Alexandre Bossi Todeschini

Objectives: The objective of this study was to review the current scientific evidence on the role of Enhanced Recovery After Surgery (ERAS) implementations in reducing postoperative opioid consumption and their potential association with the risk reduction for long-term opioid use, physical opioid dependency, and opioid addiction. Methods: A literature search was conducted using the following medical subject heading keywords: “postoperative pain,” “postoperative pain management,” “multimodal analgesia,” “ERAS,” “Enhanced Recovery,” “opioid-free analgesia,” or “opioid crisis.” Discussion: Identification and management of pre-existing psychosocial factors, comorbid pain entities, and chronic opioid use have a significant impact on the severity of postoperative pain. Different multimodal analgesia approaches have been associated with reduced postoperative pain scores and opioid consumption. Health care providers, patients, and family members should recognize the advantages of opioid-free analgesia techniques in postoperative pain management. As part of ERAS protocols, transitional pain services may consider current therapeutic alternatives for acute and long-term pain management that include minimizing perioperative opioid use and establishing adequate opioid prescription practices.

Background The description and refinement of the transsphenoidal approach would not be possible without new tools and technologies developed by surgeons to facilitate this approach, which is nowadays the standard procedure for more than 90% of sellar lesions. The latest major change in transsphenoidal surgery was the introduction of the rigid endoscope and the subsequent description of the endoscopic endonasal approach. Traditional bayoneted instruments, when used for this technique, were inadequate. New instruments designed, specifically for this technique, are necessary to facilitate the surgeon's work and improve patient outcome. Objective This study describes a novel design of dissectors created specifically for endoscopic endonasal approaches. Methods To develop and design the Angelina dissectors, we used our extensive surgical experience to identify the shortcomings of the available dissectors used for transsphenoidal surgery and created the Angelina dissectors. Results The Angelina dissector was designed with a unique shaft shape which facilitates endoscopic endonasal surgery. Conclusion Even though an endoscopic endonasal approach is possible using other instruments, the design of these dissectors aids the surgeon's work. It is our impression, based on personal experience that it allows more freedom of movement and dexterity during the procedure, which could translate as an improved patient outcome.

Tumors involving the central nervous system (CNS) include a wide variety of primary and metastatic entities. This chapter provides a neurosurgical perspective regarding some of the most common brain and spine tumors. Each subsection presents a specific tumor in the setting of a case presentation. The goal for each subsection is to review diagnostic and management pearls for the specific type of tumor presented and provide the reader with a starting point for more in depth reading.

Introduction: Pituitary carcinomas are poorly understood, rare entities. They are distinguished from adenomas not by histopathological features but rather by the presence of metastases. Objective: We discuss the diagnosis, mechanism of dissemination and pathogenesis based on a review of the literature and illustrated by a singular case. Case Report: A 59-year-old male presented with a dural-based posterior fossa lesion. He had been diagnosed with a pituitary chromophobe adenoma 43 years earlier that was treated at the time with surgery and radiation therapy. A presumptive diagnosis of a radiation-induced meningioma was made and surgery was recommended. At surgery the tumour resembled a pituitary adenoma. Histopathology, laboratory findings, and the patient’s medical history confirmed the final diagnosis of a prolactin-secreting pituitary carcinoma. To our knowledge, this is the longest reported interval between the pituitary adenoma and metastatic lesion diagnosis (43 years). Conclusion: Management should be tailored to individual patient and may include a combination of treatments (surgery, radiation therapy, chemotherapy, and hormone-targeted therapy). Functionally active tumours may be monitored with hormone levels as tumour markers.

BACKGROUND: Meningiomas are the most common primary intracranial tumor, arising from different locations, including the skull base. Despite advances in adjuvant treatments, surgical resection remains the main and best treatment for meningiomas. New surgical strategies, such as the endoscopic endonasal approach, have greatly contributed in achieving maximum and total safe resection, preserving the patient's neurological function. METHODS: Based on the senior authors large experience and a review of the current literature, we have compiled this paper. RESULTS: We review the surgical technique used at our institution and the most relevant aspects of patient selection when considering resecting a skull base meningioma using the the EEA. Further consideration is given to some skull base meningiomas arising from specific locations with some case examples. CONCLUSIONS: The EEA is not an ideal approach for every skull base meningioma. Careful evaluation of the neurovascular structures surrounding the tumor is imperative to select the appropriate surgical corridor for a safe resection. Nevertheless, for appropriately selected cases, the endoscopic technique is a very valuable tool with some evidences of being superior to the microscopic transcranial approach. A dual-trained surgeon, in both endoscopic and transcranial approaches, is the best alternative to achieve the best patient outcome.

Posterior cranial fossa meningiomas represent approximately 9% of all the intracranial meningiomas. Despite the recent reports of radiation therapy in the management of these tumors, surgical resection continues to be the first line of treatment method aiming the permanent meningioma eradication. The evolution of imaging studies improved the preoperative evaluation of meningiomas providing greater anatomical detail of small structures not previously visualized. Nonetheless, the preoperative radiological evaluation should go beyond the differential diagnosis of a posterior fossa tumor. Anatomo-radiological assessment of meningiomas is discussed in detail. Based on our clinical experience, literature review, and case illustration, we highlight important preoperative anatomo-radiological aspects of posterior fossa meningiomas and their implications in the surgical management of these tumors.