• Luca Ricciardi, Carmelo Lucio Sturiale, Alessandro Izzo, Resi Pucci, Valentino Valentini, Nicola Montano, Filippo Maria Polli, Massimiliano Visocchi, Tito Vivas-Buitrago, Kaisorn L Chaichana, Alfredo Quinones-Hinojosa, Alessandro Olivi, and Selby Chen.
• Istituto di Neurochirurgia, Università Cattolica del Sacro Cuore, Rome, Italy; Department of Neurosurgery, Mayo Clinic College of Medicine, Jacksonville, Florida, USA. Electronic address: ricciardi.lu@gmail.com.
• World Neurosurg. 2019 Jul 1; 127: 206-212.

BackgroundThe craniovertebral junction (CVJ) may be affected by several diseases. It is an anatomically complex region, involving the osteoligamentous, vascular, and nervous structures, which makes surgery challenging. In a case of ventral compression, an anterior approach is preferable, although posterior fixation is often required. Anterior transmucosal approaches are associated with high rates of complications. However, decompression and fixation by the use of retropharyngeal extramucosal approaches may be challenging.ObjectiveTo investigate the feasibility of a single-stage, anterior, extramucosal submandibular (SM) approach modification to the CVJ for simultaneous decompression and stabilization.Materials And MethodsThis was a preliminary cadaveric feasibility study on 2 injected specimens. A variation of the SM approach with a short "boomerang" incision, microsurgical decompression of the ventral CVJ, and a new hybrid construct for an anterior atlantoaxial stabilization was investigated. The surgical approach, the decompression, and the instrumentation technique have been described. In addition, intraprocedural images and radiographs and also postprocedural computed tomographic images were collected. Furthermore, surgical exposure, working corridors and angles, and decompression grade were measured.ResultsThe SM approach provided wide exposure of the ventral CVJ and the possibility for instrumentation and decompression by removing the anterior arch of C1 and the odontoid process.ConclusionA single- stage anterior extramucosal SM approach for decompression and stabilization of the CVJ is feasible and could result in shorter surgical duration, avoiding the complications related to both the transmucosal approach and the prone position, although specific related risks exist. Mechanical investigation of this hybrid system and in vivo studies are needed to confirm our results.Copyright © 2019 Elsevier Inc. All rights reserved.

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