Endoscopic and Microscopic Extended Subfrontal Approach to the Clivus: A Comparative Anatomical Study

ABSTRACT

Ten cadaveric heads fixed and injected were dissected in the operative position. An enlarged subfrontal approach was adopted. The clival bone was drilled as much as possible under direct microscopic vision. Dissection in blind angles was avoided until the clival dura was exposed. The rigid 4-mm endoscope (angled 0 degrees and 30 degrees) was secured in a holder so the surgical cavity could be inspected. The residual bone was drilled under endoscopic visualization. The amount of bone removed was measured and compared with that removed under microscopic view. Blind angles in both microscopic and endoscopic views were recorded. The additional area of clival bone removed under endoscopic visualization compared with microscopic visualization was 467 mm² (range, 176 to 753 mm²; standard deviation, 208.8 mm²).The amount of additional bone removed under endoscopy was inversely and significantly related to the minimal distance between the vertical segment of the two cavernous carotid arteries (p = 0.04). The endoscope is of great value in the removal of clival bone through the extended subfrontal approach. Its use improves the visualization of angles that are blind under the microscope.

KEYWORDS

Anatomy - clivus - endoscopy - microsurgery - skull base

REFERENCES

• 1 Sekhar L N, Nanda A, Sen C N, Snyderman C N, Janecka I P. The extended frontal approach to tumors of the anterior, middle and posterior skull base.  J Neurosurg . 1992;  76 198-206
• 2 Derome P, Akerman M, Anquez L. Les tumeurs spheno-ethmoidales. Possibilites d'exerese et de reparation chirurgicales.  Neurochirurgie (suppl) . 1972;  18 1-164
• 3 Gay E, Sekhar L N, Rubinstein E. Chordomas and chondrosarcomas of the cranial base: results and follow-up of 60 patients.  Neurosurgery . 1995;  36 887-897
• 4 Brown A P, Spetzler R F. [comment].  Neurosurgery . 1995;  36 896
• 5 Sen C N, Sekhar L N, Schramm V L, Janecka I P. Chordoma and chondrosarcoma of the cranial base: an 8-year experience.  Neurosurgery . 1989;  25 931-941
• 6 Sekhar L N, Raso J L, Tzortzidis F. Extended frontal transbasal approach: anatomy. In: Sekhar LN, De Oliveira E, eds. Cranial Microsurgery, Approaches and Techniques New York: Thieme Verlag; 1999: 76-81
• 7 Derome P, Visot A, Monteil J P, Maestro J L. Management of cranial chordomas. In: Sekhar LN, Schramm VL, eds. Tumors of the Cranial Base Diagnosis and Treatment. New York: Futura; 1987: 607-622
• 8 Perneczky A, Fries G. Endoscope-assisted brain surgery: part 1-evolution, basic concept and current technique.  Neurosurgery . 1998;  42 219-224
• 9 Jho H D, Carrau R L, Ko Y, Daly M A. Endoscopic pituitary surgery: an early experience.  Surg Neurol . 1997;  47 213-223
• 10 Jho H D, Carrau R L, McLaughlin M R, Somaza S C. Endoscopic transsphenoidal resection of a large chordoma in the posterior fossa.  Acta Neurochir (Wien) . 1997;  139 343-348