{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,5,23]],"date-time":"2026-05-23T09:07:17Z","timestamp":1779527237527,"version":"3.53.1"},"reference-count":90,"publisher":"Journal of Neurosurgery Publishing Group (JNSPG)","issue":"2","content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["FOC"],"published-print":{"date-parts":[[2016,2]]},"abstract":"\n OBJECTIVE<\/jats:title>\n The microscopic transoral, endoscopic transnasal, and endoscopic transoral approaches are used alone and in combination for a variety of craniovertebral junction (CVJ) pathologies. The endoscopic transoral approach provides a more direct exposure that is not restricted by the nasal cavity, pterygoid plates, and palate while sparing the potential morbidities associated with extensive soft-tissue dissection, palatal splitting, or mandibulotomy. Concerns regarding the extent of visualization afforded by the endoscopic transoral approach may be limiting its widespread adoption.<\/jats:p>\n <\/jats:sec>\n \n METHODS<\/jats:title>\n A dissection of 10 cadaver heads was undertaken. CT-based imaging guidance was used to measure the working corridor of the endoscopic transoral approach. Measurements were made relative to the palatal line. The built-in linear measurement tool was used to measure the superior and inferior extents of view. The superolateral extent was measured relative to the midline, as defined by the nasal process of the maxilla. The height of the clivus, odontoid tip, and superior aspect of the C-1 arch were also measured relative to the palatal line. A correlated clinical case is presented with video.<\/jats:p>\n <\/jats:sec>\n \n RESULTS<\/jats:title>\n The CVJ was accessible in all cases. The superior extent of the approach was a mean 19.08 mm above the palatal line (range 11.1\u201327.7 mm). The superolateral extent relative to the midline was 15.45 mm on the right side (range 9.6\u201323.7 mm) and 16.70 mm on the left side (range 8.1\u201326.7 mm). The inferior extent was a mean 34.58 mm below the palatal line (range 22.2\u201341.6 mm). The mean distances were as follows: palatal line relative to the odontoid tip, 0.97 mm (range \u22124.9 to 3.7 mm); palatal line relative to the height of the clivus, 4.88 mm (range \u22121.5 to 7.3 mm); and palatal line relative to the C-1 arch, \u22122.75 mm (range \u22125.8 to 0 mm).<\/jats:p>\n <\/jats:sec>\n \n CONCLUSIONS<\/jats:title>\n The endoscopic transoral approach can reliably access the CVJ. This approach avoids the dissections and morbidities associated with a palate-splitting technique (velopharyngeal insufficiency) and the expanded endonasal approach (mucus crusting, sinusitis, and potential lacerum or cavernous-paraclival internal carotid artery injury). For appropriately selected lesions near the palatal line, the endoscopic transoral approach appears to be the preferred approach.<\/jats:p>\n <\/jats:sec>","DOI":"10.3171\/2015.11.focus15498","type":"journal-article","created":{"date-parts":[[2016,2,1]],"date-time":"2016-02-01T03:36:55Z","timestamp":1454297815000},"page":"E11","source":"Crossref","is-referenced-by-count":12,"title":["The endoscopic transoral approach to the craniovertebral junction: an anatomical study with a clinical example"],"prefix":"10.3171","volume":"40","author":[{"given":"Andrew K.","family":"Chan","sequence":"first","affiliation":[{"name":"Departments of Neurological Surgery and"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Arnau","family":"Benet","sequence":"additional","affiliation":[{"name":"Departments of Neurological Surgery and"},{"name":"Otolaryngology, University of California, San Francisco, California"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Junichi","family":"Ohya","sequence":"additional","affiliation":[{"name":"Departments of Neurological Surgery and"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Xin","family":"Zhang","sequence":"additional","affiliation":[{"name":"Departments of Neurological Surgery and"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Todd