the cranial base: complication analysis, avoidance, and management

During the past decade, applications of anterior and anterolateral cranial approaches for both benign and malignant pathologies have expanded in frequency and application. Complications associated with these procedures impact significantly on patient outcome. The primary aim of this study is to detail the strategies for complication management and avoidance developed from experience with 120 patients who underwent anterior and anterolateral cranial base procedures during the past 14 years.

Between July 1990 and February 2004, 62 male and 58 female patients underwent 120 combined (neurological surgery and otolaryngology joint participation) anterior and anterolateral cranial base procedures. Fifty-four percent had malignant pathology, and 46% had benign pathology. The approaches taken were transfacial (10%), extended subfrontal (33%), lateral craniofacial (23%), and anterior craniofacial (35%). Thirty-day morbidity and mortality were analyzed.

Twenty (17%) patients experienced at least one complication. Malignancy and reoperation, regardless of histology, appeared to affect the complication rate. A decline in complications occurred with experience, in part because of changes in management that reflected the complication experience (25% in Patients 0-31, 18% in Patients 32-70, 10% in Patients 71-120). Methodology is detailed for avoidance and management of retraction injury, infection, tension pneumocephalus, cerebrospinal fluid leak, pericranial flap failure, free flap sizing, dural banding, intracranial hypotension, and cerebrovascular events. Individual patient analysis, complications timing, and strategy for management are discussed.

Improved patient outcomes for anterior and anterolateral cranial base surgery are, in part, directly related to the ability to avoid and manage associated complications. Experience, avoidance, and interdiction are key factors in complication management.