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Hybrid antero-lateral transcondylar approach to the clivus: a laboratory investigation and case illustration

  • Original Article - Neurosurgery general
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Abstract

Background

Surgical treatment of lesions involving the ventral craniovertebral junction (CVJ) and the lower clivus, traditionally involved complex lateral or transoral approaches to the skull base. However, mid or upper clivus involvement requires more extensive lateral approaches. Recently, the endoscopic endonasal approach (EEA) has become the standard for upper CVJ lesions and medial clival, and a valuable alternative for those tumors extending in its upper third as well as laterally. However, the EEA is associated with an increased risk of post-operative CSF leakage and infection when the tumor is characterized by an intradural extension. Furthermore, whenever the tumor has significant lateral and/or inferior extension below the odontoid process, the chances for a complete resection decrease.

Method

To analyze the extent of exposure of a hybrid microscopic-endoscopic transcondylar antero-lateral approach to the CVJ and clival region, and to verify its effectiveness in terms of mid and upper clival access. Five silicone-injected cadaver heads were used. Following a standard antero-lateral approach, condylectomy and jugular tubercle drilling were performed, after which angled endoscopes were utilized to extend the bone resection to the clivus. A volumetric assessment of the amount of clival removal was carried out. A case of CVJ chordoma operated through this approach is presented.

Results

The hybrid antero-lateral transcondylar approach provides adequate exposure of the ventral CVJ, up to the dorsum sellae and the sphenoid sinus, the contralateral petrous apex, and the contralateral paraclival internal carotid artery (ICA). Approximately 60% of the total clival volume can be removed with this approach. The main limitation is the limited visualization of the ipsilateral paraclival ICA and petrous apex.

Conclusion

The hybrid antero-lateral transcondylar approach is a valuable surgical option for CVJ tumor extending from C2 to the mid and upper clivus.

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Acknowledgments

We thank Karl Storz SE & Co. (Tuttlingen, Germany) for kindly making their equipment available in order to allow us to complete our investigation. We thank Professor Beth De Felici for the English revision.

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Authors and Affiliations

  1. Department of Neurosurgery, Hôpital Lariboisière, Assistance Publique-Hôpitaux de Paris, Université de Paris, 2 rue Ambroise Pare, 75010, Paris, France

    Davide Tiziano Di Carlo, Eduard HJ Voormolen, Thibault Passeri, Pierre-Olivier Champagne, Nicolas Penet, Anne Laure Bernat & Sébastien Froelich

  2. Laboratory of experimental neurosurgery, Department of Neurosurgery, Hôpital Lariboisière, Assistance Publique-Hôpitaux de Paris, Université de Paris, 2 rue Ambroise Pare, 75010, Paris, France

    Davide Tiziano Di Carlo, Eduard HJ Voormolen, Pierre-Olivier Champagne, Nicolas Penet, Anne Laure Bernat & Sébastien Froelich

Authors
  1. Davide Tiziano Di Carlo
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  2. Eduard HJ Voormolen
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  3. Thibault Passeri
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  4. Pierre-Olivier Champagne
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  6. Anne Laure Bernat
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  7. Sébastien Froelich
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Corresponding author

Correspondence to Sébastien Froelich.

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The authors declare that they have no conflict of interest.

Ethical approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee (Hôpital Lariboisière, Assistance Publique – Hôpitaux de Paris, Université Paris – Diderot) and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

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Comments

This interesting paper deals with a modified anterolateral approach (novel hybrid antero-lateral transcondylar approach - HALT) to lesions involving cranio-vertebral junction (CVJ), upper and lateral aspect of the clivus. Traditionally, the surgical treatment of lesions involving the ventral CVJ comprises complex lateral or transoral approaches to the skull base. A standard antero-lateral approach, condylectomy and jugular tubercle drilling were performed, after which angled endoscopes were utilized to extend the bone resection to the clivus. The need of cadaver labs sometimes face with budget difficulty to fulfill the gold standard required by rich countries; nevertheless we all learned that it is possible to demonstrate its feasibility also in presence of limited resources (1). In my opinion the choice of an Extreme lateral approach should be better compared with the potententials of a standard submandibular retropharingeal aka Mc Afee approach, the latter providing a wide surgical domain as well. In the Authors ‘ statements, the identification of the lower clivus as the superior limit of transoral is purely orientative, since in special conditions, i.e. in childhood, it is possible to reach up to the superior third of the clivus by using a standard transoral approach (2). Finally to be underlined that the use of endoscope for CVJ surgery was first conceived for transmucosal surgeries (transnasal and transoral) as totally endoscopic approach and later on to extramucosal CVJ surgeries (i.e. anterolateral) as endocopic assisted procedures; such a definition, later on and more properly, became hybrid microscopic endoscopic surgery particulary intriguing for the significance of progression form its previous ancillary to the present leading actor surgical role (3).

Massimiliano VISOCCHI

Rome, Italy

REFERENCES

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Di Carlo, D.T., Voormolen, E.H., Passeri, T. et al. Hybrid antero-lateral transcondylar approach to the clivus: a laboratory investigation and case illustration. Acta Neurochir 162, 1259–1268 (2020). https://doi.org/10.1007/s00701-020-04343-4

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