D.","family":"Vogel","sequence":"additional","affiliation":[{"name":"Departments of Neurological Surgery and"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Daniel W.","family":"Flis","sequence":"additional","affiliation":[{"name":"Otolaryngology, University of California, San Francisco, California"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Ivan H.","family":"El-Sayed","sequence":"additional","affiliation":[{"name":"Otolaryngology, University of California, San Francisco, California"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Praveen V.","family":"Mummaneni","sequence":"additional","affiliation":[{"name":"Departments of Neurological Surgery and"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1754","reference":[{"key":"b1-focus15498","series-title":"Neurosurgery","first-page":"201","article-title":"Transoral exposure of the atlantoaxial region","volume":"3","author":"Apuzzo","year":"1978"},{"key":"b2-focus15498","series-title":"J Neurosurg","first-page":"1229","article-title":"Novel embalming solution for neurosurgical simulation in cadavers","volume":"120","author":"Benet","year":"2014"},{"key":"b3-focus15498","series-title":"Laryngoscope","first-page":"1760","article-title":"Impact of platybasia and anatomic variance on surgical approaches to the craniovertebral junction","volume":"124","author":"Burke","year":"2014"},{"key":"b4-focus15498","series-title":"J Neurol Surg Rep","first-page":"e37","article-title":"Endoscopic transnasal approach for urgent decompression of the craniocervical junction in acute skull base osteomyelitis","volume":"76","author":"Burns","year":"2015"},{"key":"b5-focus15498","series-title":"Neurosurgery","first-page":"296","article-title":"Evolution of transoral surgery: three decades of change in patients, pathologies, and indications","volume":"73","author":"Choi","year":"2013"},{"issue":"3","key":"b6-focus15498","series-title":"Neurosurg Focus","first-page":"E4","article-title":"Experience with intraoperative navigation and imaging during endoscopic transnasal spinal approaches to the foramen magnum and odontoid","volume":"36","author":"Choudhri","year":"2014"},{"key":"b7-focus15498","series-title":"Ann R Coll Surg Engl","first-page":"321","article-title":"The transoral approach to the base of the brain and upper cervical cord","volume":"67","author":"Crockard","year":"1985"},{"key":"b8-focus15498","series-title":"J Bone Joint Surg Br","first-page":"350","article-title":"Transoral decompression and posterior fusion for rheumatoid atlantoaxial subluxation","volume":"68","author":"Crockard","year":"1986"},{"key":"b9-focus15498","series-title":"Neurosurgery","first-page":"351","article-title":"Endoscopic image-guided transcervical odontoidectomy: outcomes of 15 patients with basilar invagination","volume":"70","author":"Dasenbrock","year":"2012"},{"key":"b10-focus15498","series-title":"Head Neck","first-page":"547","article-title":"Nasal morbidity following endoscopic skull base surgery: a prospective cohort study","volume":"33","author":"de Almeida","year":"2011"},{"key":"b11-focus15498","series-title":"J Craniovertebr Junction Spine","first-page":"44","article-title":"Combined transnasal and transoral endoscopic approaches to the craniovertebral junction","volume":"1","author":"El-Sayed","year":"2010"},{"key":"b12-focus15498","series-title":"World Neurosurg","first-page":"183","article-title":"The 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Case report and review of the literature","volume":"7","author":"Fraser","year":"2007"},{"key":"b14-focus15498","series-title":"Eur Spine J","first-page":"661","article-title":"Endoscopic transnasal resection of the odontoid: case series and clinical course","volume":"20","author":"Gempt","year":"2011"},{"key":"b15-focus15498","series-title":"J Neurosurg","first-page":"962","article-title":"Basilar invagination: a study based on 190 surgically treated patients","volume":"88","author":"Goel","year":"1998"},{"key":"b16-focus15498","series-title":"J Neurosurg","first-page":"511","article-title":"The