The skull base surgery is one of the most demanding surgeries. There are different structures that can be injured easily, by operating in the skull base. It is very important for the neurosurgeon to choose the right approach in order to reach the lesion without harming the other intact structures. Due to the pioneering work of Cushing, Hirsch, Yasargil, Krause, Dandy and other dedicated neurosurgeons, it is possible to address the tumor and other lesions in the anterior, the mid-line and the posterior cranial base. With the transsphenoidal, the frontolateral, the pterional and the lateral suboccipital approach nearly every region of the skull base is exposable.In the current state many different skull base approaches are described for various neurosurgical diseases during the last 20 years. The selection of an approach may differ from country to country, e.g., in the United States orbitozygomaticotomy for special lesions of the anterior skull base or petrosectomy for clivus meningiomas, are found more frequently than in Europe.The reason for writing the review was the question: Are there keyhole approaches with which someone can deal with a vast variety of lesions in the neurosurgical field?In my opinion the different surgical approaches mentioned above cover almost 95% of all skull base tumors and lesions. In the following text these approaches will be described.These approaches are:1) pterional approach2) frontolateral approach3) transsphenoidal approach4) suboccipital lateral approachThese approaches can be extended and combined with each other. In the following we want to enhance this philosophy.

Background:An important part of neurosurgical training is the improvement of surgical skills. Acquiring microsurgical skills follows a learning curve, influenced by specific exercises, feedback, and training. Aim of training should be rapid learning success. The study shows the way in which video-based training can influence the learning curve.Methods:Over a period of 18 months (2011-2012) 12 residents were evaluated in spinal surgery (12 cases per resident) by a skilled evaluator based on different criteria. The evaluation criteria (exposition of important anatomy, intraoperative bleeding, efficacy of using bipolar cauterization) were weighted and added to a single quality-score. The participating residents were divided into two groups. Only one group (n = 5) received video-based training.Results:Residents showed an individually different but explicit increase in microsurgical skills. The quality-score during the first surgery compared with the end point of the study demonstrated a faster improvement of surgical skills in the group with video-based training than in the group without special training. Considering all residents together, the video-training group displayed a steeper gradient of microsurgical success. Comparison of the single resident's microsurgical skills showed individual disparities. Various biases that influence the learning success are under examination.Conclusion:Video-based training can improve microsurgical skills, leading to an improved learning curve. An earlier entry of the learning curve plateau in the video-training group promotes a higher acquisition of surgical skills. Because of the positive effect, we plan to apply the video-based training model to other neurosurgical subspecialties, especially neurovascular and skull base surgery.

Spinal cord stimulation (SCS) for intractable pain syndromes has become a pillar of modern pain management. Common complications include lead migration, implant infection, cerebral spinal fluid leak, and lead fracture. Spinal epidural abscess due to spinal cord stimulator implantation is a very rare occurrence with only two cases reported in the literature so far. We present an illustrative case and discuss the pathophysiology and best clinical management for this very rate entity.

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