Anatomical restrictions in the transsphenoidal, transclival approach to the upper clival region: A cadaveric, anatomic study

Abstract

Objective: Tumours in the clival region are difficult to remove surgically. Before the 1970s, clival tumours had very high mortality and morbidity rates.

Methods: An anatomic dissection was performed on 24 spheno-occipital bone blocks obtained from 28 adult cadavers. The internal carotid artery, paraclival carotid tubercle, sixth cranial nerve and dorsum sellae in the upper clival region were analyzed qualitatively and quantitatively. For the histological evaluation, 4 samples were decalcified and sagittal sections were cut. From the eight blocks obtained, 32 incisions were made in the axial plane, and the tissue was analyzed.

Results: Using microscopy, a clival recess was clearly identified in 15 of the 24(62.5%) samples. Paraclival carotid tubercles were observed in 19 (79.16%) of the samples. In the upper clival and petroclival region, the sixth cranial nerve had directional changes at the dural porus, the petrous apex and the lateral wall of the cavernous segment of the internal carotid artery. At the dorsum sellae level, the distance between the medial surfaces of both internal carotid arteries was a mean of 15.33 +/- 2.12 mm. This distance at the pharyngeal tubercle was a mean of 38.95 +/- 4.67 mm. On all the histological sections, the distance of the sixth cranial nerve from the dural porus to the cavernous sinus was within the basilar plexus, along with the subarachnoid membranes around it. On the petrous apex level, the sixth cranial nerve was fixed to the petrous apex and the internal carotid artery with connective tissue formed by dense collagen fibres. The sixth cranial nerve and the internal carotid artery are tightly surrounded by dense collagen connective tissue, and the relative proximity between the carotids on the dorsum sellae level can be easily damaged during the transsphenoidal-transclival approach. Similarly, due to the ligamentous fixation on the dural porus and the petrous apex surfaces, there is a high risk of injury to the carotid artery and sixth cranial nerve.

Conclusion: This study determines the relationship between the sixth cranial nerve and the internal carotid artery at the upper clivus and to provide morphologic details that is essential for the risks of transclival surgery.