endoscopic endonasal approach to the odontoid and its impact on early extubation and feeding","volume":"122","author":"Goldschlager","year":"2015"},{"key":"b17-focus15498","series-title":"Spine (Phila Pa 1976)","first-page":"1580","article-title":"Atlantoaxial fusion and retrodental pannus in rheumatoid arthritis","volume":"22","author":"Grob","year":"1997"},{"key":"b18-focus15498","series-title":"J Neurosurg","first-page":"16","article-title":"The transoral approach to the superior cervical spine. A review of 53 cases of extradural cervicomedullary compression","volume":"71","author":"Hadley","year":"1989"},{"key":"b19-focus15498","series-title":"J Neurosurg Pediatr","first-page":"549","article-title":"Transnasal odontoid resection followed by posterior decompression and occipitocervical fusion in children with Chiari malformation Type I and ventral brainstem compression","volume":"5","author":"Hankinson","year":"2010"},{"key":"b20-focus15498","series-title":"Spine J","first-page":"542","article-title":"Endoscopic endonasal odontoidectomy with anterior C1 arch preservation in elderly patients affected by rheumatoid arthritis","volume":"13","author":"Iacoangeli","year":"2013"},{"key":"b21-focus15498","series-title":"Neurol India","first-page":"188","article-title":"Transoral decompression for craniovertebral osseous anomalies: perioperative management dilemmas","volume":"47","author":"Jain","year":"1999"},{"issue":"1 Suppl","key":"b22-focus15498","series-title":"Neurosurgery","first-page":"E213","article-title":"The expanded endonasal approach: a fully endoscopic transnasal approach and resection of the odontoid process: technical case report","volume":"57","author":"Kassam","year":"2005"},{"key":"b23-focus15498","series-title":"World Neurosurg","first-page":"713","article-title":"Endoscopic endonasal versus open transcranial resection of anterior midline skull base meningiomas","volume":"77","author":"Komotar","year":"2012"},{"key":"b24-focus15498","series-title":"J Neurosurg Spine","first-page":"376","article-title":"Endonasal endoscopic resection of the odontoid process in a nonachondroplastic dwarf with juvenile rheumatoid arthritis: feasibility of the approach and utility of the intraoperative Iso-C three-dimensional navigation. Case report","volume":"8","author":"Laufer","year":"2008"},{"key":"b25-focus15498","series-title":"Spine (Phila Pa 1976)","first-page":"E139","article-title":"Endonasal endoscopic resection of an os odontoideum to decompress the cervicomedullary junction: a minimal access surgical technique","volume":"34","author":"Leng","year":"2009"},{"key":"b26-focus15498","series-title":"Skull Base","first-page":"151","article-title":"Transoral approach and extended modifications for lesions of the ventral foramen magnum and craniovertebral junction","volume":"18","author":"Liu","year":"2008"},{"issue":"4","key":"b27-focus15498","series-title":"Neurosurg Focus","first-page":"E17","article-title":"Endoscopic endonasal transclival transodontoid approach for ventral decompression of the craniovertebral junction: operative technique and nuances","volume":"38","author":"Liu","year":"2015"},{"key":"b28-focus15498","series-title":"Childs Nerv Syst","first-page":"1187","article-title":"Surgical approaches: postoperative care and complications \u201ctransoral-transpalatopharyngeal approach to the craniocervical junction\u201d","volume":"24","author":"Menezes","year":"2008"},{"key":"b29-focus15498","series-title":"J Neurosurg","first-page":"895","article-title":"Transoral-transpharyngeal approach to the anterior craniocervical junction. Ten-year experience with 72 patients","volume":"69","author":"Menezes","year":"1988"},{"key":"b30-focus15498","series-title":"J Neurosurg","first-page":"500","article-title":"Odontoid upward migration in rheumatoid arthritis. An analysis of 45 patients with \u201ccranial settling\u201d","volume":"63","author":"Menezes","year":"1985"},{"key":"b31-focus15498","series-title":"Neurosurgery","first-page":"1045","article-title":"Transoral