2025 Proffered Presentations
S071: UTILITY OF BIORBITOFRONTAL CRANIOTOMY IN THE TRANSSPHENOIDAL ERA - A 30 YEAR SINGLE SURGEON EXPERIENCE
Joseph D Castellanos, BS1; Shrey Patel, MS1; Jacob J Kosarchuk, MD2; Carl Heilman, MD2; 1Tufts University School of Medicine; 2Tufts Medical Center
Background: The biorbitofrontal (BOF) craniotomy offers extensive exposure to the anterior cranial fossa and paranasal sinuses. Although the trend in skull base surgery increasingly favors minimally invasive techniques, transcranial approaches like the BOF remain an important tool in the skull base surgeon’s armamentarium. The BOF approach provides exceptional visibility of both normal and pathological anatomy, facilitating controlled dissection and easier skull base reconstruction. Additionally, the extensive exposure afforded by this technique minimizes the need for retraction, thereby reducing the risk of iatrogenic brain injury.
This study evaluates overall outcomes, complications including infection, cerebrospinal fluid (CSF) leak, perioperative stroke, and others in patients who underwent BOF by a single surgeon; a similar study was published over a decade ago from our institution, and here we present an updated analysis of cases over the last 30 years. Our goal is to highlight the continued relevance and strengths of the BOF technique in an era increasingly dominated by minimally invasive skull base surgery.
Methods: We conducted a retrospective analysis of patients treated by the primary neurosurgeon (CH) between 1994 and 2022 who underwent biorbitofrontal craniotomy at our institution. Comprehensive data were collected, including diagnosis, presenting symptoms, and perioperative complications. Specific metrics of interest included the incidence of infection, occurrence of CSF leaks, utilization of lumbar drains both prophylactically and therapeutically, and the incidence of stroke. Data were analyzed using descriptive statistics to assess the frequency and nature of these complications.
Results: 107 patients were identified for this study. We obtained complete information from 31 patient charts and partial information from 53 patient charts for a total of 84 patients considered in the study. The average patient age was 50 years. There were 46 female and 38 male patients. The most treated pathology was olfactory groove meningiomas (30, 28%, average size 4233mm3), followed by sinonasal cancer (16, 15%, average size 5355mm3), CSF leak (9, 8.5%), sellar/parasellar tumors (7, 6.5%, 797mm3), and intracranial cysts (7, 6.5%, 1066mm3). Other conditions included craniosynostosis (2, 1.8%), esthesioneuroblastoma (3, 2.8%, 5796 cm3), planum sphenoidale meningioma (6, 5.6%, 10890 cm3), sarcoma (1, 0.9%), and infectious pathologies (2, 1.8%). GTR was achieved in 84% of all patients across all pathologies in which resection was the goal.
Post-operative complications were meningitis (3%), CSF leak requiring reoperation (3%), and stroke (3%). A lumbar drain was prophylactically used in 7% of patients. Bone flap infection occurred in CSF leak repair (11%), esthesioneuroblastoma resection (33%), and sinonasal cancer resection (8%). CSF leak occurred in one infectious pathology (50%) and one planum sphenoidale meningioma (17%). DVT occurred in one patient with planum sphenoidale meningioma (17%). Prophylactic use of a lumbar drain in one patient (11%) for CSF leak, one patient (14%) for cyst resection, and one patient with sinonasal cancer (6%). Post-operative lumbar drain was used in one patient with an infectious pathology (50%) and planum sphenoidale meningioma (17%) due to CSF leak.
Conclusion: In the minimally invasive era, the biorbitofrontal approach remains an asset for surgeons treating anterior skull base pathology.