Abstract
Objective This study was aimed to achieve gross-total removal of a chordoma of the craniocervical
junction via an endonasal approach ([Fig. 1]).
Fig. 1 Pre- and postoperative images of the craniocervical junction chordoma. (A) It shows a preoperative sagittal T2-weighted MRI image. (B) It shows a preoperative axial T2-weighted MRI image. Note that a T2-hyperintense
lesion is located in the lower clivus and the odontoid. (C) It shows the postoperative sagittal T1-weighted gadolinium enhanced MRI image. (D) shows a postoperative axial T2-weighted MRI image. These images show the fat graft
used for closure, but no evident tumor remnant. MRI, magnetic resonance imaging
Design The present study is a case report.
Setting The study was conducted at neurosurgical clinic of university hospital.
Participant A 40-year-old male, with normal neurologic exam and no prior medical history, presented
with a 2-year history of cervicalgia. On preoperative imaging, a midline lesion, with
image characteristics of chordoma, was seen in the lower clivus and odontoid. It had
limited lateral extension.
Main Outcome Measures This study measures postoperative neurological deficits and postoperative tumor volume
on magnetic resonance imaging (MRI).
Results A binostril approach to the upper nasopharynx was performed using endoscope at 30-
and 45-degree angles. Subsequently, a heart-shaped mucosal flap was made and the clivus
was drilled to expose the lesion ([Fig. 2]). After initial debulking, the ring of C1 was slightly drilled to reach the tumor
in and around the odontoid. Postoperative MRI showed that a gross-total resection
was achieved. The patient had no neurologic deficits postoperatively. Pathologic examination
revealed a chordoma of the classical type.
Fig. 2 Illustration of the endoscopic endonasal surgical technique. (A) It shows the surgical route (blue arrow), and location of the heart-shaped mucosal
flap that was made in the upper nasopharynx (blue crescent). This figure highlights
that angled endoscopes are needed to visualize the relevant operative field (yellow
translucent triangle). (B) shows the axial view, (C) shows an intraoperative endoscopic view of the incision performed to achieve a heart-shaped
mucosal flap, as was utilized during this case, and (D) shows the coronal view. (B and D) They show the results of postoperative image analysis, during which we segmented
the drill cavity (in blue) and projected it on the preoperative CT scan of the patient.
Note that besides the inferior clivus, the superior part of the ring of C1 was also
drilled slightly to reach the tumor in the odontoid. CT, computed tomography.
Conclusion An endoscopic endonasal approach, utilizing the heart-shaped flap and angled endoscopes
and instruments, can be considered for resection of select cases of craniocervical
junction chordoma with limited lateral expansion.
The link to the video can be found at: https://youtu.be/rwVoZJRBIEo.
Keywords
chordoma - craniocervical junction - endoscopy - endonasal
