Pituitary neurologic surgery: A unique subspecialty in evolution

Objective: To review the evolving approaches to surgical management of pituitary tumors during the past century which may predict future directions. Methods: We undertook a retrospective review of selected literature published during the past century and report the trends in the treatment of pituitary tumors. Results: Harvey Cushing's extraordinary influence on American neurosurgery and remarkably successful pituitary surgical series were the foundation for the development of a highly subspecialized neurosurgical operative field. Continued evolution in the treatment of pituitary tumors has been historically based on the following: (1) the development of exogenous cortisone and vasopressin; (2) the development of high-voltage and nuclear radiation therapy; (3) the experience gained from total hypophysectomy for "endocrine" driven malignant lesions and diabetic retinopathy; (4) the development of the image intensifier and television intraoperative fluoroscopic control; (5) the use of endoscopes in pituitary surgical procedures; (6) the application of the operating microscope to transsphenoidal approaches; (7) the development of the imaging modalities of computed tomographic scanning and subsequent magnetic resonance imaging; and (8) the concepts surrounding "minimally invasive" surgical techniques. Conclusion: The pituitary surgical techniques of today have evolved primarily because of extraordinary past accomplishments. The approaches used continue to maximize tumor resection and preserve functioning pituitary tissue. New intraoperative imaging techniques will forge the future of the field of pituitary neurosurgery, and the expected outcomes will be improved surgical success and lower perioperative morbidity.