Endoscopic Endonasal Approach for Resection of Clival Chordomas: A Systematic Review and Meta-Analysis.

BACKGROUND AND

OBJECTIVES

Clival chordoma is a rare, locally invasive tumor originating from notochord remnants. The endoscopic endonasal approach (EEA) offers direct midline access, but the ideal balance between radicality and safety remains debated because of perioperative complications and mortality. The aim of this study was to synthesize oncologic and safety outcomes of EEA for clival chordomas, focusing on extent of resection, recurrence, and complications.

METHODS

PubMed, Embase, Scopus, and Web of Science were searched through September 2025. We included observational studies of clival chordoma treated through EEA reporting extent of resection and outcomes. Exclusion criteria included alternative approaches, nonchordoma histologies, non-English/Spanish/Portuguese reports, series with <5 patients, and secondary evidence. Single-group random-effects meta-analyses of proportions were performed; heterogeneity was summarized with I 2 .

RESULTS

We included 18 observational studies comprising 1197 patients. The mean follow-up was 55.1 months. Pooled gross total resection was 48.3% (95% CI: 39.6-57.6; I 2 = 94%). Near-total, subtotal, and partial resection rates were 29.2%, 27.2%, and 9%, respectively. Mortality during follow-up was 10.8% (95% CI: 5.7-19.4; I 2 = 83%). Pooled cerebrospinal fluid leak rate was 12.4% (95% CI: 6.8%-16.6%; I 2 = 64%). Complications included cranial nerve palsy 7.5% (95% CI: 4.4%-12.4%; I 2 = 68%), paresis 4.1% (95% CI: 2.3%-7.1%; I 2 = 40%), diplopia 3.7% (95% CI: 0.0%-13.4%; I 2 = 51%), brain infarction 1.2% (95% CI: 0.02.8%; I 2 = 14%), major hemorrhage 0.3% (95% CI: 0.0%-1.3%; I 2 = 6%), and hematoma 0.2% (95% CI: 0.0%-1.2%; I 2 = 0%).

CONCLUSION

In contemporary EEA for clival chordomas, about half of the patients achieve gross total resection. Recurrence approaches ∼32% at reported follow-up. Morbidity is driven chiefly by cranial nerve deficits (∼8%), whereas major vascular and bleeding events are uncommon.

PROSPERO REGISTRATION NUMBER: CRD420251155783.