Article
Reconstruction of the clivus after surgical resection of destructive clival tumors: technical note and surgical results
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Authors
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M. Nakamura
- Neurochirurgische Klinik, Medizinische Hochschule Hannover, Hannover
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T. Stoever
- Klinik für Otorhinolaryngologie, Johann Wolfgang Goethe-Universität, Frankfurt am Main
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T. Lenarz
- Klinik für Otorhinolaryngologie, Medizinische Hochschule Hannover, Hannover
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J.K. Krauss
- Neurochirurgische Klinik, Medizinische Hochschule Hannover, Hannover
| Published: | April 28, 2011 |
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Outline
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Objective: Large clival tumors may lead to considerable destruction of the clivus. The surgical resection of these tumors is demanding and the resulting tumor defect needs appropriate reconstruction depending on the extent of tumor removal. In some cases, duraplasty with soft tissue coverage alone may not be sufficient to prevent CSF leak or other related CNS complications, especially when the defect is large and the tumor did not respect any dural barrier. Hard reconstruction of the clivus may provide an additional shielding in these cases. We report our experience using calvarial split grafts for bony reconstruction of the clivus.
Methods: All patients were operated through an anterior approach to the clivus (transnasal, transfacial) using microsurgical technique in collaboration with ENT surgeons between January 2006 and April 2010. In all cases, the extent of clival destruction and the dural defect necessitated bony reconstruction as an additional support to enable a stable duraplasty. Calvarial split grafts were obtained from the frontal skull. Bony reconstruction was performed with a two layer calvarial split graft and multiple soft layers of free pericranial flaps and fascia lata. Additional sealing was obtained using fibrin glue and fibrin-coated sponge. Lumbar drainage was implanted in all patients. Clinical data were collected prospectively including preoperative medical history, radiological, operative and histological findings as well as follow-up records.
Results: Our report includes 3 men with a mean age of 45 years (40–50 years). Bony reconstruction was performed after surgical removal of a recurrent chondrosarcoma, clivus chordoma and sinonasal carcinoma. Surgical resection of the tumor and clival reconstruction were performed without any complications. There was no additional cranial nerve deficit after surgery and no morbidity related to the site of calvarial bone removal. There was no CSF fistula during the postoperative course and follow-up (1–18 months).
Conclusions: Reconstruction of the clivus with free calvarial bone split grafts provided good support for duraplasty and adequate prevention of a CSF fistula in these selected patients. This technique may be easily applied in cases with large bony clival defects in order to protect the exposed brain stem from the nasopharyngeal cavity.
