Surgical access for clivus chordoma. The University of California, San Francisco, experience

Surgical approaches to clivus chordoma are discussed. The approaches described in this article have been used in an attempt to minimize morbidity while maximizing exposure. The transseptal-transsphenoidal approach is appropriate for biopsy or for subtotal removal of small midline lesions of the upper (retrosellar) clivus only. The radical pterygomaxillotomy approach is used for gaining access to chordomas of the upper half of the clivus, with or without lateral extension. Removal of the lateral, posterior, and (if necessary) medial walls of the maxillary sinus is followed by resection of most of the contents of the pterygopalatine fossa. The pterygoid plates are then removed with a drill. The sphenoid sinus and upper clivus are then exposed for tumor removal. For more inferior lesions, we have modified the transoral-transpharyngeal approach by creating an inferiorly based posterior pharyngeal flap, which increases exposure of the clivus, particularly laterally. This flap can be extended laterally for paraclival extension. This approach allows removal of the lateral clivus as far laterally as the hypoglossal canal, with no dissection of tongue, mandible, lip, or cervical soft tissues.