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Edwin Detrez
ENC 1102
Professor Leslie Wolcott
7/18/2014
Collaboration of Neuro-Conversation
One outstandingly controversial topic in the neurological community is that of
endoscopic neurosurgery, sometimes known as endoneurosurgery, and whether or not it is too
dangerous to be used as a means of operation on a patient. An endoscope is a small camera-like
device that allows a surgeon to penetrate tissue and even view the tissue on a microscopic level
for delicate and precise operation on a patient. Endoscopes can also be used to enter the skull and
brain without incision such as in sinus surgery where the endoscope is put in through the nose.
Only about 0.06% of the neurosurgeons in the United States (of which there approximately
1,500) utilize an endoscope as a means to operate. Many professionals in the field argue that
there are far too many possible risks and complications that can occur for endoneurosurgery to
be considered as a recommended form of surgery. Some complications include cerebral fluid
(brain fluid) pressure increase, Blood pressure increase in the cranial (head) area, and
cerebrospinal fluid leaks. On the contrary, other peer professionals argue that endoneurosurgery,
despite the risks given now, should be explored because that is the only way the practice will
evolve and eliminate the risks.
The following extensively researched annotated bibliography attempts to investigate and
reveal the conversation surrounding endoscopic neurosurgery. The following annotations extract
important data from different research sources about endoscopic neurosurgery. A large majority
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of these resources are comprised of academic journals and periodicals. Sources that attempt to
describe the dangers and complications with endoneurosurgery will be included along with those
that present its benefits to those suffering head injuries, mental disorders, or conditions
pertaining to the skull or brain. This annotated bibliography will expose the research surrounding
specifically what complications can occur for endoneurosurgery, what methods are used when
operating and why they pose a threat to a patients health, and what benefits they might ensure
for the patient including increasing life longevity and even health quality. This annotated
bibliography will also explore the outcomes of procedures that have been done already, whether
or not a majority of the neurological community recommends this type of surgery as a sufficient
means of operation, and how that relates to the future of endoscopic neurosurgery.

Abd-El-Barr, M., & Cohen, A. (2013). The origin and evolution of neuroendoscopy. Child's
Nervous System, 29(5), 727-737. doi:10.1007/s00381-013-2055-2
In this article, Muhammad Abd-El-Barr and co-author Alan Cohen, doctors in the
Department of Neurosurgery at Boston Children's Hospital, and Harvard Medical School
respectively, divulge the ancient techniques and origin of endoscopic neurosurgery. The
authors reveal that endoscopic neurosurgery had its origin in Ancient Egypt. The
Egyptians would study the brain and its reactions through surgery through the nose. The
authors then claim that endoscopic neurosurgery evolved from the idea of entering the
endoscope through natural soft spots or holes called fontanels. This produces the least
damage to tissue in the head. This article is important to my research because it provides
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insight into how long endoscopic neurosurgery has been around and raises questions
about why it hasnt evolved into something greater or more widely accepted.

Ammirati, M., Wei, L., & Ciric, I. (2013). Short-term outcome of endoscopic versus microscopic
pituitary adenoma surgery: a systematic review and meta-analysis. Journal Of Neurology,
Neurosurgery & Psychiatry, 84(8), 843-849. doi:10.1136/jnnp-2012-303194
Professor Mario Ammirati, of Department of Neurosurgery at Ohio State University,
proposed an experiment in which he produces 10 cases in which endoscopy was used to
invade and diagnose patients with pituitary adenoma. Pituitary ademoa is a condition
where a noncancerous tumor invades the pituitary gland (located just under the brain) and
causes increase in cerebral-spinal fluid pressure, blood pressure in the brain, nerve
damage, and an increase in growth hormones which cause facial deformities. Ammirati
produces the results of the 38 cases of surgery and provides the feedback from the
operations. Out of the 38 cases, only 8 of the patients experienced complication and
returned growth after a 6-month period. This demonstrates the articles purpose and
importance to this research because it reveals the successive nature of endoscopic
neurosurgery. This supports pro-endoneurosurgical claims from members of neurological
community that endoscopic neurosurgery can assist in severe cases and should be
invested in to minimize the amount of patients who experience complications.

