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FarMedial Expanded Endonasal Approach to the Inferior Third of the Clivus: The Transcondylar and Transjugular Tubercle Approaches

Morera, Victor A. MD; Fernandez-Miranda, Juan C. MD; Prevedello, Daniel M. MD; Madhok, Ricky MD; Barges-Coll, Juan MD; Gardner, Paul M.D; Carrau, Ricardo MD; Snyderman, Carl H. MD; Rhoton, Albert L. Jr MD; Kassam, Amin B. MD

doi: 10.1227/01.NEU.0000369926.01891.5D

OBJECTIVE: The endoscopic endonasal transclival approach is a valid alternative for treatment of lesions in the clivus. The major limitation of this approach is a significant lateral extension of the tumor. We aim to identify a safe corridor through the occipital condyle to provide more lateral exposure of the foramen magnum.

METHODS: Sixteen parameters were measured in 25 adult skulls to analyze the exact extension of a safe corridor through the condyle. Endonasal endoscopic anatomic dissections were carried out in nine colored latex–injected heads.

RESULTS: Drilling at the lateral inferior clival area exposed two compartments divided by the hypoglossal canal: the jugular tubercle (superior) and the condylar (inferior). Completion of a unilateral ventromedial condyle resection opens a 3.5 mm (transverse length) * 10 mm (vertical length) lateral surgical corridor, facilitating direct access to the vertebral artery at its dural entry point into the posterior fossa. The supracondylar groove is a reliable landmark for locating the hypoglossal canal in relation to the condyle. The hypoglossal canal is used as the posterior limit of the condyle removal to preserve more than half of the condylar mass. The transjugular tubercle approach is accomplished by drilling above the hypoglossal canal, and increases the vertical length of the lateral surgical corridor by 8 mm, allowing for visualization of the distal cisternal segment of the lower cranial nerves.

CONCLUSION: The transcondylar and transjugular tubercle “far medial” expansions of the endoscopic endonasal approach to the inferior third of the clivus provide a unique surgical corridor to the ventrolateral surface of the ponto- and cervicomedullary junctions.

Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania (Morera) (Fernandez-Miranda)(Prevedello)(Madhok)(Barges-Coll)(Gardner)

Neuroscience Institute, John Wayne Cancer Institute at Saint John's Health Center, Santa Monica, California (Carrau)

Department of Neurological Surgery and Department of Otolaryngology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania (Snyderman)(Kassam)

Department of Neurological Surgery, University of Florida, Gainesville, Florida (Rhoton)

Reprint requests: Daniel M. Prevedello, MD, Department of Neurological Surgery, 200 Lothrop Street, PUH B400, Pittsburgh, PA 15213. E-mail:

Received, August 4, 2009.

Accepted, January 11, 2010.

Copyright © by the Congress of Neurological Surgeons