odontoidectomy","volume":"56","author":"Mummaneni","year":"2005"},{"key":"b32-focus15498","series-title":"Am J Rhinol","first-page":"601","article-title":"Experience with the expanded endonasal approach for resection of the odontoid process in rheumatoid disease","volume":"21","author":"Nayak","year":"2007"},{"key":"b33-focus15498","series-title":"Childs Nerv Syst","first-page":"1971","article-title":"Endoscopic endonasal odontoidectomy in a child with chronic type 3 atlantoaxial rotatory fixation: case report and literature review","volume":"28","author":"Patel","year":"2012"},{"issue":"5 Suppl 2","key":"b34-focus15498","series-title":"Neurosurgery","first-page":"437","article-title":"Endoscopic image-guided transoral approach to the craniovertebral junction: an anatomic study comparing surgical exposure and surgical freedom obtained with the endoscope and the operating microscope","volume":"64","author":"Pillai","year":"2009"},{"issue":"4","key":"b35-focus15498","series-title":"Neurosurg Focus","first-page":"E15","article-title":"Evolution from microscopic transoral to endoscopic endonasal odontoidectomy","volume":"37","author":"Ponce-G\u00f3mez","year":"2014"},{"key":"b36-focus15498","series-title":"Spine","first-page":"E901","article-title":"Transoral endoscopic odontoidectomy to decompress the cervicomedullary junction","volume":"38","author":"Qiuhang","year":"2013"},{"key":"b37-focus15498","series-title":"World Neurosurg","first-page":"583","article-title":"Comparison of endoscopic transnasal and transoral approaches to the craniovertebral junction","volume":"74","author":"Seker","year":"2010"},{"key":"b38-focus15498","series-title":"Acta Neurochir Suppl (Wien)","first-page":"69","article-title":"The transoral approach to the anterior superior cervical spine. A review of 29 cases","volume":"43","author":"Spetzler","year":"1988"},{"key":"b39-focus15498","series-title":"J Clin Endocrinol Metab","first-page":"3190","article-title":"Endoscopic vs microsurgical transsphenoidal surgery for acromegaly: outcomes in a concurrent series of patients using modern criteria for remission","volume":"98","author":"Starke","year":"2013"},{"key":"b40-focus15498","series-title":"J Neurosurg","first-page":"573","article-title":"Pediatric transoral surgery: indications, complications, and long-term outcome","volume":"84","author":"Tuite","year":"1996"},{"key":"b41-focus15498","series-title":"J Neurosurg Spine","first-page":"184","article-title":"Endoscopic image-guided odontoidectomy for decompression of basilar invagination via a standard anterior cervical approach. Technical note","volume":"6","author":"Wolinsky","year":"2007"},{"key":"b42-focus15498","series-title":"J Neurosurg Spine","first-page":"929","article-title":"Endoscopic transnasal odontoidectomy without resection of nasal turbinates: clinical outcomes of 13 patients","volume":"21","author":"Yen","year":"2014"},{"key":"b43-focus15498","series-title":"J Neurosurg Spine","first-page":"637","article-title":"Endoscopic transnasal odontoidectomy combined with posterior reduction to treat basilar invagination: technical note","volume":"19","author":"Yu","year":"2013"},{"key":"b44-focus15498","series-title":"Eur Spine J","first-page":"1127","article-title":"Endoscopic transnasal odontoidectomy to treat basilar invagination with congenital osseous malformations","volume":"22","author":"Yu","year":"2013"},{"key":"b45-focus15498","series-title":"Br J Neurosurg","first-page":"315","article-title":"Reduction of rheumatoid periodontoid pannus following posterior occipito-cervical fusion visualised by magnetic resonance imaging","volume":"2","author":"Zygmunt","year":"1988"},{"key":"b1-focus15498","series-title":"Neurosurgery","first-page":"201","article-title":"Transoral exposure of the atlantoaxial region","volume":"3","author":"Apuzzo","year":"1978"},{"key":"b2-focus15498","series-title":"J Neurosurg","first-page":"1229","article-title":"Novel embalming solution for neurosurgical simulation in