Endoscopic endonasal approach vs microsurgical transcranial approach in intracranial chordoma surgery: a systematic...

Chordomas are rare, locally aggressive tumors originating from notochordal remnants, predominantly affecting the skull base. Surgical resection remains central to management, with endoscopic endonasal approach (EEA) and microsurgical transcranial approach (MTA) being the primary techniques. While EEA offers minimally invasive benefits, its efficacy compared to MTA remains debated due to limited high-quality evidence. This systematic review and meta-analysis followed PRISMA guidelines, searching PubMed, EMBASE, and Scopus databases up to May 17, 2025. Studies comparing EEA and MTA for intracranial skull base chordomas were included. Outcomes analyzed included overall survival (OS), cerebrospinal fluid (CSF) leak rate, cranial nerve function worsening, and Karnofsky Performance Status (KPS) worsening. A random-effects model synthesized data, with heterogeneity assessed using I² statistics. Five studies met inclusion criteria. No significant difference was found in OS between EEA and MTA (HR = 1.39; 95% CI: 0.79-2.45; p = 0.25). EEA showed a trend toward higher CSF leak rates (RR = 4.90; 95% CI: 0.87-27.62; p = 0.07) but significantly reduced cranial nerve function worsening (RR = 0.40; 95% CI: 0.19-0.83; p = 0.01). KPS worsening rates were similar (RR = 0.81; 95% CI: 0.49-1.35; p = 0.42). Heterogeneity ranged from low to moderate across outcomes. Endoscopic endonasal approach and MTA offer comparable survival outcomes in the surgical management of skull base chordomas. EEA is associated with reduced cranial nerve morbidity, albeit with a trend toward increased CSF leaks. Given the limited number of comparative studies and moderate heterogeneity, these findings should be interpreted cautiously.