Endoscopic endonasal minimal access approach to the clivus: case series and technical nuances.
BACKGROUND
The endoscopic endonasal transclival approach is a novel minimal-access method of managing clival pathology. Limited cases have been published.


OBJECTIVE
To summarize our clinical experience with this approach and discuss technical nuances.


METHODS
We retrospectively reviewed a prospective database of 250 endoscopic, endonasal skull base surgeries. Patients in whom a transclival approach was performed were identified. Extent of resection, complications, and clinical outcome were analyzed.


RESULTS
Seventeen patients underwent 21 procedures. Pathology included chordoma, meningioma, hemangiopericytoma, enterogenous cyst, epidermoid, and metastasis. Lumbar drain was placed intraoperatively in 9 cases and maintained for approximately 2 days postoperatively. Mean operative time was 252.8 minutes. Intraoperative cerebrospinal fluid (CSF) leak occurred in 10 cases. Greater than 95% resection was achieved in 11 of 12 cases (92%) in which it was the surgical goal. The risk of postoperative CSF leak was 4.8% for all procedures, 9.1% for procedures with large skull base defect, and 0% if a gasket-seal closure was achieved. A nasoseptal flap was used in 2 patients. There was one perioperative infarct, one case of deep vein thrombosis, and one postoperative pulmonary embolus. Mean follow-up was 8.5 months. All but one patient with preoperative cranial nerve deficits improved at last follow-up. All patients were free of disease progression at last follow-up.


CONCLUSIONS
The endonasal endoscopic transclival approach provides a minimal-access approach to the ventral midline posterior fossa skull base. The risk of CSF leak is low if appropriate closure techniques are applied.
Fraser
Justin F
JF
Department of Neurosurgery, New York Presbyterian Hospital, Weill Medical College of Cornell University, New York, New York 10065, USA.
Nyquist
Gurston G
GG
Moore
Nicholas
N
Anand
Vijay K
VK
Schwartz
Theodore H
TH
D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D003388:Cranial Fossa, Posterior / Q000473:pathology / Q000601:surgery*; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D008577:Meningeal Neoplasms / Q000601:surgery*; D008579:Meningioma / Q000601:surgery*; D008875:Middle Aged; D044583:Neuroendoscopy / Q000009:adverse effects / Q000379:methods*; D011183:Postoperative Complications; D012189:Retrospective Studies; D019292:Skull Base Neoplasms / Q000473:pathology / Q000601:surgery*; D016896:Treatment Outcome