Clinical Neurology and Neurosurgery 121 (2014) 1–9

Contents lists available at ScienceDirect

Clinical Neurology and Neurosurgery

journal homepage: www.elsevier.com/locate/clineuro

Endoscopic-assisted microsurgical techniques at the craniovertebral

junction: 4 illustrative cases and literature review
Silky Chotai a , Varun R. Kshettry a,b , Mario Ammirati a,∗
a
Dardinger Skull Base Laboratory, Department of Neurological Surgery, Ohio State University Medical Center, Columbus, USA
b
Department of Neurological Surgery, Cleveland Clinic, Cleveland, USA

a r t i c l e i n f o a b s t r a c t

Article history: Background: Endoscopic-assisted microsurgery (EAM) techniques are employed to improve visualization
Received 17 December 2013 of the surgical field while minimizing brain retraction and trauma to neurovascular structures. There have
Received in revised form 24 February 2014 been several reports in the literature on the indications and advantages of endoscopic-assisted techniques
Accepted 5 March 2014
when operating at the craniovertebral junction (CVJ). The purpose of this study was to present illustrative
Available online 13 March 2014
cases and to perform a literature review of endoscopic-assisted microsurgical techniques at the CVJ.
Methods: A review of the literature was compiled through MEDLINE/OVID and using cross-references of
Keywords:
articles on Pubmed. Illustrative cases from the senior author’s clinical series are presented to highlight
Neurosurgery
Endoscopic-assisted
indications and the utility of EAM at the CVJ.
Craniovertebral junction Results: Our literature review supports the utility of the endoscope in the transoral, transcervical, lateral,
far lateral and posterolateral approaches. In particular EAM can be used in the transoral approach to
increase surgical exposure of the clivus and minimize the need to split the soft palate while in the far
lateral and posterolateral approaches, EAM can improve visualization down narrow or deep surgical
corridors to help identify critical neurovascular structures and minimize the need for extensive bony
removal. In general, the endoscope can be used to look around bony, vascular, or neoplastic lesions
to visualize the surgical space behind these structures as well as to assess for tumor remnants after
microsurgical resection.
Conclusion: EAM techniques can improve illumination and visualization of the surgical field at the CVJ. In
addition, the EAM techniques can help to minimize the need for brain retraction or extensive exposures.
Utilization of both the endoscope and the microscope allows the surgeon to benefit from the advantages
of each modality.
© 2014 Elsevier B.V. All rights reserved.

Contents

1. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
2. Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
3. Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
3.1. Transoral approach . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
3.2. Transcervical approach . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
3.3. Lateral approaches . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
3.4. Posterior approaches . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
4. Illustrative cases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
4.1. Case #1: small anterior tumor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
4.2. Case #2: anterolateral tumor with hypoglossal extension . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

∗ Corresponding author at: Department of Neurological Surgery, Ohio State University Medical Center, N1025 Doan Hall, 410 W. 10th Avenue, Columbus 43210, USA.
Tel.: +1 614 293 1970.
E-mail addresses: silky.chotai@live.com (S. Chotai), Mario.Ammirati@osumc.edu (M. Ammirati).

http://dx.doi.org/10.1016/j.clineuro.2014.03.004
0303-8467/© 2014 Elsevier B.V. All rights reserved.
2 S. Chotai et al. / Clinical Neurology and Neurosurgery 121 (2014) 1–9

4.3. Case #3: lateral tumor obscuring the lower cranial nerves . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
4.4. Case #4: vascular identification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
5. Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
5.1. Maximizing optical properties . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
5.2. Classification of endoscopic-assisted techniques . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
5.3. Utility of the semi-sitting position in CVJ surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
5.4. Limitations of endoscopic-assisted techniques . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
5.5. Next steps . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
6. Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Funding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

