Transoral Approach to the Craniovertebral Junction: A Neuronavigated Cadaver Study

  • Francesco Signorelli
  • Alessandro Costantini
  • Vittorio Stumpo
  • Giulio Conforti
  • Alessandro Olivi
  • Massimiliano Visocchi
Part of the Acta Neurochirurgica Supplement book series (NEUROCHIRURGICA, volume 125)


More than 100 years after the first description by Kanavel of a transoral–transpharyngeal approach to remove a bullet impacted between the atlas and the clivus [1], the transoral approach (TOA) still represents the ‘gold standard’ for surgical treatment of a variety of conditions resulting in anterior craniocervical compression and myelopathy [2, 3]. Nevertheless, some concerns—such as the need for a temporary tracheostomy and a postoperative nasogastric tube, and the increased risk of infection resulting from possible bacterial contamination and nasopharyngeal incompetence [4–6]—led to the introduction of the endoscopic endonasal approach (EEA) by Kassam et al. [7] in 2005. Although this approach, which was conceived to overcome those surgical complications, soon gained wide attention, its clear predominance over the TOA in the treatment of craniovertebral junction (CVJ) pathologies is still a matter of debate [3]. In recent years, several papers have reported anatomical studies and surgical experience with the EEA, targeting different areas of the midline skull base, from the olfactory groove to the CVJ [8–19]. Starting from these preliminary experiences, further anatomical studies have defined the theoretical (radiological) and practical (surgical) craniocaudal limits of the endonasal route [20–25]. Our group has done the same for the TOA [26, 27] and compared the reliability of the radiological and surgical lines of the two different approaches. Very recently, a cadaver study, with the aid of neuronavigation, tried to define the upper and lower limits of the endoscopic TOA [28].


