How I do it: endoscopic endonasal approach to the inferior third of the clivus
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HOW I DO IT - NEUROSURGICAL TECHNIQUES
How I do it: endoscopic endonasal approach to the inferior third of the clivus Eugenio Cárdenas Ruiz-Valdepeñas 1
&
Ariel Kaen 1 & Gustavo Pérez Prat 2 & Jesus Ambrosiani Fernandez 3
Received: 7 November 2017 / Accepted: 30 January 2018 # Springer-Verlag GmbH Austria, part of Springer Nature 2018
Abstract Background Nowadays, endoscopic endonasal expanded approach targeting for the clival lower third is well described in literature. Nonetheless, great variations can be found among surgical groups, specially during the earlier stages of this procedure. Method We present a step by step description of the clival lower third approach until entering the dural space, setting its bony limits. We describe the basipharyngeal flap tailoring as a helpful option for latter reconstruction. The study of cadaveric specimens adds clarifying dissections. Conclusions The expansion in the coronal plane is providential in most of the intradural lesions of the inferior clivus. Basipharyngeal flap may help seal the surgical defects in this area. Keywords Lower clivus . Basipharyngeal flap . Endonasal reconstruction . Endoscopic approach . Expanded endonasal . Coronal plane
Relevant surgical anatomy Lesions compromising the lower third of the clivus are comprised between the foramen lacerum and foramen magnum [1] (Fig. 1). The inferior petrous sinus in intracranial surface runs parallel to the petroclival fissure on the extracranial surface. The supracondylar groove landmarks the hypoglossal canal location, which splits the lower clivus in two halves; the upper being the tubercular compartment and the lower being the condylar compartment [2]. Two bicortical bony prominences are divided by the hypoglossal canal trajectory. So, we can divide the lateral part of this lower third of the clivus in three
Electronic supplementary material The online version of this article (https://doi.org/10.1007/s00701-018-3483-2) contains supplementary material, which is available to authorized users. * Eugenio Cárdenas Ruiz-Valdepeñas [email protected] 1
Department of Neurological Surgery, Hospital Virgen Del Rocío, Avenida Manuel Siurot s/n, 41013 Seville, Spain
2
Department of Neurological Surgery, Hospital Vall d’Hebron, Barcelona, Spain
3
Faculty of Anatomy, University of Sevilla, Seville, Spain
portions (supratubercular, tubercular, and condylar compartments) (Fig. 5). The petroclival fissure stands as this approach lateral limit on the supratubercular and tubercular compartments. The petrous segment of the carotid artery is not found at risk, as long as those are purely infravidian located [3]. However, aiming for the lateral region of the petroclival fissure means to be at risk for superficial and deep plane bleeding due to parapharyngeal internal carotid artery (ICA) damage on the former and petrous sinus injury on the latter (Fig. 2).
Description of the technique Nasal fossa approach The extended nasoseptal flap (NSF) is tailored first of all [4]. Both inferior turbinate tails are retracte
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