Minimal access or optimal access: What to target?

Neurosurgery, in recent times, has reached a point where we can safely say that, today, it is not only about dealing with the execution of pathology but also about minimal or no damage to the surroundings, choosing the right direct path and simple, safe, and effective surgery. Microneurosurgery may well be directly correlated with the batting style of “The Wall” of India, where the commentators rightly said “usage of wrist movements.” It is more of a clean surgery with minimal effective movement of the hands.

However, dealing with any pathology requires an outer opening to reach the target. At times, you need to unlearn what you have learnt till date to realize that it is invariably a very small target portion, when you had opened a pretty big area. As in, to reach the base of the skull via a transsylvian approach, and target an IC aneurysm, a craniopharyngioma, or more so even a deep-seated meningioma, apart from a clear visualization of the basic structures and opening of the cisterns, you do not need a huge cranial opening. Once the cisterns are opened, it paves the way for a beautiful brain relaxation and move your microinstruments freely. Though yes, your imaginative eyes do tell you that there is a significant edema or the guy on the table may develop postoperative edema necessitating a decompression later.

What's worse, is just a hefty fancy thinking of usage of minimal access with improper patient selection. Every new instrument added to the neurosurgical armamentarium today should act just an add-on at your disposal. It should not act as binary numbers to you, dictating terms to only use them for a real minimalistic approach. Of course, over a period of learning time, it is but obvious that the access route becomes simplistic, smaller, safer, and more direct.

A minimal access approach for canal stenosis without giving undue address to proper decompression of nerves would not give the ideal benefit as would have been required. Hence, what's more important is to start with an optimal access approach to deal with the pathology, learn over a course of time, get a proper patient selection, and then taper your skills in getting as minimal access to the problem as deemed necessary, and not just directly jumping to get minimal access heads on.

No conflict of interest has been declared by the author(s).

Publication History

Received: 14 December 2019

Accepted: 24 December 2019

Article published online:
16 August 2022