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. 2021 Apr;41(Suppl. 1):S51-S58.
doi: 10.14639/0392-100X-suppl.1-41-2021-05.

Multidisciplinary approach to the craniovertebral junction. Historical insights, current and future perspectives in the neurosurgical and otorhinolaryngological alliance

Massimiliano Visocchi  1   2   3 , Francesco Signorelli  1 , Claudio Parrilla  4 , Gaetano Paludetti  4   3 , Mario Rigante  4   3
Affiliations

Multidisciplinary approach to the craniovertebral junction. Historical insights, current and future perspectives in the neurosurgical and otorhinolaryngological alliance

Massimiliano Visocchi et al. Acta Otorhinolaryngol Ital. 2021 Apr.

Abstract

Approccio multidisciplinare alla giunzione cranio vertebrale. Cenni storici, attuali orientamenti e prospettive future nell’alleanza tra neurochirurgia ed otorinolaringoiatria.

Riassunto: Storicamente considerata “terra di nessuno”, la regione della giunzione cranio-vertebrale, così come la chirurgia di questa sede, hanno guadagnato altissima considerazione negli anni recenti per la complessità anatomica, funzionale e tecnica. La gestione multidisciplinare e l’alleanza tra neurochirurghi e otorinolaringoiatri anche in questo ambito è diventata sempre più forte negli anni. La giunzione cranio-vertebrale ha una architettura anatomica ossea, neurovascolare e muscolare unica e complessa in quanto non solo separa e congiunge il cranio con il rachide cervicale, ma presenta pattern speciali di flessione, estensione e rotazione assiale. La stabilità è garantita da una complessa combinazione di supporti ossei e ligamentosi, che consentono ampi gradi di motilità. La conoscenza dell’anatomia e della fisiologia della giunzione cranio-vertebrale consente di comprendere meglio le procedure chirurgiche e le patologie specifiche che interessano questa regione anatomica. Sebbene siano passati anni dell’inizio della chirurgia pioneristica di questa regione, le lesioni situate nella porzione anteriore della giunzione cranio-vertebrale rimangono ancora una stimolante sfida per il neurochirurgo. Molti studi sono presenti in letteratura con l’intento di esaminare l’anatomia microchirurgica delle porzioni anteriori, posteriori, extra e intradurali della giunzione cranio-vertebrale, così come le differenze e tutte le possibili vie di approccio a 360° per esporre al meglio e trattare patologie di questa regione. In questa revisione verrà effettuata una disamina sullo stato dell’arte in tale chirurgia, partendo dall’esperienza personale, dalle pubblicazioni e dalla letteratura più recente, al fine di sottolineare quando la collaborazione multidisciplinare sia fondamentale, altamente consigliata o non strettamente necessaria nella gestione delle patologie della regione cranio-vertebrale.

Keywords: craniovertebral junction; endoscopy; extreme lateral approach; far lateral approach; instrumentation and fusion; submandibular retropharyngeal approach; transnasal approach; transoral approach.

Plain language summary

Historically considered as a nobody’s land, craniovertebral junction (CVJ) surgery or specialty recently gained high consideration as symbol of challenging surgery as well as selective top level qualifying surgery. The alliance between Neurosurgeons and Otorhinolaringologists has become stronger in the time. CVJ has unique anatomical bone and neurovascular structures architecture. It not only separates from the subaxial cervical spine but it also provides a special cranial flexion, extension, and axial rotation pattern. Stability is provided by a complex combination of osseous and ligamentous supports which allows a large degree of motion. The perfect knowledge of CVJ anatomy and physiology allows to better understand surgical procedures of the occiput, atlas and axis and the specific diseases that affect the region. Although many years passed since the beginning of this pioneering surgery, managing lesions situated in the anterior aspect of the CVJ still remains a challenging neurosurgical problem. Many studies are available in the literature so far aiming to examine the microsurgical anatomy of both the anterior and posterior extradural and intradural aspects of the CVJ as well as the differences in all the possible surgical exposures obtained by 360° approach philosophy. Herein we provide a short but quite complete at glance tour across the personal experience and publications and the more recent literature available in order to highlight where this alliance between Neurosurgeon and Otorhinolaringologist is mandatory, strongly advisable or unnecessary.

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Conflict of interest statement

Conflict of interest

The Authors declare no conflict of interest.

Figures

Figure 1.
Figure 1.
Anatomical studies comparing the exposure of transoral (A) and endoscopic transnasal approach (B, C) followed by exposure of the anterior arch of C1 (D), odontoid (E) and its removal (F) through a combined transoral transnasal approach.
Figure 2.
Figure 2.
Importance of accurate preoperative radiological evaluation in order to choose the best corridor of approach. (A) CT scan of children with impression basilaris in which we preferred a transnasal corridor. (B) Angio CT showing an internal carotid kinking in the pharyngeal wall that exclude the anterior route to the CVJ.
Figure 3.
Figure 3.
Use of navigation system to perform a biopsy of a lesion (arrow) of the odontoid on sagittal and axial MRI (A, B, C). Intraoperative view with CT scan (D, E, F) The cross-air revealed a correct target reached through a minimally invasive EEA. The biopsy revealed a localization of myeloma.
Figure 4.
Figure 4.
Axial CT scan (A) and T2 weighted MRI (B) of platybasia and impressio basilaris with bulbo-medullar compression (rounded area) treated through a pure transnasal endoscopic approach. In the inferior line post-operative CT scan (C) and MRI (D) showing a decompression of the bulbopontine (arrow) angle and the posterior stabilization (*) the absence of tracheostomy can be also observed.
Figure 5.
Figure 5.
CT scan (A) and T2 (B) and T1(C) weighted MRI of a case of impressio basilaris and platybasia + bulbo-medullar compression (rounded area) This lesion was treated with transoral approach that allowed a wide exposure and resection from clivus to C1(⎨) and decompression (arrow) as showed in postoperative CT (D) and T2 (E) and T1(F) MRI, in which you can observe the presence of tracheostomy (*).
See this image and copyright information in PMC

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