Transsphenoidal Approach to the Clival Region Lesions

Objective: The increasing use of the microsurgical and endoscopic technique in transsphenoidal surgery has introduced the endonasal approach for midline clival lesions as the most direct route to the clivus and anterior brainstem which uses nasal cavities and sinuses. Using endoscopic approach we are able to reach the entire central skull base from the frontal sinus anteriorly to the clivus and region of the foramen magnum and odontoid process inferiorly. Methods: In the period of past 5 years we operated eight clival chordomas, five metastases, two dermoid cysts, one neuroendocrine active tumor, one multiple myeloma, and two granulomas, mostly using endoscope. Surgical approach for these lesions was determined on MR, MSCT, and MSCT-angio findings. Endoscopic approach was chosen in cases where the anatomy of nasal septum and sphenoid sinus permitted so. Results: In most operations the visualization of the tumor margins was possible. Tumor recurrence appeared in four cases which were all malignant and were treated by gamma-knife and proton-beam radiotherapy. Postoperative complications included rhinoliquorrhea in three cases solved by external lumbar drainage or sphenoid sinus tamponade. There were two infections successfully treated by antibiotics. Conclusion: Transsphenoidal approach to clival lesions, in transseptal or endoscopic way, is recommended in well selected cases of midline clival pathology without significant lateral extension. It minimizes the morbidity associated with more invasive and aggressive approaches, shortens the hospital stay, allowing at the same time an equal or even better degree of tumor resection compared with other techniques.