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Maugeri R, Bonosi L, Brunasso L, Costanzo R, Santi S, Signorelli F, Iacopino DG, Visocchi M. Not Every Size Fits All: Surgical Corridors for Clival and Cervical Chordomas-A Systematic Review of the Literature and Illustrative Cases. J Clin Med 2024; 13:5052. [PMID: 39274265 PMCID: PMC11396282 DOI: 10.3390/jcm13175052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2024] [Revised: 08/20/2024] [Accepted: 08/21/2024] [Indexed: 09/16/2024] Open
Abstract
Introduction. Clival chordomas represent a rare but clinically significant subset of skull base tumors, characterized by a locally aggressive nature and a location in proximity to vital neurovascular structures. Surgical resection, often combined with adjuvant therapies, remains the cornerstone of clival chordoma treatment, and various approaches and techniques have evolved to maximize tumor removal while preserving neurological function. Recent advancements in skull base surgery, imaging, and adjuvant therapies have improved outcomes by reducing morbidity and thus enhancing long-term survival. Methods and Results. We have conducted a systematic review on PubMed/Medline following PRISMA guidelines regarding indications, the extent of resection (EOR), and complication rates. Then, we present three illustrative cases from our personal experience, which started 25 years ago with CVJ instrumentation procedures and 15 years ago with anterior decompressive transmucosal procedures performed with the aid of an operative microscope, an endoscope, and neuroradiological monitoring. Conclusions. Traditionally, the transoral approach (TOA) is the most frequently used corridor for accessing the lower clivus and the anterior craniovertebral junction (CVJ), without the need to mobilize or retract neural structures; however, it is associated with a high rate of complications. The endonasal approach (EEA) provides access to the anterior CVJ as well as to the lower, middle, and superior clivus, decreasing airway and swallowing morbidity, preserving palatal function, decreasing postoperative pain, and reducing the incidence of tracheostomy. The submandibular retropharyngeal approach (SRA) allows unique access to certain cervical chordomas, which is better suited when the lesion is located below the clivus and in the midline.
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Affiliation(s)
- Rosario Maugeri
- Neurosurgical Clinic, AOUP "Paolo Giaccone", Post Graduate Residency Program in Neurologic Surgery, Department of Experimental Biomedicine and Clinical Neurosciences, School of Medicine, University of Palermo, Via del Vespro 127, 90127 Palermo, Italy
| | - Lapo Bonosi
- Neurosurgical Clinic, AOUP "Paolo Giaccone", Post Graduate Residency Program in Neurologic Surgery, Department of Experimental Biomedicine and Clinical Neurosciences, School of Medicine, University of Palermo, Via del Vespro 127, 90127 Palermo, Italy
| | - Lara Brunasso
- Neurosurgical Clinic, AOUP "Paolo Giaccone", Post Graduate Residency Program in Neurologic Surgery, Department of Experimental Biomedicine and Clinical Neurosciences, School of Medicine, University of Palermo, Via del Vespro 127, 90127 Palermo, Italy
| | - Roberta Costanzo
- Neurosurgical Clinic, AOUP "Paolo Giaccone", Post Graduate Residency Program in Neurologic Surgery, Department of Experimental Biomedicine and Clinical Neurosciences, School of Medicine, University of Palermo, Via del Vespro 127, 90127 Palermo, Italy
| | - Samuele Santi
- Department of Neurosurgery, Fondazione Policlinico Agostino Gemelli IRCCS, Largo Agostino Gemelli 8, 00168 Rome, Italy
| | - Francesco Signorelli
- Department of Neurosurgery, Fondazione Policlinico Agostino Gemelli IRCCS, Largo Agostino Gemelli 8, 00168 Rome, Italy
| | - Domenico Gerardo Iacopino
- Neurosurgical Clinic, AOUP "Paolo Giaccone", Post Graduate Residency Program in Neurologic Surgery, Department of Experimental Biomedicine and Clinical Neurosciences, School of Medicine, University of Palermo, Via del Vespro 127, 90127 Palermo, Italy
| | - Massimiliano Visocchi
- Department of Neurosurgery, Fondazione Policlinico Agostino Gemelli IRCCS, Largo Agostino Gemelli 8, 00168 Rome, Italy
- Institute of Neurosurgery, Catholic University of the Sacred Heart, Largo Francesco Vito 1, 00168 Rome, Italy
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Shah J, Kam J, Castle-Kirszbaum M, Uren B, Rimmer J, Goldschlager T. Tension Pneumocephalus Secondary to Positive Pressure Ventilation Following Endoscopic Endonasal Skull Base Surgery: Three-Year Follow-Up After Implementation of an Institutional Protocol. World Neurosurg 2024; 188:e613-e617. [PMID: 38843965 DOI: 10.1016/j.wneu.2024.05.178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2024] [Revised: 05/30/2024] [Accepted: 05/31/2024] [Indexed: 06/28/2024]
Abstract
BACKGROUND Tension pneumocephalus (PMC) is a rare and feared complication following the endonasal endoscopic approach (EEA) to skull base procedures. This is a neurosurgical emergency that requires urgent decompression to avoid catastrophic neurologic damage or death. An avoidable cause is the application of positive pressure ventilation (PPV) in EEA patients for postoperative hypoxia. Our institution implemented a hospital-wide protocol in response to this to identify and manage at-risk patients; this paper aims to identify if this protocol was effective in lowering the rates of tension PMC secondary to PPV. RESULTS In the 3 years following the implementation of the protocol, 110 patients underwent EEAs, from which 1 case of tension PMC (found to be not secondary to PPV) was identified. This is compared with 2 cases of tension PMC secondary to PPV over the preceding 5 years, out of 406 EEA patients. This constitutes a quantifiable reduction in PPV-related tension PMC in both standard and extended approach EEAs, signifying the effective uptake of the protocol. CONCLUSIONS We found no cases of tension PMC after PPV following EEA skull base surgery in our institution since the implementation of an institution-wide guideline. This underscores the utility of our simple and cost-effective preventative protocol in reducing the overall rates of tension PMC following the inadvertent postoperative application of PPV. Further research is needed to study the comparative risks and benefits of PPV in the post-EEA patient and thus inform future iterations of the protocol.