Bruin, R., Furth, W., Verbaan, D., Georgalas, C., Fokkens, W. W., & Reinartz, S. S. (2014).
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Initial experiences with endoscopic rhino-neurosurgery in Amsterdam. European
Archives Of Oto-Rhino-Laryngology, 271(6), 1525-1532. doi:10.1007/s00405-013-2662
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In this article, Rick Bruin, Head of the Department of Neurosurgery at the Academic
Medical Centre in Amsterdam, describes cases of neurosurgical patients that have both
good and bad outcomes. This article is very controversial in that Bruin states that there
are many complications and that endoneurosurgery should be studied more before
applying it as a adequate means of operation however, he also states cases in which it has
benefitted patients and even allowed a patient with a brain tumor operation to be
clinically cleared of the tumor and restored to full health. Bruin describes the methods
used in endoneurosurgery which he states are the most practiced because they have the
fewest risks and the least complications. The method he describes is that of sinus

Chotai, S., Kshettry, V. R., & Ammirati, M. (2014). Endoscopic-assisted microsurgical
techniques at the craniovertebral junction: 4 illustrative cases and literature review.
Clinical Neurology & Neurosurgery, 1211-9. doi:10.1016/j.clineuro.2014.03.004
In this article, doctors Silky Chotaia, Mario Ammiratia, of the Department of
Neurological Surgery at Ohio State University Medical Center, and Dr. Mario Ammirati
of the Department of Neurological Surgery at Cleveland Clinic, describe endoscopic
microsurgical techniques for operation on the brain. The authors claim that endoscopic
neurosurgery can prevent brain retraction and trauma to neurovascular (nerves) structures
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while performing surgery. They attempt this by illustrating cases in which
endoneurosurgery was used to operate on brain injured patients. The authors concluded
after research that endoscopic assistance can improve visualization down narrow or deep
corridors in the brain to see important nerves, veins, and other structures. This article is
important to my research because it provides evidence supporting the authors claim and
supporting the claim of those in the neurological community, that endoneurosurgery is
beneficial and that neurosurgeons should invest more time in studying and perfecting this
means of surgery.
Cote, M., Kalra, R., Wilson, T., Orlandi, R. R., & Couldwell, W. T. (2013). Surgical fidelity:
comparing the microscope and the endoscope. Acta Neurochirurgica, 155(12), 2299-
2303. doi:10.1007/s00701-013-1889-4
In this article, doctors Martin Cote, Ricky Kalra, Taylor Wilson, and William T.
Couldwell compare the benefits and hindrances in using an endoscope versus a
microscope in neurosurgery. Instead of actually performing surgical procedures in vivo
(in living organisms), the authors had groups of medical residents and professional
surgeons practice motor skills on each a microscope and an endoscope to begin their
experiment. The authors had them perform variety of tasks using both instruments and
recorded the accuracy and speed at which they completed them. The results of the
experiment were that both tasks came within close quarters when comparing accuracy,
but when it came to speed the resident group completed the task more quickly with the
microscope. However, the neurosurgeons had virtually no gap in time when using both
instruments. The authors concluded that both the microscope and the endoscope are
excellent means of visual assistance during neurosurgery but a quicker time was achieved
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when using the microscope instead. This article demonstrates its importance in this
bibliography because it compares a modern and accepted form of visual surgery, the
microscope, to an unused and not widely practiced form using the endoscope. This
supports the claim that the endoscope is not as efficient as current means of operation and
is not worth the risk factor it involves.


