Surgical management of midline skull-base tumors: a new approach

TLDR

Surgical treatment of skull‑base tumors has historically been limited by clival access and complications such as pharyngeal wound breakdown, CSF fistula, and meningitis. The authors employed a Le Fort I osteotomy to expose the clivus, enabling aneurysm control and reducing CSF fistula risk. In 13 operations on 10 patients, the approach achieved partial or total tumor resection with no CSF fistula, preserved or improved neurological status, pain relief in most symptomatic cases, good cosmetic outcomes, and can be safely repeated for recurrence.

Abstract

Many surgical approaches to the clivus and upper cervical spine have been used in the treatment of skull-base tumors over the past 50 years. However, the outcome of surgery has been complicated by difficulties of access to the whole clivus, together with pharyngeal wound breakdown with subsequent development of cerebrospinal fluid (CSF) fistula and meningitis. A technique described recently utilized Le Fort I osteotomy to improve exposure of the clivus in the approach to vertebrobasilar aneurysms, facilitating control of the aneurysm and reducing the risk of posttraumatic CSF fistula. The same approach, via maxillotomy, has permitted partial or total tumor resection in 13 consecutive procedures carried out at Atkinson Morley's Hospital on 10 patients presenting with tumors of the skull base. Neurological status was either improved or unchanged in all patients postoperatively, and pain relief was obtained in five of eight cases in which this was a presenting symptom. No patient developed a CSF fistula following surgery. Cosmetic results were good, and no problems related to malocclusion were reported. This approach may be used to advantage in the surgical treatment of skull-base tumors, at initial presentation, and can be repeated without undue difficulty should there be tumor recurrence.