J Neurol Surg B Skull Base 2013; 74 - A168
DOI: 10.1055/s-0033-1336292

Reconstructive Challenges in the Extended Endoscopic Transclival Approach

Ameet R. Kamat 1(presenter), Gregg Goldstein 1, James N. Palmer 1, John Y.K. Lee 1, Jason G. Newman 1, Nithin D. Adappa 1
  • 1Philadelphia, PA, USA

Objective: The extended endoscopic approach (EEA) to clival tumors has become an accepted alternative to traditional open approaches with comparative levels of tumor resection. Cerebrospinal fluid (CSF) leaks are the most common postoperative complication encountered after EEA. Although the reported rate of CSF leaks for EEA have continued to decrease in the reported literature, the transclival approach still continues to present significant reconstructive challenges. Our objective is to present our experience with EEA to clival pathology with specific focus on skull base reconstruction and CSF leak. We sought to examine the factors that make reconstruction in this region more challenging than elsewhere and hope to shed light on technical nuances that can help to prevent this complication.

Study Design: Retrospective cohort study.

Methods: We examined a consecutive series of 37 patients undergoing EEA for skull base tumors including 9 patients with clival pathology. All patients were examined for incidence of postoperative CSF leak in relation to the tumor pathology, tumor location, intradural versus extradural, tumor size (mm), reconstruction technique, and use of a lumbar drain.

Results: The overall incidence of postoperative CSF leak in this cohort was 10.8% (four patients). Three (75%) of the patients who had a postoperative CSF leak underwent a transclival approach (P < 0.05). All three (33%) clival tumor patients who had a CSF leak underwent an intradural dissection (P < 0.05). Use of a lumbar drain and tumor size did not significantly correlate with CSF leak rate.

Conclusion: The EEA technique has improved significantly since its initial description. Advancements such as the vascularized nasoseptal flap have improved postoperative CSF leak rates. Despite this, intradural transclival approaches continue to pose a challenge. Further investigation is necessary to aid in technique improvements to facilitate the unique challenges associated with transclival approaches.