DelGuardio, J. & Ingley, A. (2010). Treatment of endoscopic sinus and microscopic skull base
surgery. American Journal of Otolaryngology, 31(4), 226-230. Doi:
10.1016/j.amjoto.2009.02.012
In this article, Professor John M. DelGuardio, of Emory University School of Medicine,
explores the dangers of endoscopic research in trans-skull base surgery. Trans-skull base
surgery is a type of surgery in which the surgeon makes an incision on the back of the
head near the neck. DelGuardio explains that post-surgery, patients have been
documented with severe headaches and altered mental state due to the surgery. He also
presents these complications with endoscopic sinus surgery (ESS). ESS is a type of
neurosurgery dating back to the ancient Egyptians in which the surgeon, instead of
making an incision through the head base, uses an endoscope through the nose to perform
surgery. Professor DelGuardio produces ten case-studies in his article that demonstrate
the possible aftereffects and complications with endoscopic neurosurgery, on being,
cerebrospinal fluid leaks. This condition is when your spinal fluid leaks into your brain
due to raised blood pressure when a surgeon makes the incision. This article is imperative
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to my research because it supports the claim that endoscopic exploration and operation is
much too dangerous and can cause too many complications to be considered a
recommended for of surgery.
Graham, S., Iseli, T., Karnell, L., Clinger, J., Hitchon, P., & Greenlee, J. (2009). Endoscopic
approach for pituitary surgery improves rhinologic outcomes. Annals Of Otology,
Rhinology & Laryngology, 118(9 Part 1), 630-635.

In this article, Dr. Scott Graham of the Department of Otolaryngology-Head and Neck
Surgery, provides research data on the improvement of quality of life after endoscopic
neurosurgery removes complications of lesions and tumors of the anterior skull base. He
includes cases from pituitary gland surgery patients and detailed records of case studies
which provide an account for how their lives improved over time after the surgery. This
article is important to my research because it shows detailed long term cases that
endoscopic neurosurgery can improve not only the lifespan, but the quality of life of the
patients on which the surgery is performed.

Griffith, H. B. (1977). Endoneurosurgery: Endoscopic Intracranial Surgery. Proceedings of the
Royal Society of London. Series B, Biological Sciences, (1119). 261.
In Endoneurosurgery: Endoscopic Intracranial Surgery, H.B. Griffith, Head of the
Department of Neurological Surgery at Frenchay Hospital, provides a brief history of
endoscopic neurosurgery. Griffith presents that in 1912 the first endoscope was used to
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operate in vivo on a patient in the cerebral ventricles. In vivo is a term used to describe an
experiment done inside a living organism. The cerebral ventricles are the folds or gaps
between brain tissues. Griffith tells that there were two attempts with and endoscope to
operate on a patient and both patients died, one died post operatively and the other five
years later. Griffith explains that despite this, and three years later, endoneurosurgery was
a huge leap in neuroscience and that this discovery inspired Harold Hopkins, a man
famous for his inventions of fiber optic lenses, to create a small lens devise used to study
and operate on critical and delicate points in the human body. In his article, Griffith
provides pictures of the first endoscopes and their design templates. Griffith argues that
advances in endoneurosurgery have led to countless discoveries that have benefitted
spinal, cerebral, and skull patients. She attributes the discovery of cerebral-spinal fluid
absorption (how quickly spinal fluid accepts drugs) rate to the advances of the endoscope.
This article supports the claim that endoscopic neurosurgery has benefitted neurosurgical
patients and it demonstrates the fact that despite risks and failed operations, neurosurgery,
born in about 1912, has come a very long way and continues to grow.

Meier, P., Guzman, R., & Erb, T. (n.d). Endoscopic pediatric neurosurgery: implications for
anesthesia. Pediatric Anesthesia, 24(7), 668-677.
In this article, Dr. Petra M. Meier and Dr. Raphael Guzman, professor at Harvard
Medical School and Head of the Division of Pediatric Neurosurgery at the University
Children's Hospital Basel respectively, describe the complications and limitations that
endoscopic neurosurgery can provide. They also dig into detail about proper techniques
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to minimize risk in endoneurosurgery such as how to keep blood and cranial fluid
pressure down. Guzman and Meiers article mainly explains the complications in infants
as opposed to the other articles. Meier explains that endoneurosurgery is more difficult to
perform in infants because their brain tissue and skull tissue is much softer than that of
adults which can lead to easily damaged organs. This article is vital to research because it
demonstrates the range in age that neurosurgery is performed and demonstrates that the
hazards and complications are similar despite the age range. It also depicts the different
entry locations in an infants skull and since their tissue is softer, it allows for more
access points to intracranial tissue (tissue located inside the head).


