Transoral Versus Transnasal Approach for Craniovertebral Junction Pathologies: Never Say Never

For many years, the microsurgical transoral approach (TOA) has been accepted as the "gold standard" for the surgical treatment of a variety of congenital, developmental, and acquired pathologies affecting the craniovertebral junction. In the present study, we try to investigate both experimental and clinical fronts of such a challenging surgery, starting from the updated literature experience. TOA is actually presented as an "old-fashioned" surgical technique dealing with possible bacterial contamination, the need of postoperative nose gastric tube feeding for a week, the possible nasopharyngeal incompetence, and the postoperative tongue swelling. Otherwise, the endoscopic endonasal approach (EEA) appears strongly supported by the modern literature as the true "minimally invasive" procedure.

Our clinical experience deals with 23 anterior procedures in paediatric and adult patients (17 TOA and 6 EEA). We further report on our experimental cadaver laboratory study of 12 subjects.

All the patients of TOA group but one were discharged after posterior procedures within two weeks and improved or remained unchanged after surgery and during the follow-up. No mayor complications occurred in TOA group. In EEA group two patients died for cerebrospinal fluid infection, for disease progression and for heart attack.

Our and other available data suggest that no clear superiority of EEA over endoscopic TOA can be assessed so far; on the other hand, EEA can produce complications similar to TOA in craniovertebral junction surgery.