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Affiliation(s)
- Jainam Shah
- Department of Neurosurgery, Monash University, Melbourne, Australia.
| | - Jeremy Kam
- Department of Neurosurgery, Monash Health, Melbourne, Australia; Department of Surgery, Monash University, Melbourne, Australia
| | - Mendel Castle-Kirszbaum
- Department of Neurosurgery, Monash Health, Melbourne, Australia; Department of Surgery, Monash University, Melbourne, Australia
| | - Brent Uren
- Department of Surgery, Monash University, Melbourne, Australia; Department of Otolaryngology, Head and Neck Surgery, Monash Health, Melbourne, Australia
| | - Jo Rimmer
- Department of Surgery, Monash University, Melbourne, Australia; Department of Otolaryngology, Head and Neck Surgery, Monash Health, Melbourne, Australia
| | - Tony Goldschlager
- Department of Neurosurgery, Monash Health, Melbourne, Australia; Department of Surgery, Monash University, Melbourne, Australia
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Webb KL, Pruter WW, Hinkle ML, Walsh MT. Comparing Surgical Approaches for Craniopharyngioma Resection Among Adults and Children: A Meta-analysis and Systematic Review. World Neurosurg 2023; 175:e876-e896. [PMID: 37062335 DOI: 10.1016/j.wneu.2023.04.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Accepted: 04/10/2023] [Indexed: 04/18/2023]
Abstract
BACKGROUND Craniopharyngioma treatment often necessitates surgical resection. Conventional approaches, such as transcranial and transsphenoidal approaches, are predominantly used. However, a recently adopted supraorbital approach may be more efficacious. Thus, this meta-analysis and systematic review aimed to compare the efficacy of the transcranial, transsphenoidal, and supraorbital approaches for resection and treatment of craniopharyngiomas. METHODS This study was performed following PRISMA guidelines. Analyses were performed according to study design: (1) analyses for studies comparing several surgical approaches; and (2) analyses of all included studies. Random effects meta-analysis models were used to pool odds ratios among studies comparing several approaches. Similarly, categorical meta-regression models were used to examine the effect of surgical approach as a covariate of outcome data for all studies. Statistics were performed using Comprehensive Meta-Analysis software (CMA 3.3, Biostat, Englewood, NJ) (significance set at P < 0.05). RESULTS Patients were well-matched for age, sex, and preoperative comorbidities between groups stratified by surgical approach. Analyses including 22 studies that compared several approaches demonstrated that the transsphenoidal group had a greater occurrence of postoperative visual improvement (P < 0.0001), lesser occurrence of visual deterioration (P < 0.0001), and lower tumor recurrence rate (P = 0.015) compared with the transcranial group. Only 2 studies compared the supraorbital approach to another approach, limiting analyses. Analyses including all studies demonstrated that the supraorbital group did not differ to either the transcranial or transsphenoidal group for any examined variables. CONCLUSIONS The present study suggests that the transsphenoidal approach is associated with improved clinical outcomes for craniopharyngioma resection. There are limited data regarding the supraorbital approach, warranting future investigation.
