Quantitative anatomical comparison of transnasal and transcranial approaches to the clivus
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Background and objective
The clivus was defined as “no man’s land” in the early 1990s, but since then, multiple approaches have been described to access it. This study is aimed at quantitatively comparing endoscopic transnasal and microsurgical transcranial approaches to the clivus in a preclinical setting, using a recently developed research method.
Multiple approaches were performed in 5 head and neck specimens that underwent high-resolution computed tomography (CT): endoscopic transnasal (transclival, with hypophysiopexy and with far-medial extension), microsurgical anterolateral (supraorbital, mini-pterional, pterional, pterional transzygomatic, fronto-temporal-orbito-zygomatic), lateral (subtemporal and subtemporal transzygomatic), and posterolateral (retrosigmoid, far-lateral, retrolabyrinthine, translabyrinthine, and transcochlear). An optic neuronavigation system and dedicated software were used to quantify the working volume of each approach and calculate the exposure of different clival regions. Mixed linear models with random intersections were used for statistical analyses.
Endoscopic transnasal approaches showed higher working volume and larger exposure compared with microsurgical transcranial approaches. Increased exposure of the upper clivus was achieved by the transnasal endoscopic transclival approach with intradural hypophysiopexy. Anterolateral microsurgical transcranial approaches provided a direct route to the anterior surface of the posterior clinoid process. The transnasal endoscopic approach with far-medial extension ensured a statistically larger exposure of jugular tubercles as compared with other approaches. Presigmoid approaches provided a relatively limited exposure of the ipsilateral clivus, which increased in proportion to their invasiveness.
This is the first anatomical study that quantitatively compares in a holistic way exposure and working volumes offered by the most used modern approaches to the clivus.
KeywordsClivus Comparative study Endoscopy Microsurgery Quantitative study Skull base surgery
Digital Imaging and Communications in Medicine
endoscopic transnasal transclival approach
endoscopic transnasal transclival approaches
ETCA with far-medial extension
ETCA with intradural hypophysiopexy approach
- GTx-Eyes II – UHN
Guided Therapeutics software developed at University Health Network – Toronto, Canada
Innovation Development Exploration Assessment Long term
internal acoustic canals
microsurgical transcranial approaches
pterional transzygomatic approach
presigmoid retrolabyrinthine infratentorial approach
subtemporal transzygomatic approach
presigmoid transcochlear infratentorial approach
presigmoid translabyrinthine infratentorial approach
We thank Prof. R. Rezzani, Ph.D., Head of the Section of Anatomy and Pathophysiology of Brescia, for study support, Prof. Giuseppe Lanzino, M.D., for study supervision, and Elisa Colombo, M.S., for her guidance.
Compliance with ethical standards
Conflict of interest
The authors declare that they have no conflict of interest.
Research involving human participants and/or animals and informed consent
This work was performed according to the ethical standards of our Institutional Review Board. All human cadaveric studies have been performed in accordance with the ethical standards laid down in the 1964 Declaration of Helsinki and its later amendments. The manuscript does not contain clinical studies or patient data.
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