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Cranial base surgery
  1. NIGEL MENDOZA

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    Cranial base surgery. Edited by james t robertson, hugh b coakham,and jon h robertson. (Pp 688, £150.00). London: Churchill Livingstone,2000. ISBN 0-443-056854.

    Cranial Base Surgery is a multiauthored textbook with internationally recognised contributors from Europe and the United States of America. The stated aim of the editors is to collate the experience of skull base surgeons to provide an account of the contemporary management of skull base lesions including surgical techniques and outcome data. However, because of the rarity of some of the lesions, the authors admit that long term data on their outcomes are not yet available, which precludes definitive statements about the best management plans.

    The book is divided into four sections dealing initially with presentation and diagnosis and sequentially with the surgical approaches, pathological conditions and finally with adjuvant therapy for cranial base tumours.

    The section on general considerations concentrates on neuroimaging, interventional neuroradiology, neurophysiological monitoring, and neuroanaesthesia. The chapter on critical surgical anatomy is excellent and certainly for this reviewer provided a useful revision exercise.

    The chapters dealing with surgical approaches to the cranial base will be most useful to those who are in training rather than providing any new information to those who already have an established practice, although it does provide a logical overview of the different approaches.

    The mark of a good operative text is whether, when one has read and digested it, one would have the confidence to undertake the procedure. For experienced surgeons the answer would be yes but for those in training the text is not supported by the quality of the illustrations. These are largely black and white and have been executed by different artists, which gives them a non-uniform appearance. The intraoperative photographs are unsatisfactory; for example, a picture of a juvenile nasopharyngeal angiofibroma was unrecognisable.

    The third section comprises 13 chapters relating to the individual surgical pathology of tumours and vascular lesions. In these chapters there is repetition of the material alluded to in thesurgical approaches section. Despite this the transglabellar subfrontal approach was not described either in the surgical approaches section or in the chapter on olfactory groove meningiomas.

    The chapters on surgical pathology would have benefited from having standard subheadings which would have simplified access to specific information such as that relating to outcome data. The excellent chapter by Jennetta and Resnick on microvascular decompression would have provided an ideal template for this, and the intraoperative colour photographs in the chapter on the microsurgical treatment of trigeminal neuralgia demonstrates what might have been achieved in the other chapters where such quality photographs were absent. The management algorithms at the end of each chapter of surgical pathology provide a useful adjunct although I note no mention of stereotactic radiosurgery was made in relation to the treatment of trigeminal neuralgia.

    Much work and no little suffering has characterised the evolution of the surgical approaches to the skull base. There can be no doubt that on occasion these formidable surgical procedures may have led to as the authors state “unnecessary significant morbidity“. It is encumbent upon us to embrace advances which might in the future make our surgical approaches redundant. It is to be hoped that over the next 10-20 years results of carefully undertaken studies comparing outcome and morbidity between surgery and adjuvant therapies will allow us to make definitive decisions as to how best manage patients with skull base tumours. It is to be hoped that future editions of this text (either as a paper text or CD Rom) will reflect these results.

    The last chapter is about primary bone disease of the skull base. It is not clear why it is included in the section relating to adjuvant therapy and would have been more appropriate in the section on surgical pathologies.

    The book itself is attractive to look at and handle with good quality paper and font.

    In summary, this is an excellent text book review of the state of the art of cranial base surgery, largely fulfilling the stated aims of the editors. I would hope that a future edition would include improved illustrations and more editing of the operative procedures.

    I would certainly recommend this book to those in training with an interest in skull base surgery and to those already established who wish to have a definitive textbook to delve into occasionally.

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