Clayton Rawson

Background/Objectives: The endoscopic transorbital approach (ETOA) has emerged over little more than a decade as a minimally invasive corridor to the anterior and middle cranial fossae, reaching territory lateral to the optic nerve and internal carotid artery that is difficult to access endonasally. Its flagship indication is the spheno-orbital meningioma, where the corridor aligns with the pathology and functions best as a planned, often decompressive strategy rather than a route to radical resection. This narrative review synthesizes the current evidence and defines the approach’s role, limitations, and priorities. Methods: PubMed/MEDLINE, Scopus, and Web of Science were searched for English-language anatomical studies, clinical series, systematic reviews, and meta-analyses on the transorbital approach published between January 2016 and August 2026. Results: The evidence remains dominated by small, retrospective, single-center series and a handful of recent meta-analyses. Reported short-term outcomes—favorable proptosis relief, acceptable visual and cranial-nerve results, low pooled complication rates, and short recovery—are encouraging but constrained by short follow-up, heterogeneous nomenclature, and outcome reporting that grades residual tumor globally rather than by anatomical compartment. Gross total resection rates are lower than after transcranial surgery, and oncological equivalence has not been established. Technical, reconstructive, ophthalmic, and anatomical factors define the corridor’s ceiling, and ETOA is best positioned against endonasal and transcranial alternatives as a complementary rather than competing tool. Conclusions: ETOA is an established corridor whose maturation depends on reconstructive refinement, a flatter learning curve, standardized terminology and outcome sets, and prospective comparative data—consolidation rather than anatomical expansion.

Introduction: Chordomas are rare, locally aggressive tumors of the spine and skull base typically managed with maximal surgical resection followed by adjuvant radiotherapy. Although postoperative radiotherapy improves local control, the optimal interval for initiation remains uncertain, as early delivery may exacerbate wound-related complications while delayed initiation may allow tumor progression. Methods: We performed a retrospective cohort analysis using the multi-center, national TriNetX Research Network. Adults with histologically confirmed skull base and/or spinal chordoma who underwent surgical resection followed by radiotherapy were stratified into ultraearly (≤2 weeks), standard (4–6 weeks), or delayed (≥10 weeks) radiotherapy initiation groups. Propensity score matching was used to adjust for demographic and clinical covariates. The primary outcome was all-cause mortality at 1, 3, and 5-years. Secondary outcomes included wound dehiscence, surgical site infection, and neurologic complications. Results: A total of 378 patients met the inclusion criteria. Ultraearly radiotherapy was not associated with significant differences in mortality at 1 year (RR 1.338; 95% CI 0.833–2.15; p = 0.22), 3 years (RR 1.233; 95% CI 0.858–1.772; p = 0.25), or 5 years (RR 1.196; 95% CI 0.876–1.633; p = 0.25) compared with standard timing. Delayed radiotherapy, however, demonstrated significantly reduced mortality at 1 year (RR: 0.53; 95% CI: 0.331–0.851; p = 0.01), 3 years (RR 0.641; 95% CI 0.449–0.914; p = 0.01), and 5 years (RR 0.654; 95% CI 0.473–0.905; p = 0.01) compared with standard timing. Event counts for secondary outcomes were insufficient for robust statistical comparison. Conclusions: Radiotherapy timing following surgical resection of chordoma did not impact short-term survival, but delayed radiotherapy significantly decreased 1, 3 and 5-year mortality. Rare secondary complications were seen. These findings suggest that the delayed initiation of radiotherapy may be helpful for patients with chordoma, supporting the need for prospective, long-term studies to clarify the balance between oncologic efficacy and perioperative morbidity.

Background: Traumatic brain injury (TBI) is a leading cause of mortality and disability, particularly in patients on anticoagulation therapy. While anticoagulants are linked to higher TBI mortality, the specific impact of direct oral anticoagulants (DOACs) and vitamin K antagonists (VKAs) on severe TBI (sTBI) outcomes remains unclear, especially in light of newer reversal agents. Therefore, this study evaluates long-term mortality and complication risks associated with pre-injury use of DOACs and VKAs in sTBI patients from a large, real-world cohort. Methods: A retrospective cohort study was conducted using the TriNetX global research network, identifying patients with sTBI between 2016 and 2022. Patients were grouped based on pre-injury anticoagulant use: DOAC, VKA, or none. Propensity score matching was performed, adjusting for age, comorbidities, and baseline characteristics. The primary outcome was all-cause mortality at 1-, 3-, 6-, and 12-months post-injury. Secondary outcomes included hospital and surgical complications up to 30 days post-injury. Results: A total of 40,563 patients met the inclusion criteria. At all time intervals, no significant mortality differences were found between the PSM-matched groups. Conclusions: In patients with sTBI, pre-injury DOAC or VKA use was not associated with increased short- or long-term mortality. These findings suggest that, with current perioperative practices, anticoagulation can be managed without adversely affecting outcomes.