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Quantitative anatomical comparison of transnasal and transcranial approaches to the clivus

  • Original Article - Neurosurgical Anatomy
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Abstract

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.

Methods

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.

Results

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.

Conclusions

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.

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Abbreviations

CSF:

cerebrospinal fluid

CT:

computed tomography

DICOM:

Digital Imaging and Communications in Medicine

ETCA:

endoscopic transnasal transclival approach

ETCAs:

endoscopic transnasal transclival approaches

ETCAFM:

ETCA with far-medial extension

ETCAH:

ETCA with intradural hypophysiopexy approach

FL:

Far-lateral approach

FTOZ:

Fronto-temporal-orbito-zygomatic approach

GTx-Eyes II – UHN:

Guided Therapeutics software developed at University Health Network – Toronto, Canada

IDEAL:

Innovation Development Exploration Assessment Long term

IACs:

internal acoustic canals

MPT:

mini-pterional approach

MTCAs :

microsurgical transcranial approaches

PT:

pterional approach

PTTZ:

pterional transzygomatic approach

SO:

supraorbital approach

RL:

presigmoid retrolabyrinthine infratentorial approach

RS:

retrosigmoid approach

ST:

subtemporal approach

STTZ:

subtemporal transzygomatic approach

TC:

presigmoid transcochlear infratentorial approach

TL:

presigmoid translabyrinthine infratentorial approach

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Acknowledgments

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.

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Authors and Affiliations

  1. Neurosurgery, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Largo Spedali Civili, 1, 25123, Brescia, Italy

    Edoardo Agosti, Giorgio Saraceno, Francesco Belotti, Marco M. Fontanella & Francesco Doglietto

  2. TECHNA Institute, University Health Network, Toronto, Ontario, Canada

    Jimmy Qiu

  3. Section of Anatomy and Physiopathology, Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy

    Barbara Buffoli & Luigi F. Rodella

  4. Otorhinolaryngology, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy

    Marco Ferrari, Davide Mattavelli, Alberto Schreiber & Piero Nicolai

  5. Department of Public Health Sciences, Karolinska Institute, Stockholm, Sweden

    Elena Raffetti

  6. Radiology, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy

    Marco Ravanelli & Roberto Maroldi

  7. Division of Anatomy, Center for Anatomy and Cell Biology, Medical University of Vienna, Vienna, Austria

    Lena Hirtler

  8. Department of Neurosurgery, Toronto Western Hospital, University of Toronto, Toronto, Ontario, Canada

    Fred Gentili

  9. Department of Medical Imaging, University of Toronto, Toronto, Canada

    Walter Kucharczyk

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  1. Edoardo Agosti
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  2. Giorgio Saraceno
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  3. Jimmy Qiu
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  18. Francesco Doglietto
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Corresponding author

Correspondence to Francesco Doglietto.

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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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Agosti, E., Saraceno, G., Qiu, J. et al. Quantitative anatomical comparison of transnasal and transcranial approaches to the clivus. Acta Neurochir 162, 649–660 (2020). https://doi.org/10.1007/s00701-019-04152-4

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  • DOI: https://doi.org/10.1007/s00701-019-04152-4

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