cadavers","volume":"120","author":"Benet","year":"2014"},{"key":"b3-focus15498","series-title":"Laryngoscope","first-page":"1760","article-title":"Impact of platybasia and anatomic variance on surgical approaches to the craniovertebral junction","volume":"124","author":"Burke","year":"2014"},{"key":"b4-focus15498","series-title":"J Neurol Surg Rep","first-page":"e37","article-title":"Endoscopic transnasal approach for urgent decompression of the craniocervical junction in acute skull base osteomyelitis","volume":"76","author":"Burns","year":"2015"},{"key":"b5-focus15498","series-title":"Neurosurgery","first-page":"296","article-title":"Evolution of transoral surgery: three decades of change in patients, pathologies, and indications","volume":"73","author":"Choi","year":"2013"},{"issue":"3","key":"b6-focus15498","series-title":"Neurosurg Focus","first-page":"E4","article-title":"Experience with intraoperative navigation and imaging during endoscopic transnasal spinal approaches to the foramen magnum and odontoid","volume":"36","author":"Choudhri","year":"2014"},{"key":"b7-focus15498","series-title":"Ann R Coll Surg Engl","first-page":"321","article-title":"The transoral approach to the base of the brain and upper cervical cord","volume":"67","author":"Crockard","year":"1985"},{"key":"b8-focus15498","series-title":"J Bone Joint Surg Br","first-page":"350","article-title":"Transoral decompression and posterior fusion for rheumatoid atlantoaxial subluxation","volume":"68","author":"Crockard","year":"1986"},{"key":"b9-focus15498","series-title":"Neurosurgery","first-page":"351","article-title":"Endoscopic image-guided transcervical odontoidectomy: outcomes of 15 patients with basilar invagination","volume":"70","author":"Dasenbrock","year":"2012"},{"key":"b10-focus15498","series-title":"Head Neck","first-page":"547","article-title":"Nasal morbidity following endoscopic skull base surgery: a prospective cohort study","volume":"33","author":"de Almeida","year":"2011"},{"key":"b11-focus15498","series-title":"J Craniovertebr Junction Spine","first-page":"44","article-title":"Combined transnasal and transoral endoscopic approaches to the craniovertebral junction","volume":"1","author":"El-Sayed","year":"2010"},{"key":"b12-focus15498","series-title":"World Neurosurg","first-page":"183","article-title":"The importance of platybasia and the palatine line in patient selection for endonasal surgery of the craniocervical junction: a radiographic study of 12 patients","volume":"76","author":"El-Sayed","year":"2011"},{"key":"b13-focus15498","series-title":"J Neurosurg Spine","first-page":"61","article-title":"Endoscopic biopsy sampling of tophaceous gout of the odontoid process. 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A review of 53 cases of extradural cervicomedullary compression","volume":"71","author":"Hadley","year":"1989"},{"key":"b19-focus15498","series-title":"J Neurosurg Pediatr","first-page":"549","article-title":"Transnasal odontoid resection followed by posterior decompression and occipitocervical fusion in children with Chiari malformation Type I and ventral brainstem compression","volume":"5","author":"Hankinson","year":"2010"},{"key":"b20-focus15498","series-title":"Spine J","first-page":"542","article-title":"Endoscopic endonasal odontoidectomy with anterior C1 arch preservation in elderly patients affected by rheumatoid arthritis","volume":"13","author":"Iacoangeli","year":"2013"},{"key":"b21-focus15498","series-title":"Neurol India","first-page":"188","article-title":"Transoral decompression for craniovertebral osseous anomalies: perioperative management dilemmas","volume":"47","author":"Jain","year":"1999"},{"issue":"1 Suppl","key":"b22-focus15498","series-title":"Neurosurgery","first-page":"E213","article-title":"The expanded endonasal approach: a fully endoscopic transnasal approach and resection of the odontoid process: technical case report","volume":"57","author":"Kassam","year":"2005"},{"key":"b23-focus15498","series-title":"World Neurosurg","first-page":"713","article-title":"Endoscopic endonasal versus