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Background: Surgical treatment of lesions involving the ventral craniovertebral junction (CVJ) and the lower clivus, traditionally involved complex lateral or transoral approaches to the skull base. However, mid or upper clivus involvement requires more extensive lateral approaches. Recently, the endoscopic endonasal approach (EEA) has become the standard for upper CVJ lesions and medial clival, and a valuable alternative for those tumors extending in its upper third as well as laterally. However, the EEA is associated with an increased risk of post-operative CSF leakage and infection when the tumor is characterized by an intradural extension. Furthermore, whenever the tumor has significant lateral and/or inferior extension below the odontoid process, the chances for a complete resection decrease. Method: To analyze the extent of exposure of a hybrid microscopic-endoscopic transcondylar antero-lateral approach to the CVJ and clival region, and to verify its effectiveness in terms of mid and upper clival access. Five silicone-injected cadaver heads were used. Following a standard antero-lateral approach, condylectomy and jugular tubercle drilling were performed, after which angled endoscopes were utilized to extend the bone resection to the clivus. A volumetric assessment of the amount of clival removal was carried out. A case of CVJ chordoma operated through this approach is presented. Results: The hybrid antero-lateral transcondylar approach provides adequate exposure of the ventral CVJ, up to the dorsum sellae and the sphenoid sinus, the contralateral petrous apex, and the contralateral paraclival internal carotid artery (ICA). Approximately 60% of the total clival volume can be removed with this approach. The main limitation is the limited visualization of the ipsilateral paraclival ICA and petrous apex. Conclusion: The hybrid antero-lateral transcondylar approach is a valuable surgical option for CVJ tumor extending from C2 to the mid and upper clivus. [ABSTRACT FROM AUTHOR]

Craniovertebral junction chordomas can represent a surgical challenge, especially when intradural extension and contact with neurovascular structures is involved. To date, there is still controversy on the choice of optimal surgical corridor for such lesions, with endoscopic endonasal, far lateral and anterolateral corridors being those most commonly used. In this operative video, we present a case of craniovertebral junction chordoma with significant bone destruction and intradural extension ( Fig. 1 ). The tumor was safely removed using an anterolateral approach with transposition of the vertebral artery to gain access to the lateral craniovertebral junction. The endoscope is demonstrated to help with intradural tumor removal, providing a wide angle of view through a relatively narrow dural opening ( Fig. 2 ). In this video, nuances of the anterolateral approach, chordoma removal strategies and closure technique are presented in detail. A gross total resection was achieved, and the postoperative course was uneventful. In summary, the anterolateral approach with endoscopic assistance can offer a safe and effective corridor for the surgical management of craniovertebral junction chordomas. The link to the video can be found at: https://youtu.be/pC0YxKgNoMY. [ABSTRACT FROM AUTHOR]