Pathology of the craniocervical junction (CCJ) is challenging to treat due to the complex bony, ligamentous, and neurovascular structures that comprise this region. There are many unique pathologies of the CCJ, including spine tumors, arthritides, and fractures, each of which requires comprehensive treatment strategies, which often include surgery. Determining the optimal surgical approach to the CCJ is based on the goals of surgical intervention and location of the pathology. In general, the approach is dictated based on whether the pathology is ventral or dorsal to the spinal cord, its location within the CCJ, and the extent of involvement of adjacent neurovascular structures. The transmandibular approach, despite its associated morbidity, is a useful technique in the surgical armamentarium to address ventral CCJ pathology. We describe the indications for this approach, how to successfully perform the procedure, and the associated intraoperative and post-operative risks.
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