1. Introduction
junction,” “transoral,” “transcervical,” “far lateral,” “suboccipi-
tal,” “retrocondylar,” “transatlantal,” or “extreme lateral.” Search
A urologist in Chicago, V.L. L’Espinasse, provided the first pub-
result abstracts were reviewed for pertinent papers including
lished description of the use of an endoscope in a neurosurgical
reviews, clinical series, and laboratory investigations.
procedure in 1917, when he used a cystoscope to perform an
endoscopic choroid plexus coagulation [1,2]. This first attempt
highlighted a new innovation in neurosurgery – the ability to obtain 3. Results
a panoramic view of the surgical field with good illumination in
a narrow surgical corridor using the endoscope. Despite this dis- A number of surgical approaches to the CVJ have been devel-
covery, endoscopes were not widely adapted in neurosurgery until oped over the last several decades. These approaches can be
the invention of the Hopkins rigid rod lens in the 1960s that pro- divided into anterior, lateral, and posterior approaches. Within the
vided superior optics suitable for neurosurgical use [3]. Shortly anterior approaches are the transoral and endoscopic endonasal
thereafter, Perneczky was one of the first to popularize the use of transclival [22,24–30]. The lateral approaches include the extreme
the endoscope as an adjunctive tool for visualization and surgical lateral, transatlantal or direct lateral, and anterolateral approaches
manipulations while performing intracranial microsurgical proce- [31–36]. Finally, the posterior approaches include the far lateral,
dures [4–7]. He coined the term “endoscopic-controlled” surgery posterolateral, and midline suboccipital approaches [31,33,37–43].
to indicate when surgical manipulations are performed under sole The endoscope has been incorporated as an adjunct in several of
endoscopic visualization. This is opposed to “endoscopic-assisted” these approaches.
microsurgery (EAM), in which the endoscope is used as a visual-
ization adjunct, but primary surgical manipulations are performed 3.1. Transoral approach
under microscopic visualization. Since then several neurosurgeons
have incorporated endoscopic-assisted microsurgery (EAM) for The transoral approach provides direct exposure of anterior
various skull base pathologies. The use of endoscopes to visual- pathology at the CVJ. Several cadaveric studies have demonstrated
ize pertinent anatomical features during microsurgery has been the utility of endoscopic-assisted techniques to complement
described for a wide array of neurosurgical procedures including the standard microsurgical transoral approach [22,26,44]. In a
for inspection of the suprasellar cistern after transcranial resection cadaveric quantitative study, the surgical area exposed over the
of craniopharyngioma [8,9], inspection of the trigeminal or facial posterior pharyngeal wall was significantly greater with the endo-
nerve during microvascular decompression [10,11], to visualize the scope compared to the microscope without any compromise
posterior third ventricle and pineal gland during a supracerebellar of surgical freedom. More importantly, the extent of the clivus
infratentorial approach for pineal tumors [12,13], and to visual- exposed without splitting the soft palate was significantly greater
ize the seventh nerve during the surgical resection of vestibular with the endoscope (9.5 ± 0.7 mm) compared to the microscope
schwannomas and other cerebellopontine angle tumors [14–18]. (2.0 ± 0.4 mm) (P < 0.05) [22]. A 30◦ endoscope can significantly
Endoscopic-assisted techniques are employed to improve visu- increase the surgical working area.
alization of the surgical field while minimizing brain retraction and In a clinical series of seven patients that underwent the transoral
trauma to neurovascular structures. The endoscope can provide approach with EAM, the authors qualitatively concluded that the
increased illumination and higher magnification with a wider view use of the endoscope allowed for a more radical decompression
angle and increased depth of field. The benefit can be particularly as demonstrated by post-decompression contrasted fluoroscopy
seen in narrow surgical corridors, angled spaces, and regions with compared to their microsurgical transoral technique alone [44].
multiple neurovascular structures that need to be identified and Another clinical study utilized endoscopic transoral (2), endonasal
preserved while working in the space around and beyond them. (2), and combined (4) approaches in 8 patients. Compared to a
In this way, the potential benefit of EAM while operating at the cohort undergoing a transoral transpalatal approach, the endo-
craniovertebral junction (CVJ) is evident. There have been sev- scopic cohort had significantly reduced length of hospital stay
eral reports in the literature on the indications and advantages of and reduced need for prolonged intubation or tracheostomy [26].
endoscopic-assisted techniques when operating at the CVJ [19–24]. Incision of the palate and posterior pharyngeal wall as well as
The purpose of this study was to present illustrative cases and to prolonged retraction of the tongue can result in increased orop-
perform a literature review of endoscopic-assisted microsurgical haryngeal edema and postoperative airway obstruction.
techniques at the CVJ.
3.2. Transcervical approach
2. Methods
The transcervical approach has been used as an alternative
A review of the literature was compiled through MEDLINE/OVID approach to the anterior mid-lower clivus and foramen magnum. A
and we searched reference section of articles for additional refer- cadaveric study demonstrated that the high anterior transcervical
ences on Pubmed, using the terms “endoscope,” “endoscopic,” or approach with anterior far-lateral clivectomy and inferior petrosec-
“endoscopic-assisted” in combination with either “craniovertebral tomy extends the exposure to include the cerebellopontine angle
 S. Chotai et al. / Clinical Neurology and Neurosurgery 121 (2014) 1–9 3

Fig. 1. Preoperative axial (a) and sagittal (b) T1-weighted gadolinium enhanced MRI demonstrating a 9-mm enhancing mass anterior to the medulla.

