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  • Author or Editor: Andrew S. Little x
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Andrew S. Little, Luis Perez-Orribo, Nestor G. Rodriguez-Martinez, Phillip M. Reyes, Anna G. U. S. Newcomb, Daniel M. Prevedello and Neil R. Crawford


Endoscopic endonasal approaches to the craniovertebral junction (CVJ) and clivus are increasingly performed for ventral skull-base pathology, but the biomechanical implications of these approaches have not been studied. The aim of this study was to investigate the spinal biomechanics of the CVJ after an inferior-third clivectomy and anterior intradural exposure of the foramen magnum as would be performed in an endonasal endoscopic surgical strategy.


Seven upper-cervical human cadaveric specimens (occiput [Oc]–C2) underwent nondestructive biomechanical flexibility testing during flexion-extension, axial rotation, and lateral bending at Oc–C1 and C1–2. Each specimen was tested intact, after an inferior-third clivectomy, and after ligamentous complex dissection simulating a wide intradural exposure using an anterior approach. Angular range of motion (ROM), lax zone, and stiff zone were determined and compared with the intact state.


Modest, but statistically significant, hypermobility was observed after inferior-third clivectomy and intradural exposure during flexion-extension and axial rotation at Oc–C1. Angular ROM increased incrementally between 6% and 12% in flexion-extension and axial rotation. These increases were primarily the result of changes in the lax zone. No significant changes were noted at C1–2.


Inferior-third clivectomy and an intradural exposure to the ventral CVJ and foramen magnum resulted in hypermobility at Oc–C1 during flexion-extension and axial rotation. Although the results were statistically significant, the modest degree of hypermobility observed compared with other well-characterized CVJ injuries suggests that occipitocervical stabilization may be unnecessary for most patients.

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George A. C. Mendes, Curtis A. Dickman, Nestor G. Rodriguez-Martinez, Samuel Kalb, Neil R. Crawford, Volker K. H. Sonntag, Mark C. Preul and Andrew S. Little


The primary disadvantage of the posterior cervical approach for atlantoaxial stabilization after odontoidectomy is that it is conducted as a second-stage procedure. The goal of the current study is to assess the surgical feasibility and biomechanical performance of an endoscopic endonasal surgical technique for C1–2 fixation that may eliminate the need for posterior fixation after odontoidectomy.


The first step of the study was to perform endoscopic endonasal anatomical dissections of the craniovertebral junction in 10 silicone-injected fixed cadaveric heads to identify relevant anatomical landmarks. The second step was to perform a quantitative analysis using customized software in 10 reconstructed adult cervical spine CT scans to identify the optimal screw entry point and trajectory. The third step was biomechanical flexibility testing of the construct and comparison with the posterior C1–2 transarticular fixation in 14 human cadaveric specimens.


Adequate surgical exposure and identification of the key anatomical landmarks, such as C1–2 lateral masses, the C-1 anterior arch, and the odontoid process, were provided by the endonasal endoscopic approach in all specimens. Radiological analysis of anatomical detail suggested that the optimal screw entry point was on the anterior aspect of the C-1 lateral mass near the midpoint, and the screw trajectory was inferiorly and slightly laterally directed. The custommade angled instrumentation was crucial for screw placement. Biomechanical analysis suggested that anterior C1–2 fixation compared favorably to posterior fixation by limiting flexion-extension, axial rotation, and lateral bending (p > 0.3).


This is the first study that demonstrates the feasibility of an endoscopic endonasal technique for C1–2 fusion. This novel technique may have clinical utility by eliminating the need for a second-stage posterior fixation operation in certain patients undergoing odontoidectomy.

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Paul A. Gardner, Juan C. Fernandez-Miranda, Carl H. Snyderman and Eric W. Wang