open transcranial resection of anterior midline skull base meningiomas","volume":"77","author":"Komotar","year":"2012"},{"key":"b24-focus15498","series-title":"J Neurosurg Spine","first-page":"376","article-title":"Endonasal endoscopic resection of the odontoid process in a nonachondroplastic dwarf with juvenile rheumatoid arthritis: feasibility of the approach and utility of the intraoperative Iso-C three-dimensional navigation. Case report","volume":"8","author":"Laufer","year":"2008"},{"key":"b25-focus15498","series-title":"Spine (Phila Pa 1976)","first-page":"E139","article-title":"Endonasal endoscopic resection of an os odontoideum to decompress the cervicomedullary junction: a minimal access surgical technique","volume":"34","author":"Leng","year":"2009"},{"key":"b26-focus15498","series-title":"Skull Base","first-page":"151","article-title":"Transoral approach and extended modifications for lesions of the ventral foramen magnum and craniovertebral junction","volume":"18","author":"Liu","year":"2008"},{"issue":"4","key":"b27-focus15498","series-title":"Neurosurg Focus","first-page":"E17","article-title":"Endoscopic endonasal transclival transodontoid approach for ventral decompression of the craniovertebral junction: operative technique and nuances","volume":"38","author":"Liu","year":"2015"},{"key":"b28-focus15498","series-title":"Childs Nerv Syst","first-page":"1187","article-title":"Surgical approaches: postoperative care and complications \u201ctransoral-transpalatopharyngeal approach to the craniocervical junction\u201d","volume":"24","author":"Menezes","year":"2008"},{"key":"b29-focus15498","series-title":"J Neurosurg","first-page":"895","article-title":"Transoral-transpharyngeal approach to the anterior craniocervical junction. Ten-year experience with 72 patients","volume":"69","author":"Menezes","year":"1988"},{"key":"b30-focus15498","series-title":"J Neurosurg","first-page":"500","article-title":"Odontoid upward migration in rheumatoid arthritis. An analysis of 45 patients with \u201ccranial settling\u201d","volume":"63","author":"Menezes","year":"1985"},{"key":"b31-focus15498","series-title":"Neurosurgery","first-page":"1045","article-title":"Transoral odontoidectomy","volume":"56","author":"Mummaneni","year":"2005"},{"key":"b32-focus15498","series-title":"Am J Rhinol","first-page":"601","article-title":"Experience with the expanded endonasal approach for resection of the odontoid process in rheumatoid disease","volume":"21","author":"Nayak","year":"2007"},{"key":"b33-focus15498","series-title":"Childs Nerv Syst","first-page":"1971","article-title":"Endoscopic endonasal odontoidectomy in a child with chronic type 3 atlantoaxial rotatory fixation: case report and literature review","volume":"28","author":"Patel","year":"2012"},{"issue":"5 Suppl 2","key":"b34-focus15498","series-title":"Neurosurgery","first-page":"437","article-title":"Endoscopic image-guided transoral approach to the craniovertebral junction: an anatomic study comparing surgical exposure and surgical freedom obtained with the endoscope and the operating microscope","volume":"64","author":"Pillai","year":"2009"},{"issue":"4","key":"b35-focus15498","series-title":"Neurosurg Focus","first-page":"E15","article-title":"Evolution from microscopic transoral to endoscopic endonasal odontoidectomy","volume":"37","author":"Ponce-G\u00f3mez","year":"2014"},{"key":"b36-focus15498","series-title":"Spine","first-page":"E901","article-title":"Transoral endoscopic odontoidectomy to decompress the cervicomedullary junction","volume":"38","author":"Qiuhang","year":"2013"},{"key":"b37-focus15498","series-title":"World Neurosurg","first-page":"583","article-title":"Comparison of endoscopic transnasal and transoral approaches to the craniovertebral junction","volume":"74","author":"Seker","year":"2010"},{"key":"b38-focus15498","series-title":"Acta Neurochir Suppl (Wien)","first-page":"69","article-title":"The transoral approach to the anterior superior cervical spine. 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