Skull Base Complications: Lessons Learned in the First 5 Years of Practice

Introduction: Skull base and cerebrovascular surgery is laden with technical challenges. These complex surgeries may sometimes lead to morbidities, often with grave consequences. Stroke, cranial neuropathies, CSF fistulas, and hemorrhage are among the complications noted in skull base surgery. Expertise in skull base surgery takes many years of training and practice to obtain. Fellowships, cadaver dissections, and courses are frequent modalities by which the road to expertise is begun in skull base surgery. However, the early years of practice in skull base surgery are a "crash course" in avoidance and management of complications. Our objective is to describe some of these lessons that we have learned in the early years of our skull base practice. We emphasize surgical decision making, technical errors, and learning from those with more experience.

Methods: After obtaining IRB approval, we performed a review of a prospectively maintained database of all of our cases from September 2007 to September 2012. The cases were divided by pathology, and all cases with major and minor complications were further evaluated. Complications were labeled as Type 1 (inexperience/greed), Type 2 (inadvertent but avoidable), and Type 3 (inadvertent and unavoidable). Complication rates were determined and trends were noted as more experience was gained.

Results: A total of 1020 complex intracranial operations were performed during our study period. An overall complication rate of 3.75% was noted for these cases. The majority of these complications were Type 2. The number and proportion of Type 1 complications increased from year 1 to year 3 and then decreased significantly from year 3 to year 5. Stroke after aneurysm surgery, meningitis after tumor surgery, and small vessel ischemia were among the complications with the most severe postoperative functional disability.

Conclusions: Many lessons have been learned in the early phases of our skull base practice. The importance of preoperative planning and decision making is highlighted. Minimizing Type 1 and Type 2 complications is a constant goal. Maintaining humility, seeking expertise from those with more experience, and constant improvement in surgical techniques are lessons that we greatly advocate for those seeking to start a career in skull base surgery.