in front of the cranial nerves. An endoscope can be inserted through
the final exposure achieved. The anterior surface of brainstem from
the pontomesencephalic sulcus to the medulla (at the mid portion
of the olive), the distal vertebral arteries, anterior spinal arteries,
vertebrobasilar junction and the basilar artery and its branches can
be visualized. A corridor to insert the endoscope lateral to the brain-
stem can be created by extradural bone resection lateral to the
petroclival fissure. The CNs III through XII can be viewed through
this corridor [24].
Several clinical studies have demonstrated that the endoscopic
transcervical odontoidectomy through a tubular retractor with
two-staged and one-staged posterior fusion allows access to the
ventral CVJ pathology without need of prolonged intubation, tra-
cheostomy, enteral feeding by a gastrostomy tube or prolonged
hospitalization [45–48]. The advantages of this approach compared
to other ventral approach include a direct access to pathology
with the avoidance of cranial nerves, an uncontaminated field and
improved lateral exposure. One of the potential consequences of
this approach is iatrogenic CVJ instability.
3.3. Lateral approaches
The lateral transatlantal or direct lateral approach was
introduced for resection of the odontoid as an alternative to the

Fig. 2. Intraoperative picture after right posterolateral craniectomy, right C1 hemilaminectomy, and dural opening. (a) 2.7 mm 0◦ endoscope inserted between the vertebral
artery (V) and caudal loop of the posterior inferior cerebellar artery (P). (b–d) Endoscopic views during progressive advancement of the endoscope to the tumor (black
arrow) in the premedullary cistern. (e) Demonstration of contralateral vertebral artery (white arrow). (f) Postoperative T1-weighted contrasted MRI demonstrating gross total
resection of the mass.
4 S. Chotai et al. / Clinical Neurology and Neurosurgery 121 (2014) 1–9
transoral approach or for anterior CVJ pathologies with significant
lateral extension [49]. Advantages of the lateral approach includes
the ability to directly control any dural tears, a sterile operating
environment, and the ability to fuse during the same operation [21].
For CVJ malformations, especially during dens removal through the
lateral approach, the blind spots under the microscope may result
in substandard decompression and complications such as dural
tears and CSF leak. In a cadaveric study demonstrating the endo-
scopic assisted lateral transatlantal approach, the identification and
drilling of the dens was performed under endoscopic visualization.
Both straight and angled scopes provided a good view of the base of
the dens, the adjacent dura, and the contralateral atlanto-occipital
and atlanto- axial joints. The incorporation of the endoscope allows
for a complete removal of the odontoid process and decompression
of the anterior thecal sac. In addition, the contralateral atlanatoccip-
ital joints can be better visualized under endoscopic view [21]. The
use of the endoscope can provide an adequate view of the depth
of the operative site in a variety of positions and this can allow
flexibility in patient positioning when there are disease-related
restrictions. This feasibility of using endoscope assistance during
a lateral transatlantal approach in the cadaveric models has not yet
been demonstrated in clinical studies. Further clinical studies are
needed to comment on the maneuverability and ability to remove
the anterior CVJ pathologies using endoscopic assistance during the
lateral transatlantal approach.
3.4. Posterior approaches
Several cadaveric studies have demonstrated the use and ben-
efits of EAM in the far lateral approach [19,50]. One study divided
the corridors for inserting the endoscope into upper, middle and
lower corridors. The upper corridor is enclosed by the CNs 7–8
rostrally, cerebellum medially, CNs 9–10 caudally and dura later-
ally. Introducing a 0◦ lens in the upper corridor provides a view
of the basilar artery (BA) and perforators, anterior inferior cerebel-
lar artery (AICA), and the anterior brainstem. The middle corridor
is defined by CNs 9–10 rostrally, CN 12 caudally, brainstem medi-
ally and dura laterally. This corridor provides a view of bilateral
verterbral arteries, the BA and perforators, anterior spinal artery
(ASA), bilateral AICAs, and anterior brainstem. The introduction of
30◦ endoscope into the lower corridor – enclosed by CN 12 ros-
trally, CN 11 laterally and brainstem medially – provides a view of
bilateral VAs, ASA and the ventral aspect of the exit zone of CN 12
[19].
For access to anterior and anterolateral CVJ lesions, the
transcondylar and retocondylar approaches are most commonly
employed. One cadaveric study compared the difference in the
exposure of the petroclival region between the keyhole far lat-
eral retrocondylar approach and the far lateral transcondylar
transtubercular approach [50]. The petroclival exposure with
the keyhole retrocondylar approach was improved significantly
using the straight endoscope 1147.80 mm2 compared to operat-
ing microscope 756.28 ± 50.73 mm2. In addition, the incorporation
