Department of Neurosurgery, New York Presbyterian Hospital, Weill Medical College of Cornell University, New York, New York, USA.
J Neurosurg. 2010 May;112(5):1061-9. doi: 10.3171/2009.7.JNS081504.
Transcranial approaches to clival chordomas provide a circuitous route to the site of origin of the tumor often involving extensive bone drilling and brain retraction, which places critical neurovascular structures between the surgeon and pathology. For certain chordomas, the endonasal endoscopic transclival approach is a novel minimal access, but it is an equally aggressive alternative providing the most direct route to the tumor epicenter.
The authors present a consecutive series of patients undergoing endonasal endoscopic resection of clival chordomas. Extent of resection was determined by postoperative volumetric MR imaging and divided into > 95% and < 95%.
Seven patients underwent 10 operations. Preoperative cranial neuropathies were present in 4. The mean patient age was 52.0 years. The mean tumor volume was 34.9 cm3. Intraoperative lumbar drainage was used in 1 patient, and the tumors extended intradurally in 3. One patient underwent 2 intentionally palliative procedures for subtotal debulking. Greater than 95% resection was achieved in 7 of 8 operations in which radical resection was the goal (87%). All tumors with volumes < 50 cm3 had > 95% resection (p = 0.05). The overall mean follow-up was 18.0 months. Cranial neuropathies resolved in all 3 patients with cranial nerve VI palsies. One patient with recurrent nasopharyngeal chordoma died of disease progression; another experienced 2 recurrences before receiving radiation therapy. All surviving patients remain progression free. There were no intraoperative complications; however, 1 patient developed a pulmonary embolus postoperatively. There were no postoperative CSF leaks.
The endonasal endoscopic transclival approach represents a less invasive and more direct approach than a transcranial approach to treat certain moderate-sized midline skull base chordomas. Longer follow-up is necessary to determine comparability to transcranial approaches for long-term control. Large tumors with significant extension lateral to the carotid artery may not be suitable for this approach.
经颅入路治疗颅底斜坡脊索瘤需要迂回到达肿瘤起源部位，通常需要广泛的骨钻取和脑组织牵拉，这使得关键的神经血管结构位于外科医生和病变之间。对于某些脊索瘤，经鼻内镜经颅底入路是一种新的微创方法，但它也是一种同样激进的替代方法，可以提供到达肿瘤中心的最直接途径。
作者介绍了一系列连续接受经鼻内镜下斜坡脊索瘤切除术的患者。通过术后容积磁共振成像确定切除程度，并分为>95%和<95%。
7 名患者接受了 10 次手术。术前存在颅神经病变 4 例。患者平均年龄为 52.0 岁。肿瘤平均体积为 34.9cm3。1 例患者术中使用腰椎引流，3 例肿瘤向硬膜内延伸。1 例患者因肿瘤大部分切除而行 2 次姑息性减瘤术。在 8 例以根治性切除为目标的手术中，有 7 例达到了>95%的切除率（87%）。所有体积<50cm3的肿瘤均达到了>95%的切除率（p=0.05）。总的平均随访时间为 18.0 个月。所有 3 例伴有 VI 颅神经麻痹的患者颅神经病变均得到缓解。1 例复发性鼻咽部脊索瘤患者死于疾病进展；另 1 例在接受放疗前复发 2 次。所有存活患者均无肿瘤进展。无术中并发症；然而，1 例患者术后发生肺栓塞。无术后脑脊液漏。
经鼻内镜经颅底入路与经颅入路相比，是一种侵袭性更小、更直接的治疗某些中等大小中线颅底脊索瘤的方法。需要更长时间的随访，以确定其在长期控制方面与经颅入路的可比性。对于向颈内动脉外侧明显延伸的大型肿瘤，可能不适合这种方法。
