Reconstructive challenges in the extended endoscopic transclival approach.

Area of Science:

• Neurosurgery
• Skull Base Surgery
• Endoscopic Endonasal Surgery

Background:

• The extended endoscopic approach is increasingly used for skull base pathologies.
• Clival pathologies present unique surgical challenges, particularly regarding cerebrospinal fluid (CSF) leak and reconstruction.
• Minimally invasive techniques aim to reduce morbidity associated with traditional open approaches.

Purpose of the Study:

• To present the institutional experience with the extended endoscopic approach for clival pathology.
• To analyze the incidence and risk factors for postoperative cerebrospinal fluid (CSF) leak.
• To discuss reconstruction challenges and outcomes in this patient cohort.

Main Methods:

• A consecutive series of 37 patients undergoing extended endoscopic skull base surgery were reviewed.
• Nine patients with clival pathology were specifically analyzed.
• Data collected included tumor pathology, location, size, reconstruction methods, and use of lumbar drain to assess CSF leak incidence.

Main Results:

• The overall incidence of postoperative CSF leak was 10.8%.
• Patients undergoing a transclival approach had a significantly higher incidence of CSF leak (75%, p < 0.05).
• Intradural dissection in clival pathology cases was associated with a higher risk of CSF leak (p < 0.05).

Conclusions:

• Advancements like the vascularized nasoseptal flap have improved CSF leak rates in extended endoscopic skull base surgery.
• Transclival approaches remain technically demanding and associated with higher CSF leak rates.
• Further research and technical innovation are required to address the specific challenges of the clival region.