Defining the Clival Recess Surgical Corridor and Clival Classification System for Approach to Sellar Pathology

Document Type

Article

Abstract

BACKGROUND: Sellar masses within the pars intermedius, bordered anteriorly by normal pituitary gland/stalk, and/or with ectatic cavernous carotid anatomy are challenging and high risk when approached through the endonasal standard direct/anterior sellar approach. This approach portends itself to a higher risk of pituitary gland/stalk injury and subtotal resection with the aforementioned anatomic variants. OBJECTIVE: To describe the indirect clival recess corridor approach to sellar lesions. This corridor is a "silent" point of access to lesions in this region endoscopically. While skull base teams may have used this approach to some degree, it has not yet been described in the literature to our knowledge. METHODS: We defined the clival recess surgical corridor with skull base craniometric measurements and use a case example with aberrant anatomy to illustrate the approach. We cross-sectionally reviewed 42 patients with sellar and suprasellar masses. To describe the approach's anatomy, we devised and defined the terms dorsum sella plumb line, anatomic corridor, angle of osseous, and operative corridor. RESULTS: Created novel clival aeration grade informing surgical planning. Classified clival aeration as Grade 1 (100%-75% aeration), Grade 2 (75%-50% aeration), Grade 3 (50%-25% aeration), and Grade 4 (25%-0% aeration). This classification system determines extent of drilling of the clivus required to optimize the clival recess corridor approach and its limitations. CONCLUSION: The clival recess surgical corridor is effective for accessing pituitary lesions within the sella. Consider the indirect approach when a standard direct/anterior sellar approach has high risk for vascular injury and/or endocrinological dysfunction.

Medical Subject Headings

Humans; Cranial Fossa, Posterior (diagnostic imaging, surgery, anatomy & histology); Skull Base (diagnostic imaging, surgery, anatomy & histology); Nose; Skull Base Neoplasms (diagnostic imaging, surgery, pathology); Pituitary Gland (diagnostic imaging, surgery)

Publication Date

5-1-2023

Publication Title

Operative neurosurgery (Hagerstown, Md.)

E-ISSN

2332-4260

Volume

24

Issue

5

First Page

e315

Last Page

e321

PubMed ID

36716036

Digital Object Identifier (DOI)

10.1227/ons.0000000000000609

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