A Transcervical Transclival Approach to the Ventral Surface of the Brain Stem for Removal of a Clivus Chordoma

Abstract

B ECAVSr of the surgical inaccessibili ty and resistance to radiotherapy of clivus chordomas, the prognosis for pa t ien ts with this lesion has generally been h o p e l e s s . 4,6,13,16,22,24,2s,31,34,37 Nonsurgical t r e a t m e n t of clivus chordomas with radium the r apy 7 and by stereotact ic placement of y t t r i u m 906o has been repo~ed, but surgical r emova l of the tumor , al though usually incomplete, seems to be the best means of pal l ia t ing clinical symptoms . Previous surgical approaches to clivus chordomas include a t ransseptal sphenoidal route, 3 a t ransnasal r o u t e ) 4 an intraoral excision, 11 a t ransoral approach with resection of the lower jaw and soft palate, 35 a transoral t r anspa la ta l approach, 3s,4~ and a subtemporal or subparieto-occipi tal exposure with tentorial splitting, s,44,4s,57 Because these approaches are so often accompanied by meningeal infection 21,3s and occasionally by serious hemorrhage, 21 an approach through the neck would be more desirable. Dur ing recent studies in our laboratory on the cerebral blood flow in the isolated int racrania l circulation in monkeys, we needed to ligate the basi lar artery. This was accomplished by the anter ior surgical app roach through the clivus described by Whi te and Alb in) s T h e ease with which this procedure was accomplished when aided by microins t rumenta t ion (Zeiss dissecting microscope) suggested a possible clinical use. Accordingly, we invest igated the possibility of a similar t ranscl ival operation in man by dissecting 33 cadavers and by anatomical observat ions in living pat ients during radical neck operations for cancer. These prelimin a r y studies enabled us to remove a clivus chordoma employing a transcervical exposure of the clivus through a re t ropharyngeal app roach which has not to our knowledge been previously a t tempted .