Expanded endonasal approach: the rostrocaudal axis. Part II. Posterior clinoids to the foramen magnum

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Object

Transsphenoidal approaches have been used for a century for the resection of pituitary and other sellar tumors. Recently, however, the standard endonasal approach has been expanded to provide access to other parasellar lesions. With the addition of the endoscope, this expansion has significant potential for the resection of skull base lesions.

Methods

The anatomical landmarks and surgical techniques used in expanded (extended) endoscopic approaches to the clivus and cervicomedullary junction are reviewed and presented, accompanied by case illustrations of each segment (or module) of approach.

The caudal portion of the midline anterior skull base and the cervicomedullary junction is divided into modules of approach: the middle third of the clivus, its lower third, and the cervicomedullary junction. Case illustrations of successful resections of lesions via each module of the approach are presented and discussed.

Conclusions

Endoscopic expanded endonasal approaches to caudally located midline anterior skull base and cervicomedullary lesions are feasible and hold great potential for decreased morbidity. The effectiveness and appropriate use of these techniques must be evaluated by close examination of outcomes as case series expand.

Abbreviations used in this paper:BA = basilar artery; CA = carotid artery; CSF = cerebrospinal fluid; ICA = internal carotid artery; MR = magnetic resonance; SIS = superior intercavernous sinus; VBJ = vertebrobasilar junction.

Object

Transsphenoidal approaches have been used for a century for the resection of pituitary and other sellar tumors. Recently, however, the standard endonasal approach has been expanded to provide access to other parasellar lesions. With the addition of the endoscope, this expansion has significant potential for the resection of skull base lesions.

Methods

The anatomical landmarks and surgical techniques used in expanded (extended) endoscopic approaches to the clivus and cervicomedullary junction are reviewed and presented, accompanied by case illustrations of each segment (or module) of approach.

The caudal portion of the midline anterior skull base and the cervicomedullary junction is divided into modules of approach: the middle third of the clivus, its lower third, and the cervicomedullary junction. Case illustrations of successful resections of lesions via each module of the approach are presented and discussed.

Conclusions

Endoscopic expanded endonasal approaches to caudally located midline anterior skull base and cervicomedullary lesions are feasible and hold great potential for decreased morbidity. The effectiveness and appropriate use of these techniques must be evaluated by close examination of outcomes as case series expand.

Abbreviations used in this paper:BA = basilar artery; CA = carotid artery; CSF = cerebrospinal fluid; ICA = internal carotid artery; MR = magnetic resonance; SIS = superior intercavernous sinus; VBJ = vertebrobasilar junction.

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Article Information

Contributor Notes

Address reprint requests to: Amin B. Kassam, M.D., University of Pittsburgh School of Medicine, 203 Lothrop Street, Suite 500, Pittsburgh, Pennsylvania 15213. email: kassamab@upmc.edu.

© Copyright 1944-2019 American Association of Neurological Surgeons

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