A concise history of skull base surgery: what is its contribution to neurosurgery?

Skull base neurosurgery (SBNS) emerged as a specialized branch of microneurosurgery as it addressed the challenges posed by intricate skull base anatomy. Initially developed through close collaboration with otolaryngologists, SBNS expanded in the 1990s and has undergone substantial advancements over the following decades. In this review, we analyze whether SBNS evolved as an organic development within neurosurgery or an external innovation, and we review key historical literature to support of either hypothesis.

This is a synthetic, narrative historical review. An initial Pubmed review was performed with combination of keywords of "skull base neurosurgery", "skull base surgery", "neuroanatomy", "microsurgical anatomy" and" neurosurgery complications". Resulting database was restructured based on peer to peer, semi-structured interviews of two senior skull base neurosurgeons, with over 25 skull base neurosurgeons that were active 1970s-1990s. Emerging themes formed the framework for the analysis.

The evolution of SBNS was organic. It could be categorized into four distinct phases: Initially, Early attempts preceding the systematic application of SBNS techniques, subsequently the birth phase coincided with the widespread adoption of microneurosurgery and the establishment of dedicated societies and international meetings. During the popularization phase, advances in microneuroanatomy and novel approaches enhanced outcomes. Finally, the Maturation phase brought refined surgical approaches, the reevaluation of surgical indications, and the integration of stereotactic radiosurgery and endoscopic skull base surgery as well as international collaboration and teaching activities.

SBNS emerged within neurosurgery as a means to address challenging skull base pathologies and to enable surgical access through the skull-base. Its development was driven by collaboration with otolaryngology, alongside technological innovations such as the operating microscope, power drills, endoscopy, and stereotactic radiosurgery. These innovations facilitated the creation of novel surgical approaches, which were later refined through advances in neuroanatomical knowledge and improved understanding of pathology. Over time, SBNS were integrated into general neurosurgical practice and training curricula, allowing wide implementation and continued evolution in many directions.