Commentary

When choosing the surgical approach to skull base tumors and other abnormalities in the petrous bone region, the surgeon must consider the size, location, and extent (e.g., to or across midline) of a lesion and its likely relationship to critical neurovascular structures that must be preserved. The configuration of the skull base anatomy is also an important consideration. The surgeon would like to be as “close” to the lesion as possible as long as critical neurovascular structures do not impede reasonable access. The authors clearly describe the marked variability in skull configuration and how such variation could affect reasonable surgical access. This information provides a useful and valuable reminder that this variable should be included when choosing a surgical approach. As an example, I still prefer the presigmoid retrolabyrinthine approach to many petrous apex tumors, especially those that reach or cross the midline, extend into the middle fossa, or both. This approach is tiring for the surgeon, as the authors point out, but the locations of cranial nerves III, IV, V, and VII along the skull base vessels and their critical perforators may limit adequate access to a lesion that extends significantly into the posterior fossa.