injection, where two surgeons are needed, and where the endoscope is put through the
nasal cavum (or nose) as one surgeon guides the endoscope, while the other removes the
tumor with a microscopic knife-like device. Bruin describes that 17 of the patients that
had undergone the operation experience intra-operative bleeding (bleeding inside the
skull cavity). However, 13 of these patients recovered with radiation therapy following
the procedure. This article demonstrates its purpose in my research by allowing
numerical value of cases that have succeeded versus cases that failed or where the patient
post-operatively passed. This allows the support of Bruins point that neurosurgery is
dangerous and should be studied more thoroughly, but it can also be effective.

Mielke, D., Mayfrank, L., Psychogios, M., & Rohde, V. (n.d). The anterior interhemispheric
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approach - a safe and effective approach to anterior skull base lesions. Acta
Neurochirurgica, 156(4), 689-696.
Dr. Dorothee Mielke provides a deeper insight into actual cases in this article. She
demonstrates the different surgeries that were performed in these cases and what the
injury was or why the surgery was being performed. In each case she divulges the process
for performing the surgery and its effect on the patient. She also demonstrates the results,
both short term and long terms, on the patient. This article is important to my research
because it provides actual case evidence for the success of endoscopic neurosurgery. This
will provide an excellent support module for the claim that endoscopic neurosurgery is
worth the risks it provides and can be more useful with more study and practice of the
surgical procedure.

Mohindra, S., Mohindra, S., & Gupta, K. (2013). Endoscopic repair of CSF rhinorrhea:
Necessity of fibrin glue. Neurology India, 61(4), 396-399. doi:10.4103/0028-
3886.117619
Dr. Satyawati Mohindra, of the Department of Otolaryngology and Head and Neck
Surgery at the Postgraduate Institute of Medical Education and Research, presents a study
to see if endoscopic neurosurgery and repair are worth the risks. In the experiment,
Mohindra takes twenty-seven patients with cerebral-spinal fluid (CSF) leaks and divides
them into two groups. The first group uses an endoscope to repair a broken part of the
skull where the CSF is leaking using an element called fibrin glue. The second group is
treated normally through endonasal repair without the fibrin glue. After the experiment,
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Mohindra finds that both groups performed exceptionally well with both types of surgery.
She concludes that there is minimal difference in the effectiveness of either surgery
however, endoscopic surgery is less cost effective for surgeons to use. This article is
important to my research because it demonstrates that endoscopic neurosurgery is
effective but not marginally compared to traditional neurosurgical techniques. This
supports the claim by the opposing neurological community that endoneurosurgery is not
worth investing time or money in because of the risk factors and because it does not
marginally improve surgical techniques.

San-juan, D., Barges-Coll, J., Gmez Amador, J., Daz, M., Alarcn, A., Escanio, E., & ...
Gonzlez-Aragn, M. (2014). Intraoperative monitoring of the abducens nerve in
extended endonasal endoscopic approach: A pilot study technical report. Journal Of
Electromyography & Kinesiology, 24(4), 558-564. doi:10.1016/j.jelekin.2014.04.001
Dr. Daniel San-Juan, head of the Neurophysiology Department at the National Institute of
Neurology and Neurosurgery, proposed an experiment to determine if using an
endoscope would assist and improve research in recording information about nerves in
the brain. San-Juan devised an experiment in which 14 candidates would be put under
observation of the abducen nerve (nerve under the brain behind the eye) and monitor it
for a period of time. San-Juan discovered that all abducens were successfully recorded
and he even exposed discharges in two of the patients which would have been lethal
otherwise. Dr. San-Juan concluded that endoscopic assistance in studying neurological
structures in the brain is a safe practice and can actually prevent damage of nerve tissue
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and important organs. This article, unlike many others, uses the word safe to describe the
process of using an endoscope as a means to visualize research. However, this article is
among the others that claim it can prevent injury to organs and tissue in the brain. It
supports the claim made by pro-endoscopy neurological community members that
endoneurosurgery, even just for research, is safe and an effective tool to utilize while
operating.