  1. 1.
    Kanavel AB. Bullet located between the atlas and the base of the skull: technique of removal through the mouth. Surg Clin Chicago. 1917;1:361–6.Google Scholar
  2. 2.
    Menezes AH, VanGilder JC. Transoral–transpharyngeal approach to the anterior craniocervical junction. Ten-year experience with 72 patients. J Neurosurg. 1988;69:895–903. Scholar
  3. 3.
    Visocchi M, Signorelli F, Liao C, Rigante M, Paludetti G, Barbagallo G, Olivi A. Endoscopic endonasal approach for craniovertebral junction pathologies: myth and truth in clinical series and personal experience. World Neurosurg. 2017;101:122–9. Scholar
  4. 4.
    Crockard HA. Transoral surgery: some lessons learned. Br J Neurosurg. 1995;9:283–93.CrossRefGoogle Scholar
  5. 5.
    Visocchi M. Advances in videoassisted anterior surgical approach to the craniovertebral junction. Adv Tech Stand Neurosurg. 2011;37:97–110. Scholar
  6. 6.
    Liu JK, Patel J, Goldstein IM, Eloy JA. Endoscopic endonasal transclival transodontoid approach for ventral decompression of the craniovertebral junction: operative technique and nuances. Neurosurg Focus. 2015;38:E17. Scholar
  7. 7.
    Kassam AB, Snyderman C, Gardner P, Carrau R, Spiro R. The expanded endonasal approach: a fully endoscopic transnasal approach and resection of the odontoid process: technical case report. Neurosurgery. 2005;57:E213.PubMedGoogle Scholar
  8. 8.
    Yu Y, Wang X, Zhang X, Hu F, Gu Y, Xie T, Jiang X, Jiang C. Endoscopic transnasal odontoidectomy to treat basilar invagination with congenital osseous malformations. Eur Spine J. 2013;22(5):1127–36. Scholar
  9. 9.
    Yen YS, Chang PY, Huang WC, Wu JC, Liang ML, Tu TH, Cheng H. Endoscopic transnasal odontoidectomy without resection of nasal turbinates: clinical outcomes of 13 patients. J Neurosurg Spine. 2014;21:929–37. Scholar
  10. 10.
    Wu JC, Huang WC, Cheng H, Liang ML, Ho CY, Wong TT, Shih YH, Yen YS. Endoscopic transnasal transclival odontoidectomy: a new approach to decompression: technical case report. Neurosurgery. 2008;63:ONSE92–4. Scholar
  11. 11.
    Ponce-Gomez JA, Ortega-Porcayo LA, Soriano-Baron HE, Sotomayor-Gonzalez A, Arriada-Mendicoa N, Gomez-Amador JL, Palma-Diaz M, Barges-Coll J. Evolution from microscopic transoral to endoscopic endonasal odontoidectomy. Neurosurg Focus. 2014;37:E15. Scholar
  12. 12.
    Nayak JV, Gardner PA, Vescan AD, Carrau RL, Kassam AB, Snyderman CH. Experience with the expanded endonasal approach for resection of the odontoid process in rheumatoid disease. Am J Rhinol. 2007;21:601–6. Scholar
  13. 13.
    Mazzatenta D, Zoli M, Mascari C, Pasquini E, Frank G. Endoscopic endonasal odontoidectomy: clinical series. Spine. 2014;39:846–53. Scholar
  14. 14.
    Lee A, Sommer D, Reddy K, Murty N, Gunnarsson T. Endoscopic transnasal approach to the craniocervical junction. Skull Base. 2010;20:199–205. Scholar
  15. 15.
    Goldschlager T, Hartl R, Greenfield JP, Anand VK, Schwartz TH. The endoscopic endonasal approach to the odontoid and its impact on early extubation and feeding. J Neurosurg. 2015;122:511–8. Scholar
  16. 16.
    Gladi M, Iacoangeli M, Specchia N, Re M, Dobran M, Alvaro L, Moriconi E, Scerrati M. Endoscopic transnasal odontoid resection to decompress the bulbo-medullary junction: a reliable anterior minimally invasive technique without posterior fusion. Eur Spine J. 2012;21(Suppl 1):S55–60. Scholar
  17. 17.
    Gempt J, Lehmberg J, Grams AE, Berends L, Meyer B, Stoffel M. Endoscopic transnasal resection of the odontoid: case series and clinical course. Eur Spine J. 2011;20:661–6. Scholar
  18. 18.
    Duntze J, Eap C, Kleiber JC, Theret E, Dufour H, Fuentes S, Litre CF. Advantages and limitations of endoscopic endonasal odontoidectomy. A series of nine cases. Orthop Traumatol Surg Res. 2014;100:775–8. Scholar
  19. 19.
    Choudhri O, Mindea SA, Feroze A, Soudry E, Chang SD, Nayak JV. Experience with intraoperative navigation and imaging during endoscopic transnasal spinal approaches to the foramen magnum and odontoid. Neurosurg Focus. 2014;36:E4. Scholar
  20. 20.
    Alfieri A, Jho HD, Tschabitscher M. Endoscopic endonasal approach to the ventral cranio-cervical junction: anatomical study. Acta Neurochir. 2002;144:219–25. Scholar
  21. 21.
