Less Is More in Select Pediatric Patients: Conservative Management of Skull Base Repair in the Case of a Complex Clival Chordoma

We present the case of a 13-year-old girl with an aggressive, recurrent clival chordoma complicated by a recalcitrant cerebrospinal fluid (CSF) leak. Her chordoma presentation was advanced with erosion of the clivus and C1 and C2, resulting in occipitocervical instability. After spinal decompression and fusion, a definitive endoscopic endonasal resection took place with gross total resection. The skull base was effectively repaired with a dural underlay allograft, a fat graft, and vascularized nasoseptal flap coverage. She received postoperative radiation to the clivus and skull base and adjuvant chemotherapy. Two years following her initial surgery, she had radiographic demonstration of recurrence and underwent revision endoscopic endonasal removal of recurrence around the vertebral artery and brain stem with gross total resection. The skull base was repaired with dural underlay allograft, Gelfoam, and a nasopharyngeal mucosal rotational flap, but her postoperative course was complicated with a persistent CSF leak. The skull base defect was focal and characterized by poor mucosalization due to the history of irradiation. Consideration for a tunneled pedicled temporalis flap was considered as no robust local flaps were available. Alternatively, serial debridements and focal repairs of progressively decreasing mucosal defects were performed with the aid of CSF shunting. Most notably, rotational mucosal flaps from the nasal floor and, separately, a “button” underlay–onlay fascia lata graft were employed. Over time, the repair completely mucosalized without the need for a tunneled temporalis graft. In conclusion, complex CSF skull base leaks may be better cared for in a serial fashion with local measures when vascularized repair carries high morbidity.