Schulz, M., Buehrer, C., Spors, B., Haberl, H., & Thomale, U. (n.d). Endoscopic neurosurgery in
preterm and term newborn infants-a feasibility report. Child's Nervous System, 29(5),
771-779.
Dr. Matthias Schulz, of the Department of Pediatric Neurosurgery in Charit University
Medical Center, examines the reliability and essential aspects of neuroendoscopy. He
produces an experiment that determines whether or not neuroendoscopy is of vital or
essential use in treatment of cerebral-spinal fluid leaks in infants. The experiment was
performed on 14 infants who underwent 20 endoscopic neurological procedures to stop
CSF leaks. Schulzs team took notes 36 weeks after the experiment to see if any of the
infants experienced complications. Only 2 out of the 14 (which is less than 10%) reported
complications. Schulz concluded that despite the delicate tissue of newborn infants,
endoscopic neurosurgery provided helpful guidance and delicate procedural work to the
infants cerebral area (brain.) This article is important to my research because it
demonstrates the effectiveness of endoscopic neurosurgery and supports the neurological
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communitys pro-endoscopy groups claim that endoscopic neurosurgery can assist and
benefit even children.
Wang, X., Yu, H., Cai, Z., Wang, Z., Ma, B., Zhang, Y., & Ye, Z. (2014). Anatomical Study on
Meckel Cave with Endoscopic Endonasal, Endo-Maxillary Sinus, and Endo-Pterygoid
Process Approaches. Plos ONE, 9(3), 1-5. doi:10.1371/journal.pone.0091444
Author Xuejiang Wang, of the Department of Neurology for the Nantong University
Hospital, writes an article about endoscopic neurosurgery that differs from the rest in
that, the article describes research-based endoneurosurgery instead of patient-surrounding
cases. Wangs research completely attempts to establish whether or not endoscopic
neurosurgery is a viable means to research parts of the brain. Wang describes five human
skulls taken from cadavers (deceased bodies who donate their organs to science) for
endocranial inspection (using an endoscope to enter the skull) to view a structure in the
brain called Meckels cave. Meckels cave is a fluid filled pouch on the base or bottom of
the skull filled with cerebrospinal fluid. After researching and using the cadaver skulls
with in-tact veins and nerves surrounding surround the area Wang is researching, Wang
discovered that endoscopic neurosurgery is a feasible means to operate. He states that
using an endoscope can actually protect surrounding veins and nerves that would
otherwise be destroyed during surgery. This article is imperative to my research because
it is one of the few articles that claims, without doubts, that endoneurosurgery is a viable
means of operation. Wang also provides evidence to support his claim.

Yadav, Y., Parihar, V., & Kher, Y. (2013). Complication avoidance and its management in
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endoscopic neurosurgery. Neurology India, 61(3), 217-225. doi:10.4103/0028-
3886.115051
In this article, Dr. Yad Ram Yadav, of the department of Neurosurgery at NSCB Medical
College, evaluates the potential risks involved in endoscopic neurosurgery. He shares the
different types of injuries that can occur while using an endoscope to enter the brain such
as lesions, hypothermia, Intra ventricular bleeding, Bradycardia (raised pressure of
blood vessels in brain due to irritation of tissue), Cranial nerve damage, ect. Dr. Yadav
also goes into detail about the proper precautions and steps to avoid causing injury to the
patient. This article is important to my research because Dr. Yadav describing all the
possible injuries and side effects that can occur supports the claim that endoscopic
neurosurgery is considered too much of a risk and that is why it is not virtually accepted
in the neurosurgical field.









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Cited Sources
Statistics:
"The American Association of Neurological Surgeons." AANS. N.p., n.d. Web. 18 July 2014.