The endoscope-assisted ventral approach compared with open microscope-assisted surgery for clival chordomas

The current management paradigm for clival chordomas includes cytoreductive surgery with adjuvant radiotherapy. Surgical approaches have traditionally utilized the microscope to remove these lesions through approaches that require extensive bone drilling, brain retraction, and mobilization of normal anatomy to create a suitably large corridor. The endoscopic ventral approaches provide a direct route to the tumor using natural orifices. Little data exist comparing these 2 surgical strategies. We conducted a systematic review of case series and case reports in hope of furthering our understanding of the role of endoscopy in the management of these difficult cranial base lesions.

We performed a MEDLINE (1950 to 2010) search to identify relevant studies. Statistical analyses of categorical variables such as extent of resection, morbidity, and visual outcome were carried out using chi-square and Fisher exact tests.

Thirty-seven studies, involving 766 patients, were included. Compared with the open surgery cohort, the endoscopic cohort had a significantly higher percentage of gross total resection (61.0% vs. 48.1%; P = 0.010), fewer cranial nerve deficits (1.3% vs. 24.2%, P < 0.001), fewer incidences of meningitis (0.9% vs. 5.9%, P = 0.029), less mortality (4.7% vs. 21.6%, P < 0.001), and fewer local recurrences (16.9% vs. 40.0%, P = 0.0001). There was no significant difference in the incidence of postoperative cerebrospinal fluid leak (P = 0.084). Follow-up was longer in the open compared with the endoscopic cohort (59.7 vs. 18.5 months, P < 0.001).

Our systematic analysis supports the endoscopic ventral approaches as a safe and effective alternative for the treatment of certain clival chordomas. Although the overall literature supports this technique in carefully selected patients, longer follow-up is needed to more definitively address therapeutic efficacy. Careful patient selection and meticulous multilayer closure are critical to obtaining maximal resection and acceptably low cerebrospinal fluid leak rates.