The High Road or the Low Road

Abstract

n this wonderful article, which combines cadaver dissection with case illustrations, a group of pioneering endonasal I surgeons describe their decision-making strategy in choosing between the endonasal “farmedial” approach and the transcranial “far lateral” approach to the cervicomedullary junction. Articles such as these, of which there are several, represent a healthy fourth stage in theevolutionof theendonasal approaches. This first stage, which can be called Introduction, was the presentation of the endonasal approaches involving cadaver dissection and case reports. This first stage was met with skepticism among the neurosurgical community, leading to the second stage, which can becalled Justification. In this stagesurgeonspresented larger case series showing safety and efficacy. This stage was met with curiosity and early adoption, as well as harsh criticism of complications, which required a third stage, namely Modification. In this stage the endonasal approaches and instrumentationwere altered to further reduce complications and increase efficacy.We are now entering a new stage, in which the endonasal approaches are considered safe and effective in experienced hands and the main issue becomes appropriate selection of the proper approach. This stage involves decision-making algorithms, direct comparisons between endonasal and transcranial approaches (2-8), and frank discussions of the benefits and limitations of the endonasal versus the transcranial approaches. These last set of articles, ofwhich the current article represents an excellent example, include comparisons of the pterional, supracilliary versus endonasal transplanum approaches, or the transpetrosal, subtemporal versus endonasal transpterygoidal approaches, or extended transbasal versus endonasal transcribriform approaches. The purpose is not to show that one approach is better than another, but rather to indicate in what situations one approach might be preferable and when the