Abstract
Objective While the endoscopic endonasal approach (EEA) has gained widespread acceptance for
the resection of clivus chordomas, conventional transcranial approaches still have
a crucial role in craniocervical junction (CCJ) chordoma surgery. In repeat surgery,
a carefully planned treatment strategy is needed. We present a surgical treatment
plan combining an EEA and a far-lateral craniotomy with endoscopic assistance (EA)
in the salvage surgery of a recurrent CCJ chordoma.
Case Presentation A 37-year-old woman who had undergone partial resection of a chordoma extending from
the mid-clivus to the CCJ.
Technique A two-stage surgical intervention was planned. First, we opted for an EEA with the
intention of removing only the extradural and medial compartments of the lesion. The
rationale was to avoid intradural dissection of possibly adherent tissues from the
previous procedures and to minimize the cerebrospinal fluid leak risk. One month after
the first endonasal stage, a far lateral craniotomy was performed. After removal of
the lateral mass and pedicle of C1, a large surgical corridor to the tumor was obtained.
Tumor loculations disseminated in and around the CCJ and located in the areas blind
to microscopic examination were then successfully resected with EA. An occipito-cervical
fusion was then performed during the same procedure.
Conclusion In addition to the exact location and morphology of the tumor, history of previous
surgery was an important factor in devising a treatment strategy in this case of clivus
chordoma. EA was also found to be instrumental in improving the reach of the far lateral
approach.
Keywords chordoma - endoscopic endonasal approach - far-lateral approach - salvage surgery
