• Irakliy Abramov, Mohamed A Labib, David Altshuler, Lena Mary Houlihan, Nicolas I Gonzalez-Romo, Evan Luther, Michael E Ivan, Michael T Lawton, Jacques J Morcos, and Mark C Preul.
• Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA.
• World Neurosurg. 2024 Feb 1; 182: e5e15e5-e15.

BackgroundMulticompartmental lesions of the anterior craniovertebral junction require aggressive management. However, the lesions can be difficult to reach, and the surgical procedure is difficult to understand. The aim of this study was to create a procedural, stepwise microsurgical educational resource for junior trainees to learn the surgical anatomy of the extreme lateral transodontoid approach (ELTOA).MethodsTen formalin-fixed, latex-injected cadaveric heads were dissected under an operative microscope. Dissections were performed under the supervision of a skull base fellowship-trained neurosurgeon who has advanced skull base experience. Key steps of the procedure were documented with a professional camera and a high-definition video system. A relevant clinical case example was reviewed to highlight the principles of the selected approach and its application. The clinical case example also describes a rare complication: a pseudoaneurysm of the vertebral artery.ResultsKey steps of the ELTOA include patient positioning, skin incision, superficial and deep muscle dissection, vertebral artery dissection and transposition, craniotomy, clivus drilling, odontoidectomy, and final extradural and intradural exposure.ConclusionsThe ELTOA is a challenging approach, but it allows for significant access to the anterior craniovertebral junction, which increases the likelihood of gross total lesion resection. Given the complexity of the approach, substantial training in the dissection laboratory is required to develop the necessary anatomic knowledge and to minimize approach-related morbidity.Copyright © 2023 Elsevier Inc. All rights reserved.

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