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Affiliation(s)
- Kevin L Webb
- Department of Physiology and Biomedical Engineering, Mayo Clinic, Rochester, Minnesota, USA; Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota, USA.
| | - Wyatt W Pruter
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Mickayla L Hinkle
- Department of Neurosurgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Michael T Walsh
- Department of Neurosurgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
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Alsharif TH, Gronfula AG, Alghdali LH, Hejazi M, Alanazi A, Wali SM, Alyousef M. Outcomes of Endoscopic Resection in Pediatric Skull Base Chordoma: A Systematic Review. Cureus 2023; 15:e41487. [PMID: 37551221 PMCID: PMC10404338 DOI: 10.7759/cureus.41487] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/07/2023] [Indexed: 08/09/2023] Open
Abstract
The endoscopic approach has been recommended as a primary option for treating chordomas, and it is associated with better resection rates and fewer surgical complications than transcranial surgery. This review aimed to assess the long-term consequences and evidence in the current literature regarding the endoscopic approach's efficacy in treating skull-base chordoma in children. A systematic review was conducted based on the PubMed, Web of Science, and EMBASE databases to examine the clinical outcomes of endoscopic endonasal surgery for pediatric skull base chordoma tumors. The review included studies published in English that employed specific research designs and reported on pediatric patients with skull base chordoma. Of the 268 studies initially considered, 25 met our eligibility criteria and were included in the final analysis. The average age of the patients was 11.5 years, with approximately equal number of males and females. The endoscopic endonasal approach (EEA) was the most commonly used modality. Gross total resection (GTR) was achieved in 62.7% of patients, while 18.09% had a subtotal resection (STR), and 13.83% had near-total resection only. Most patients showed significant to moderate improvement from their baseline condition and had no recurrence during their follow-up. Our findings further endorse that the endoscopic approach is a viable primary treatment option for pediatric skull base chordoma.
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Affiliation(s)
| | - Amin G Gronfula
- Orthopaedic Surgery, Royal College of Surgeons in Ireland, Dublin, IRL
| | - Lamees H Alghdali
- Internal Medicine, Royal College of Surgeons in Ireland, Dublin, IRL
| | - Mayasim Hejazi
- Emergency Medicine, Royal College of Surgeons in Ireland, Dublin, IRL
| | | | - Sahal M Wali
- Surgery, King Abdulaziz University Hospital, Jeddah, SAU
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Akins PT, Ledgerwood LG, Duong HT. Early and late complications after open and endoscopic neurosurgery for complex skull base and craniofacial pathology: Case series, illustrative cases, and review. INTERDISCIPLINARY NEUROSURGERY 2022. [DOI: 10.1016/j.inat.2022.101552] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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Baig Mirza A, Ravindran V, Okasha M, Boardman TM, Maratos E, Sinan B, Thomas N. Systematic Review Comparing Open versus Endoscopic Surgery in Clival Chordomas and a 10-Year Single-Center Experience. Skull Base Surg 2022; 83:e113-e125. [DOI: 10.1055/s-0041-1722933] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Accepted: 11/27/2020] [Indexed: 10/22/2022]
Abstract
Abstract
Objectives Chordomas are rare, slow-growing, and osteo-destructive tumors of the primitive notochord. There is still contention in the literature as to the optimal management of chordoma. We conducted a systematic review of the surgical management of chordoma along with our 10-year institutional experience.
Design A systematic search of the literature was performed in October 2020 by using MEDLINE and EMBASE for articles relating to the surgical management of clival chordomas. We also searched for all adult patients surgically treated for primary clival chordomas at our institute between 2009 and 2019.
Participants Only articles describing chordomas arising from the clivus were included in the analysis. For our institution experience, only adult primary clival chordoma cases were included.
Main Outcome Measures Patients were divided into endoscopic or open surgery. Rate of gross total resection (GTR), recurrence, and complications were measured.
Results Our literature search yielded 24 articles to include in the study. Mean GTR rate among endoscopic cases was 51.9% versus 41.7% for open surgery. Among the eight cases in our institutional experience, we found similar GTR rates between endoscopic and open surgery.
Conclusion Although there is clear evidence in the literature that endoscopic approaches provide better rates of GTR with fewer overall complications compared to open surgery. However, there are still situations where endoscopy is not viable, and thus, open surgery should still be considered if required.
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Affiliation(s)
- Asfand Baig Mirza
- Department of Neurosurgery, King's College Hospital NHS Foundation Trust, London, United Kingdom
| | - Visagan Ravindran
- Department of Neurosurgery, King's College Hospital NHS Foundation Trust, London, United Kingdom
| | - Mohamed Okasha
- Department of Neurosurgery, King's College Hospital NHS Foundation Trust, London, United Kingdom
| | | | - Eleni Maratos
- Department of Neurosurgery, King's College Hospital NHS Foundation Trust, London, United Kingdom
| | - Barazi Sinan
- Department of Neurosurgery, King's College Hospital NHS Foundation Trust, London, United Kingdom
| | - Nick Thomas
- Department of Neurosurgery, King's College Hospital NHS Foundation Trust, London, United Kingdom
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