Merits of Endoscopic Approach to Clivus Tumors and Challenges

Clival bone is no more a “no man’s land”. The three clival segments can be approached by extended endoscopic approaches for tumor removal in a minimally invasive manner, thus reducing morbidity compared to transcranial approaches. Clival resection by meticulous bone drilling provides ability to mobilize the hindering normal anatomic structures like pituitary gland, paraclival ICA, and eustachian tubes, thus improving access in upper, middle, and lower clival segments. respectively. Multilayered skull base reconstruction incorporating inlay graft, onlay graft, and pedicled nasoseptal flaps is the game-changing strategy highly effective in reducing the high CSF leak-associated morbidity of this region. Possibility of craniovertebral instability needs to be considered in the laterally extended “far-medial” transclival approaches to lower clivus.