Catalogue and Evolution of Minimally Invasive Approaches for Adult Intracranial Pathology From 2011 to 2023

Minimally invasive surgery (MIS) presents an attractive alternative to conventional open cranial approaches because it limits tissue exposure, promotes wound healing, and enhances patient satisfaction. This study aimed to describe our experience with selection and use of prospectively catalogued MIS cranial approaches to treat a variety of pathologies, highlighting clinical outcomes and trends over time.

We used a prospectively maintained database of patients undergoing cranial surgery by the senior author at our institution between 2011 and 2023. Cases were classified as open or MIS at the time of surgery. We defined MIS as inclusive of any endoscopic, endoscopic-assisted keyhole, or port-based approach, including channel-based neuro-endoscopy, endoscopic-assisted craniotomy, and exoscopic port-based approaches. The details of each approach, the pathological target, and major postoperative complications were recorded and analyzed.

Within the 13-year inclusion period, 1371 MIS procedures were performed, comprising 54% of 2540 cranial neurosurgical operations. There was a marked increase in the proportion of MIS cases from 49.4% in the initial half to 58.4% in the final half of the timeline ( P = .002). The majority of MIS cases were endoscopic endonasal approaches (n = 1068, 77.9%), including 742 (69.5%) direct and 326 (30.5%) extended approaches to treat skull base lesions. Endoscopic channel-based (n = 86, 6.3%) and keyhole approaches (n = 114, 8.3%) were used to access cortical and subcortical lesions. Hybrid microscopic/endoscopic, exoscopic/endoscopic, and blue-light endoscopic procedures increased substantially in the later years of the cohort. Complication rates changed from 12.3% to 10.7% for MIS and 11.9% to 14.2% for open cases when comparing initial with subsequent years.

MIS approaches have become increasingly valuable tools in our surgical armamentarium over the past decade, as evidenced by the evolving proportion of MIS procedures performed over time. Reasonable complication profiles further contribute to the efficacy and safety of MIS cranial approaches.