Considerations on "Endoscopic endonasal approach to the craniocervical junction: the importance of anterior C1 arch preservation or its reconstruction"*

Letter to the editor Considerations on " Endoscopic endonasal approach to the craniocervical junction: the importance of anterior C1 arch preservation or its reconstruction " * Considerazioni su " Approccio endoscopico endonasale alla cerniera craniocervicale: il ruolo della preservazione dell'arco anteriore di C1 o della sua ricostruzione " Dear Editor, i should like to make some comments of the paper of re et al. *. The authors report on 10 patients undergoing endoscopic endonasal decompression for different CCJ pathologies. in 8 patients, the authors were able to preserve the anterior C1 arch, while in 2 cases they reconstructed it with clinical improvement or stabilisation and preservation of spinal stability in all without posterior fixa-tion (mean follow-up of 31 months). Four surgical technical topics deserve particular consideration in this paper. • The assumed superiority of a transnasal approach compared with a transoral approach to the CCJ. • The BLOCKINdural BLOCKINopening BLOCKINand BLOCKINtumour BLOCKINremoval BLOCKINin BLOCKINcase BLOCKINof BLOCKINC1-C2 neoplastic lesions. • The BLOCKINendoscopic BLOCKINpannus BLOCKINremoval BLOCKINand BLOCKINsubsequent BLOCKINante-rior screw fixation by self-tapping screws for a better fracture healing and spinal realignment (only for inveterate C2 Anderson-D'Alonso type ii fractures). • The BLOCKINanterior BLOCKINarch BLOCKINof BLOCKINC1 BLOCKINreconstruction BLOCKINa) BLOCKINby BLOCKINplacing bone chips compressed between the bone under en-doscopic control and subsequent fixation with three screws and one plate or b) with autologous bone graft and titanium mash (in a non-union anterior atlas fracture after conservative treatment that developed C1 lateral masses displacement with cranial settling). Point to point considerations 1) The assumed superiority of a transnasal approach compared with a transoral approach to the CCJ. The authors comment that " the transoral-transpharyngeal technique, BLOCKINis BLOCKINstill BLOCKINconsidered BLOCKINthe BLOCKINgold BLOCKINstandard BLOCKINanterior BLOCKINap-proach BLOCKINand BLOCKINstill BLOCKINrepresents BLOCKINthe BLOCKINmost BLOCKINexperienced BLOCKINtechnique. However, BLOCKINthis BLOCKINsurgical BLOCKINtechnique BLOCKINis BLOCKINnot BLOCKINproperly BLOCKINmininvasive since this approach often involves the splitting of structures such as the soft palate, mandible and maxilla ". otherwise they proudly claim to perform " routinely posterior hard palate outer bone layer drilling in order to make it more flexible to enhance the angle of " nasopalatine line ". Such a contradictory statement apparently seems to go against the assumed superiority of a transnasal approach over a tran-soral approach. in fact, according to our experience, the 30° endoscope has been proposed for the transoral approach to avoid full soft-palate splitting, hard-palate splitting or extended maxillo/ mandibulotomy. Using the endoscope, the operator is able to look in all …