The endoscopic endonasal approach for extradural and intradural clivus lesions

To report the use of the endoscopic transnasal transclival approach to treat tumors involving the clivus region.

The clinical records of 38 patients with clivus lesions were retrospectively reviewed to determine the surgical technique used. All patients were surgically treated using any of the options of the endoscopic transnasal transclival approach at the São Paulo Skull Base Center from 2000-2011. A transsphenoidal, transpterygoidal, retropharyngeal, or a combination of approaches was chosen based on the tumor topography.

Chordomas were the most frequent tumor (26 of 38), followed by chondrosarcoma (2 of 38). Biopsy only was performed in 6 patients with metastasis to the clivus, and 1 patient with fibrous dysplasia underwent a planned partial resection. Gross total resection (GTR) was achieved in 15 of 31 (48%) patients with indications for GTR. For centrally located tumors, GTR was achieved in 75% (15 of 20 patients). Fistula was the most frequent complication (6 of 31; 19%) but was much lower in the most recent series using the nasoseptal flap (1 of 16; 6%). Tumors with lateral extensions or with previous treatment had the worst results. The presence of intradural extension was not a limiting factor for GTR.

Endoscopic transnasal surgery is an alternative approach to treatment of clivus lesions, and, in expert hands, this technique can obtain good results. Lateral extension and previous treatment were factors that could make the surgery more difficult. Intradural extension did not limit the radicality of the removal.