Abstract
Object
Lesions located in the retroclival area and at the level of the cranio-vertebral junction are typically approached through a variety of anterior, antero-lateral and postero-lateral skull-based approach, either alone or in combination. The aim of this anatomical study was to demonstrate the possibility of an endoscopic endonasal approach to the clivus and cranio-vertebral junction.
Materials and methods
Five fresh cadaver heads injected with colored latex were used. A modified endonasal endoscopic approach was made through two nostrils in all cases. Endoscopic dissections were performed using rigid endoscopes, 4 mm in diameter, 18 cm in length, with 0° lenses.
Results
Access to the clivus was possible using a lower trajectory when compared to that necessary for the sellar region. The sphenoid sinus is entered, and its inferior wall is completely removed, permitting the union of the sphenoidal and rhinopharyngeal parts of the clivus. The entire clivus can be removed, and the cranio-vertebral junction is opened, removing the anterior arch of atlas and the odontoid process. After the opening of the dura, the anterior surface of the pons and upper spinal cord with corresponding nerves and vasculature are visible.
Conclusion
The endoscopic endonasal approach to the clivus and cranio-vertebral junction could be a valid alternative for surgical treatment of anterior lesions of these regions. Adequate endoscopic skill, lab training on cadavers and dedicated tools are required for clinical applications of the approach.
Similar content being viewed by others
References
Alfieri A, Jho HD, Tschabitscher M (2002) Endoscopic endonasal approach to the ventral cranio-cervical junction: anatomical study. Acta Neurochir (Wien) 144:219–225
Bertalanffy H, Seeger W (1991) The dorsolateral, suboccipital, transcondylar approach to the lower clivus and anterior portion of the craniocervical junction. Neurosurgery 29:815–821
Cappabianca P, Alfieri A, de Divitiis E (1998) Endoscopic endonasal transsphenoidal approach to the sella: towards functional endoscopic pituitary surgery (FEPS). Minim Invasive Neurosurg 41:66–73
Cappabianca P, Frank G, Pasquini E, de Divitiis O, Calbucci F (2003) Extended endoscopic endonasal transsphenoidal approaches to the suprasellar region, planum sphenoidale and clivus. In: Cappabianca P, de Divitiis E (eds) Endoscopic endonasal transsphenoidal surgery. Springer, Berlin Heidelberg New York, pp 176–187
Cavallo LM, Cappabianca P, Galzio R, Iaconetta G, de Divitiis E, Tschabitscher M (2005) Endoscopic transnasal approach to the cavernous sinus. Anatomical study. Neurosurgery 90:111–133
Cavallo LM, Messina A, Cappabianca P, Esposito F, de Divitiis E, Gardner P, Tschabitscher M (2005) Endoscopic endonasal surgery of the midline skull base: anatomic study and clinical considerations. Neurosurg Focus 19:E2
Crockard A (1993) Transoral approach to intra/extradural tumors. In: Sekhar L, Janecka I (eds) Surgery of cranial base tumors. Raven, New York, pp 225–234
Crockard HA, Bradford R (1985) Transoral transclival removal of a schwannoma anterior to the craniocervical junction. Case report. J Neurosurg 62:293–295
Crockard HA, Pozo JL, Ransford AO, Stevens JM, Kendall BE, Essigman WK (1986) Transoral decompression and posterior fusion for rheumatoid atlanto-axial subluxation. J Bone Jt Surg Br 68:350–356
Crockard HA, Sen CN (1991) The transoral approach for the management of intradural lesions at the craniovertebral junction: review of 7 cases. Neurosurgery 28:88–98
Crumley RL, Gutin PH (1989) Surgical access for clivus chordoma. The University of California, San Francisco, experience. Arch Otolaryngol Head Neck Surg 115:295–300
de Divitiis E, Cappabianca P, Cavallo LM (2002) Endoscopic transsphenoidal approach: adaptability of the procedure to different sellar lesions. Neurosurgery 51:699–707
de Divitiis O, Conti A, Angileri FF, Conti A, La Torre D, de Divitiis O, d’Avella D, Tschabitscher M, Tomasello F (2004) Endoscopic transoral–transclival approach to the brainstem and surrounding cisternal space: anatomic study. Neurosurgery 54:125–130
Dickman CA, Spetzler RF, Sonnatag VKH (1998) Surgery of the craniovertebral junction. Thieme, New York
Donald PJ (1998) Transoral approach to the clivus and upper cervical spine. In: Donald PJ (ed) Surgery of the skull base. Lippincott, Philadelphia, pp 507–532
Esposito F, Becker DP, Villablanca JP, Kelly DF (2005) Endonasal transsphenoidal transclival removal of prepontine epidermoid tumors: technical note. Neurosurgery 56:E443
