LETTER TO THE EDITOR - NEUROSURGICAL TECHNIQUES Author response: The essense of primum no nocere–striking a balance between benefit and harm Sergey Spektor 1 & Emil Margolin 1 & Ron Eliashar 2 & Samuel Moscovici 1 Received: 9 May 2016 /Accepted: 17 May 2016 /Published online: 8 June 2016 # Springer-Verlag Wien 2016 Dear Editor, We were surprised to read the editorial (by invitation) writ- ten by Al-Shaar et al. [1] addressing our technical note on the resection of a recurrent atypical parasagittal meningioma using an endoscopic approach [2]. The editorial raises two central issues: 1. Were the indications for the endoscopic approach appropriate? 2. Was there adherence to ethical requirements with respect to the introduction of new techniques and new indica- tions, and involving patients in decisions regarding the choice of technique? In fact, every issue raised in the editorial was carefully addressed in our paper, yet the authors ignored our discussion of these topics. We clearly presented all of the problems and risks concerning management of a recurrent atypical parasagittal meningioma in a patient with a history of radiation that had led to a very poor scalp condition. In addition, we described our extensive consul- tation with a team of experienced plastic surgeons and radio- oncologists regarding treatment options. We also discussed the patient’ s involvement in the decision-making process. He pro- vided informed consent for the procedure with a complete un- derstanding of the risks related to all treatment options as well as the novelty of the approach we suggested. Thus, the statement that, B… even worse, smaller snack-size innovations … may not even be presented to the patient as an ‘innovation’…^ was inappropriate. Today, endoscopic surgery is a well-established part of the neurosurgical armamentarium. Based on our experience, we felt that the tumor could be safely accessed using endoscopic techniques. With respect to the concept of Bpushing the envelope^ regarding the indications for the endoscopic ap- proach, it is interesting to recall the strenuous efforts 20 years ago to obstruct early attempts to introduce these techniques into neurosurgical practice, given that they now represent the standard of care in an increasing range of clinical situations. In truth, we do not consider our procedure as a risky and radical technique. Venous hemorrhage from the superior sagittal sinus may be controlled much more easily than bleeding from dam- age to the internal carotid artery, which may occur during complex but increasingly routine endoscopic procedures. In fact, the endoscopic approach was considered and even- tually recommended as the optimal technique in this situation precisely because of the principle of primum non nocere. After a careful weighing of the options by a highly experienced mul- tidisciplinary team, we assumed that with standard calvarial craniotomy, with or without scalp transplant, our patient would face a high risk of infarcted scalp fall-off with life-threatening wound-healing complications due to his severe scalp atrophy. In our opinion, this risk far exceeded the risks associated with an endoscopic approach in his particular situation. We emphasize that open craniotomy remains the standard of care for the management of parasagittal meningiomas. * Sergey Spektor sergeyspektor@gmail.com 1 Department of Neurosurgery, Hadassah-Hebrew University Medical Center, Jerusalem, Israel 2 Department of Otolaryngology, Head and Neck Surgery, Hadassah-Hebrew University Medical Center, Jerusalem, Israel Acta Neurochir (2016) 158:1603–1604 DOI 10.1007/s00701-016-2848-7