Transmandibular, circumglossal, retropharyngeal approach for chordomas of the clivus and upper cervical spine

Extensive clival tumors that involve both the midline and lateral skull base compartments, or those that extend inferiorly to the anterior cervical spine, are difficult to expose in a wide fashion using any of the transmaxillary, transoral, or transcervical routes. In the transmandibular, circumglossal, retropharyngeal (TCR) approach wide access of this region can be obtained, thus allowing for a more complete resection of tumor and infiltrated bone. It also provides for an improved ability to perform dural reconstruction, should it be necessary. Over the past 4 years four patients with extensive clival chordomas underwent resection via the TCR approach. Gross-total resection was achieved in two patients, a greater than 98% resection in one patient, and a greater than 95% resection in the fourth patient. The surgical technique, all approach-related complications and morbidity, and patient outcome are discussed. If an expanded exposure of the clivus is necessary, the TCR approach is a good choice as well as a useful surgical technique to have available.