• Alfio Spina, Filippo Gagliardi, Javier Abarca-Olivas, Michele Bailo, Nicola Boari, Pablo Gonzalez-Lopez, Cristian Gragnaniello, Anthony J Caputy, and Pietro Mortini.
• Department of Neurosurgery and Gamma Knife Radiosurgery, IRCCS San Raffaele Scientific Institute, Vita-Salute University, Milan, Italy. Electronic address: spina.alfio@hsr.it.
• World Neurosurg. 2019 Dec 1; 132: e116-e123.

ObjectiveAnterior craniovertebral junction (CVJ) surgery has continued to be one of the most debated neurosurgical topics. The transoral approach (TOA) has been considered the choice for this region. However, it has some limitations and a not negligible degree of surgery-related morbidity. With the advent of endoscopy, the endoscopic endonasal approach (EEA) was developed, which minimized morbidity and improved exposure. To the best of our knowledge, despite the extensive reported data, a comparative anatomical study has not been performed and no definitive consensus has been reached on the indications for both approaches.MethodsWe compared the TOA and EEA to the CVJ using the previously described operability score (OS), calculated at 4 different targets: the C1 tubercle (C1), the lowest exposed point of the odontoid process (C2), the basion (BS) and the middle clivus (MC). The higher the OS for the selected targets, the more favorable the approach.ResultsThe TOA had higher OSs at the MC, C1, and C2 targets, and the EEA showed greater OSs at MC and C1. The TOA and EEA had similar OSs at the BS. These results have shown that the OS is more favorable at C1-C2 using the TOA and the OSs at the MC and BS were similar.ConclusionsThe OS is an effective method to compare surgical approaches. The present study demonstrated the maximal exposure capability of the 2 approaches. The TOA seemed to be superior for lower targets and the EEA for upper targets. Because of the strong variability in the CVJ anatomy and pathological features, we suggest considering the OS as a further tool to better define the best surgical approach.Copyright © 2019 Elsevier Inc. All rights reserved.

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