• Francesco Signorelli, Alessandro Olivi, Fabio De Giorgio, Vincenzo Lorenzo Pascali, and Massimiliano Visocchi.
• Institute of Neurosurgery, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy. Electronic address: francesco.signorelli1984@gmail.com.
• World Neurosurg. 2020 Aug 1; 140: 564-573.

BackgroundWe herein outline the experience matured in our equipped Cranio-Vertebral Junction Laboratory for anatomic dissection.MethodsAn extreme lateral approach (ELA) was performed on 4 fresh cadavers and submandibular approach was performed on 5. An endoscope and navigation-assisted far lateral approach (FLA) was performed in 5 injected specimens. In these specimens, a transoral approach was also performed, as well as a neuronavigation-assisted comparison between transoral and transnasal explorable distances.ResultsAs calculated with neuronavigation, statistically significant differences both in the explored craniocaudal (P = 0.003) and lateral (P = 0.008) distances were observed between the transoral approach and endoscopic endonasal approach. In FLA, neuronavigation facilitated identification and partial removal of the occipital condyle; in one case, during endoscopic intradural exploration, tearing of the emerging roots of the 11th cranial nerve occurred. In ELA, the site where the accessory nerve pierces into the sternocleidomastoid muscle was found at a distance from the tip of the mastoid between 3 and 4 cm.ConclusionsDuring dissections, as in the clinical setting, endoscope and image guidance give the surgeon a constant orientation, increasing the accuracy and the safety of the approach. Nonetheless, the encumbrance of the endoscope could represent a limit in deep and narrow corridors as those running across the craniovertebral junction, especially in "oblique" FLA and ELA, in which the surgical target is often hidden by a delicate tangle of nerves and vessels. Its use appears more suitable and safer in "straight" approaches as transoral and transnasal in which there are no neurovascular structures interposed.Copyright © 2020 Elsevier Inc. All rights reserved.

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