Combined Endoscopic Endonasal and Open Transmandibular–Transcervical Approach for Management of Giant Clival Chordomas Extended to the Craniovertebral Junction

Background: Chordomas in the clival-cervical region present challenges to the neurosurgical team due to their encroaching nature, proximity to critical neurovascular structures and for the presence, often, of cranio-cervical instability. Moreover, giant chordomas may occur with acute compression of the bulbo-medullary junction and neurological worsening. In these cases, the first goal of surgery is the decompression of the bulbo-medullary junction followed by a second stage in which the residual tumor was resected and the craniocervical junction was reconstructed.

Methods: We presented three cases of giant clival chordomas with extension to the cranio-vertebral junction and acute compression of neurovascular structure treated first by endoscopic endonasal transclival approach to decompress directly the central part of the tumors causing the compression followed by large degloving “open” procedures for the resection of lateral residual tumor and reconstruction.

Results: The endoscopic endonasal approach guaranteed an adequate bulbo-medullary decompression in all patients. The extended open transmandibular–transcervical approach allowed us the complete resection of lateral residual of the tumor and the complete reconstruction and fixation of craniovertebral junction in all patients.

Conclusion: The endoscopic transnasal approach guarantees a straightforward, saving-time and minimally invasive natural surgical corridor for promptly decompression of the anterior craniocervical junction. The subsequent open approaches provided greater lateral exposure to maximize surgical resection and optimal reconstruction with subsequent improving of patients survival and quality of life.

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