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J Neurol Surg B Skull Base
DOI: 10.1055/a-2565-9342
Original Article

Novel Strategies for Expanding the Endoscopic Caudal Access to the Craniovertebral Junction: A Cadaveric Comparative Analysis of Nasofrontal Trephination and Posterior Palatectomy

Authors

  • Moataz D. Abouammo 

    1   Department of Otorhinolaryngology-Head and Neck Surgery, Faculty of Medicine, Tanta University, Tanta, Egypt
    2   Department of Otolaryngology-Head and Neck Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, United States

  • Maithrea S. Narayanan 

    3   Department of Otolaryngology and Head–Neck Surgery, Hospital Kuala Lumpur, Jalan Pahang, Kuala Lumpur, Wilayah Persekutuan Kuala Lumpur, Malaysia

  • Mohammad Bilal Alsavaf 

    2   Department of Otolaryngology-Head and Neck Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, United States

  • Mohammed Alwabili 

    4   Department of Otorhinolaryngology-Head and Neck Surgery, Prince Sultan Military Medical City, Riyadh, Saudi Arabia

  • Simona Serioli 

    5   Division of Neurosurgery, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, Spedali Civili of Brescia, University of Brescia, Brescia, Italy

  • Guilherme Mansur 

    6   Department of Neurological Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, United States

  • Jimmy Qiu

    7   Department of Electrical and Computer Engineering, TECHNA Institute, University Health Network, Toronto, Ontario, Canada

  • Chandrima Biswas 

    6   Department of Neurological Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, United States

  • Noha E. Shalaby 

    8   Faculty of Medicine, Tanta University, Tanta, Egypt

  • Serena Capelli 

    9   Bioengineering Department, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Ranica (BG), Italy

  • Jaskaran S. Gosal 

    10   Department of Neurosurgery, All India Institute of Medical Sciences (AIIMS), Jodhpur, Rajasthan, India

  • Mohamed Ammo 

    11   Clinical Epidemiology Department, The University of Western Ontario, London, Ontario, Canada

  • Mona A. H. Shehata 

    12   Department of Tropical Medicine and Infectious Diseases, Faculty of Medicine, Tanta University, Tanta, Egypt

  • Kyle K. VanKoevering 

    2   Department of Otolaryngology-Head and Neck Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, United States

  • Kyle C. Wu 

    6   Department of Neurological Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, United States

  • Francesco Doglietto 

    13   Department of Neurosurgery, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy

  • Daniel M. Prevedello 

    6   Department of Neurological Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, United States

  • Ricardo L. Carrau 

    2   Department of Otolaryngology-Head and Neck Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, United States

Financial Support There was no financial or funding support for the project.
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Abstract

Objectives

Although the endoscopic endonasal approach (EEA) has emerged as a preferred alternative to traditional transoral access for craniovertebral junction (CVJ) surgery, its limited inferior reach beyond the C1 level remains a significant challenge. This study investigates the effectiveness of using a contralateral nasofrontal trephination (CNT) or a posterior palatectomy (PP) to enhance the caudal reach to the CVJ region.

Design

A quantitative cadaveric study.

Setting

Cadaver dissection laboratory.

Participants

A total of 15 adult human cadaveric heads.

Methods

EEA, EEA + PP, and EEA + CNT approaches to the CVJ were performed. Neuronavigation was used for objective measurements quantifying the volume of surgical freedom, surface area of deep exposure, entry point sagittal angle, and inferior reach below the odontoid process.

Main Outcome Measures and Results

EEA + CNT demonstrated superior surgical metrics across all parameters. Surface exposure was significantly greater with EEA + CNT (107.04 cm2) versus EEA + PP (86.26 cm2) and standard EEA (69.78 cm2; p < 0.001). The volume of surgical freedom showed similar superiority with EEA + CNT (60.21 cm3), followed by EEA + PP (34.14 cm3) and EEA (26.13 cm3; p < 0.001). Inferior reach below the odontoid (CNT: 6.35 cm; PP: 2.17 cm; EEA: 0.9 cm; p < 0.0001) and surgical trajectory angle (CNT: 50.1 degrees; PP: 21.4 degrees; EEA: 16.6 degrees; p < 0.0001) demonstrated significant stepwise improvements with each adjunct technique.

Conclusion

Both CNT and PP techniques significantly enhance the surgical corridor of traditional EEA for CVJ access. A CNT afforded superior surgical exposure while maintaining minimal invasiveness. PP offers a viable alternative when external incisions are undesired and lesions are confined within the C2–C3 level.

Keywords

3D photogrammetry - craniovertebral junction - endoscopic endonasal approach - endoscopic endonasal odontoidectomy - multiport endoscopic surgery - nasofrontal trephination - posterior palatectomy - quantitative analysis - skull base

Data Availability Statement

The data that support the findings of this study are available from the corresponding author upon reasonable request.


This article was selected to receive the Rhoton Award at the 34th North American Skull Base Society Conference in New Orleans, Louisiana, USA, 2025.




Publication History

Received: 16 January 2025

Accepted: 21 March 2025

Accepted Manuscript online:
25 March 2025

Article published online:
12 May 2025

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