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Abstract
We aim to establish a complete summary on the Endoscopic Endonasal Approach (EEA) to Cranio Cervical Junction (CCJ): evolution since first description, criteria to predict the feasibility and limitations, anatomical landmarks, indications and biomechanical evaluation after performing the approach. A comprehensive literature search to identify all available literature published between March 2002 and June 2015, the articles were divided into four categories according to their main purpose: 1- surgical technique, 2- anatomical landmarks and limitations, 3- literature reviews to identify main indications, 4- biomechanical studies. Thereafter, we demonstrate the approach step-by-step, using 1 fresh and 3 silicon injected embalmed cadaveric specimen heads. 61 articles and one poster were identified. The approach was first described on cadaveric study in 2002, and firstly used to perform odontoidectomy in 2005. The main indication is odontoid rheumatoid pannus and basilar invagination. The nasopalatine line (NPL), the superior nostril-hard palate Line (SN-HP), the naso-axial line (NAxL), the rhinopalatine Line (RPL) and other methods were described to predict the anatomical feasibility of the approach. The craniocervical fusion is potentially unnecessary after removal of < 75% of one occipital condyle. A recent cadaveric study stated the possibility of C1-C2 fusion via EEA. This paper reviews all available clinical and anatomical studies on the EEA to CCJ. The approach marked a significant evolution since its first description in 2002. Because of its lesser complications compared to the transoral approach, the EEA became when feasible, the approach of choice to the ventral CCJ.
Highlights
The transoral approach with its various variations has been the standard route of ventral access for the Cervical Junction (CCJ) [1,2,3,4,5]
This procedure requires a long retraction of the tongue, dissection of the soft palate and incision in the oropharynx below the level of soft palate resulting in morbidity including tracheostomy from tongue swelling, enteral tube feeding or gastrostomy, wound healing complications and velopharyngeal incompetence due to the incision below the level of the soft palate [6, 7]
The aim of this study is to identify the evolution of the Endoscopic Endonasal Approach (EEA) to CCJ since its first description to achieve a complete summary of surgical technique, anatomical and radiological landmarks that predict the feasibility and limitations of the approach, various indications, biomechanical effect of the approach on stability of CCJ, and to demonstrate a step-bystep anatomical study
Summary
The transoral approach with its various variations has been the standard route of ventral access for the CCJ [1,2,3,4,5]. In 2002, Alfieri et al [8] published the first anatomical study demonstrated that the CCJ could be sufficiently exposed by the endonasal endoscopic route This anatomical work gave the start signal to numerous anatomical and clinical studies to develop the Endoscopic Endonasal Approach (EEA). The aim of this study is to identify the evolution of the EEA to CCJ since its first description to achieve a complete summary of surgical technique, anatomical and radiological landmarks that predict the feasibility and limitations of the approach, various indications, biomechanical effect of the approach on stability of CCJ, and to demonstrate a step-bystep anatomical study
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