Frank G, Pasquini E, Mazzatenta D (2001) Extended transsphenoidal approach. J Neurosurg 95:917–918
George B, Lot G, Boissonnet H (1997) Meningioma of the foramen magnum: a series of 40 cases. Surg Neurol 47:371–379
Goel A, Desai K, Muzumdar D (2001) Surgery on anterior foramen magnum meningiomas using a conventional posterior suboccipital approach: a report on an experience with 17 cases. Neurosurgery 49:102–107
Hadley MN, Spetzler RF, Sonntag VK (1989) The transoral approach to the superior cervical spine. A review of 53 cases of extradural cervicomedullary compression. J Neurosurg 71:16–23
Hayakawa T, Kamikawa K, Ohnishi T, Yoshimine T (1981) Prevention of postoperative complications after a transoral transclival approach to basilar aneurysms. Technical note. J Neurosurg 54:699–703
James D, Crockard HA (1991) Surgical access to the base of skull and upper cervical spine by extended maxillotomy. Neurosurgery 29:411–416
Jho HD, Carrau RL (1997) Endoscopic endonasal transsphenoidal surgery: experience with 50 patients. J Neurosurg 87:44–51
Jho HD, Carrau RL, McLaughlin MR, Somaza SC (1997) Endoscopic transsphenoidal resection of a large chordoma in the posterior fossa. Acta Neurochir (Wien) 139:343–348
Jho HD, Ha HG (2004) Endoscopic endonasal skull base surgery: part 3—the clivus and posterior fossa. Minim Invasive Neurosurg 47:16–23
Kassam A, Gardner P, Snydermann C, Mintz A, Carrau R (2005) Extended endonasal approach: fully endoscopic, completely transnasal approach to the middle third of the clivus, petrous bone, middle cranial fossa, and infratemporal fossa. Neurosurg Focus 19:E6
Kassam A, Snydermann C, Gardner P, Carrau R, Spiro R (2005) The expanded endonasal approach: a fully endoscopic transnasal approach and resection of the odontoid process: technical case report. Neurosurgery 57:E213
Kawashima M, Tanriover N, Rhoton AL Jr, Ulm AJ, Matsushima T (2003) Comparison of the far lateral and extreme lateral variants of the atlanto-occipital transarticular approach to anterior extradural lesions of the craniovertebral junction. Neurosurgery 53:662–675
Laws ER (1993) Clivus chordomas. In: Sekhar LN, Janecka IP (eds) Surgery of cranial base tumors. Raven, New York, pp 679–685
Laws ER Jr (1984) Transsphenoidal surgery for tumors of the clivus. Otolaryngol Head Neck Surg 92:100–101
Maira G, Pallini R, Anile C, Fernandez E, Salvinelli F, La Rocca LM, Rossi GF (1996) Surgical treatment of clival chordomas: the transsphenoidal approach revisited. J Neurosurg 85:784–792
Margalit NS, Lesser JB, Singer M, Sen C (2005) Lateral approach to anterolateral tumors at the foramen magnum: factors determining surgical procedure. Neurosurgery 56:324–336
Menezes AH, VanGilder JC (1988) Transoral–transpharyngeal approach to the anterior craniocervical junction. Ten-year experience with 72 patients. J Neurosurg 69:895–903
Miller E, Crockard HA (1987) Transoral transclival removal of anteriorly placed meningiomas at the foramen magnum. Neurosurgery 20:966–968
Mullan S, Naunton R, Hekmat-Panah J et al (1966) The use of an anterior approach to ventrally placed tumors in the foramen magnum and vertebral column. J Neurosurg 24:536–543
Nanda A, Vincent DA, Vannemreddy PS, Baskaya MK, Chanda A (2002) Far-lateral approach to intradural lesions of the foramen magnum without resection of the occipital condyle. J Neurosurg 96:302–309
Pasztor E, Vajda J, Piffko P, Horvath M, Gador I (1984) Transoral surgery for craniocervical space-occupying processes. J Neurosurg 60:276–281
Reisch R, Bettag M, Perneczky A (2001) Transoral transclival removal of anteriorly placed cavernous malformations of the brainstem. Surg Neurol 56:106–116
Samii M, Klekamp J, Carvalho G (1996) Surgical results for meningiomas of the craniocervical junction. Neurosurgery 39:1086–1094
Yamaura A, Makino H, Isobe K, Takashima T, Nakamura T, Takemiya S (1979) Repair of cerebrospinal fluid fistula following transoral transclival approach to a basilar aneurysm. Technical note. J Neurosurg 50:834–838
Author information
Authors and Affiliations
Corresponding author
Rights and permissions
About this article
Cite this article
Cavallo, L.M., Cappabianca, P., Messina, A. et al. The extended endoscopic endonasal approach to the clivus and cranio-vertebral junction: anatomical study. Childs Nerv Syst 23, 665–671 (2007). https://doi.org/10.1007/s00381-007-0332-7
Received:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s00381-007-0332-7