    Cavallo LM, Messina A, Cappabianca P, Esposito F, de Divitiis E, Gardner P, Tschabitscher M. Endoscopic endonasal surgery of the midline skull base: anatomical study and clinical considerations. Neurosurg Focus. 2005;19:E2.PubMedGoogle Scholar
  22. 22.
    Messina A, Bruno MC, Decq P, Coste A, Cavallo LM, de Divitis E, Cappabianca P, Tschabitscher M. Pure endoscopic endonasal odontoidectomy: anatomical study. Neurosurg Rev. 2007;30:189–94. Scholar
  23. 23.
    de Almeida JR, Zanation AM, Snyderman CH, Carrau RL, Prevedello DM, Gardner PA, Kassam AB. Defining the nasopalatine line: the limit for endonasal surgery of the spine. Laryngoscope. 2009;119:239–44. Scholar
  24. 24.
    Aldana PR, Naseri I, La Corte E. The naso-axial line: a new method of accurately predicting the inferior limit of the endoscopic endonasal approach to the craniovertebral junction. Neurosurgery. 2012;71:ons308–14. Scholar
  25. 25.
    La Corte E, Aldana PR, Ferroli P, Greenfield JP, Hartl R, Anand VK, Schwartz TH. The rhinopalatine line as a reliable predictor of the inferior extent of endonasal odontoidectomies. Neurosurg Focus. 2015;38:E16. Scholar
  26. 26.
    Visocchi M, La Rocca G, Della Pepa GM, Stigliano E, Costantini A, Di Nardo F, Maira G. Anterior video-assisted approach to the craniovertebral junction: transnasal or transoral? A cadaver study. Acta Neurochir. 2014;156:285–92. Scholar
  27. 27.
    Visocchi M, Pappalardo G, Pileggi M, Signorelli F, Paludetti G, La Rocca G. Experimental endoscopic angular domains of transnasal and transoral routes to the craniovertebral junction light and shade. Spine. 2015;41(3):669–77.Google Scholar
  28. 28.
    La Corte E, Aldana PR. Endoscopic approach to the upper cervical spine and clivus: an anatomical study of the upper limits of the transoral corridor. Acta Neurochir. 2017;159:633–9. Scholar
  29. 29.
    Rhoton AL Jr. Rhoton’s cranial anatomy and surgical approaches. Philadelphia: Lippincott Williams & Wilkins; 2007.Google Scholar
  30. 30.
    Singh H, Harrop J, Schiffmacher P, Rosen M, Evans J. Ventral surgical approaches to craniovertebral junction chordomas. Neurosurgery. 2010;66(3 Suppl):96–103.CrossRefGoogle Scholar
  31. 31.
    Goel A, Cacciola F. The craniovertebral junction. Diagnosis, pathology, surgical techniques. 1st ed. Stuttgart: Thieme Medical Publishers; 2011.Google Scholar
  32. 32.
    Greenberg AD, Scoville WB, Davey LM. Transoral decompression of atlanto-axial dislocation due to odontoid hypoplasia. Report of two cases. J Neurosurg. 1968;28:266–9.CrossRefGoogle Scholar
  33. 33.
    Hsu W, Wolinsky JP, Gokaslan ZL, Sciubba DM. Transoral approaches to the cervical spine. Neurosurgery. 2010;66(3 Suppl):119–25.CrossRefGoogle Scholar
  34. 34.
    Menezes AH. Surgical approaches: postoperative care and complications “transoral-transpalatopharyngeal approach to the craniocervical junction”. Childs Nerv Syst. 2008;24:1187–93.CrossRefGoogle Scholar
  35. 35.
    Visocchi M, Della Pepa GM, Doglietto F, Esposito G, La Rocca G, Massimi L. Video-assisted microsurgical transoral approach to the craniovertebral junction: personal experience in childhood. Childs Nerv Syst. 2011;27:825–31.CrossRefGoogle Scholar
  36. 36.
    Pillai P, Baig MN, Karas CS, Ammirati M. Endoscopic image-guided transoral approach to the craniovertebral junction: an anatomic study comparing surgical exposure and surgical freedom obtained with the endoscope and the operating microscope. Neurosurgery. 2009;64(5 Suppl 2):437–42.PubMedGoogle Scholar
  37. 37.
    Shiriver MF, Kshettry VR, Sindwani R, Woodard T, Benzel EC, Recinos PE. Transoral and transnasalodontoidectomy complications: a systematic review and meta-analysis. Clin Neurol Neurosurg. 2016;148:121–9.CrossRefGoogle Scholar
  38. 38.
    Burke K, Benet A, Aghi MK, El-Sayed I. Impact of platybasia and anatomic variance on surgical approaches to the craniovertebral junction. Laryngoscope. 2014;124:1760–6.CrossRefGoogle Scholar

Copyright information

© Springer International Publishing AG, part of Springer Nature 2019

Authors and Affiliations

  • Francesco Signorelli
    • 1
  • Alessandro Costantini
    • 2
  • Vittorio Stumpo
    • 1
  • Giulio Conforti
    • 1
  • Alessandro Olivi
    • 1
  • Massimiliano Visocchi
    • 1
  1. 1.Institute of NeurosurgeryCatholic University School of MedicineRomeItaly
  2. 2.Institute of RadiologyCatholic University School of MedicineRomeItaly

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