of, both 0◦ and 30◦ endoscopes in the keyhole far-lateral
retrocondylar approach, provides a petroclival exposure area
1147.80 ± 159.57 mm2 and 1409.94 ± 155.18 mm2 respectively
greater than that provided by far lateral transcondylar transtu-
bercular keyhole microscopic approach (1066.26 ± 165.06) mm2
(P < 0.05).
Another cadaveric study compared the 3D endoscopic and
microscopic view in the far-lateral approach after partial condylec-
tomy and resection of the jugular tubercle [51]. They demonstrated
that the 3D endoscope provided better visualization of the pon-
tomedullary portion of the AICA, subarcuate artery, labyrinthine
artery, pontomedullary vein, tonsillomedullary segment of PICA,
origin of PICA, union of VA-BA, ASA, and lateral aspect of the lower
CNs. However, the study concluded that the 3D endoscopic probe
was too large and the surgical corridors for proper visualization of
deeper structures may provide reasonably safe entry, but would
significantly hamper surgical maneuverability.
The endoscope has been utilized to minimize bony exposure
required in the far lateral approach. One such approach is the min-
imally invasive supracondylar transtubercular (MIST) approach to
the lower clivus. Russo et al. in their cadaveric study described
the MIST approach as a minimally invasive alternative to the far-
lateral transtubercular approach [23]. The suboccipital craniotomy
extends from the posterolateral rim of the foramen magnum to the
medial edge of the sigmoid sinus and condyle drilling is limited to
the superior posteromedial aspect of condyle. The condylar fossa
above the condyle is drilled to expose the roof of the hypoglos-
sal canal, which is followed by extradural dissection of juglar
tubercle. The MIST approach enables introduction of endoscope
through three corridors: superiorly above CN X and inferolateral
to the flocculus, medially through the enlarged space created by
the removal of jugular tubercle between CN IX and CN XI, and
inferomedially beneath CN IX to view the basion. The advantages
of MIST over the traditional far-lateral transtubercular approach
are smaller skin incision, localized suboccipital craniotomy, no
removal or exposure of C1 arch, limited resection of the occip-
ital condyle and an extradural resection of the jugular tubercle.
Russo et al. qualitatively compared the exposure between the MIST
and far-lateral transcondylar approach; they concluded that the
exposure of lateral medulla and lower clivus is identical between
both approaches. The posterior and anterolateral foramen magnum
were better visualized with the extended far lateral approach. How-
ever, incorporation of EAM in MIST enables excellent visualization
of the anterolateral aspect of the brainstem, CNs III through XII,
the vertebral arteries bilaterally, PICA, anterior spinal artery, VB
junction, the basilar artery and its branches and upper part of the
cerebellopontine angle [23].
Another cadaveric study described a pure endoscopic far-lateral
approach, as a minimally invasive alternative to the microscopic
far-lateral approach [20]. This approach includes a small 3-cm
skin incision behind the mastoid process and partial exposure of
superior oblique and rectus capitis muscle. The endoscope can
be introduced through the exposed area to identify the atlanto-
occipital membrane, posterior arch of atlas and vertebral artery.
Several extensions including transcondylar, supracondylar and
paracondylar has been demonstrated in cadaveric illustrations. In
addition, the intradural exposure includes neurovascular struc-
tures from CN VII to dorsal root of C2, anterolateral space of foramen
magnum, cerebellomedullary fissure and fourth ventricle. The
downside of this pure endoscopic approach is the exposure cannot
be extended if needed intraoperatively and iatrogenic atlanto-
occipital instability must be addressed from a separate exposure.
In addition, the venous bleeding from emissary veins, vertebral
venous plexus, sigmoid sinus and jugular bulb might affect the
endoscopic view.
Several authors have stated similar benefits of endoscope use
in clinical series. These studies report a significant benefit in the
endoscope’s ability to identify any tumor adherent to brainstem or
clivus amenable to resection [41,52,53].
4. Illustrative cases
4.1. Case #1: small anterior tumor
An anterior tumor that is large produces natural brainstem shift
that opens the surgical corridor between the brainstem and condyle
to allow access to the tumor. However, a small to medium size
anterior tumor without brainstem shift necessitates more lateral
 S. Chotai et al. / Clinical Neurology and Neurosurgery 121 (2014) 1–9 5

Fig. 3. Preoperative axial (a), sagittal (b), and coronal (c) T1-weighted gadolinium enhanced MRI demonstrating a 2.7 cm × 2.1 cm enhancing mass anterolateral to the medulla
extending into the right hypoglossal canal.

exposure via partial condyle resection in order to adequately illu- according to a previously published protocol (Fig. 5) [54]. The tumor
minate the anterior space with the microscope. We have found that was first debulked above the vertebral artery and on superior sur-
the endoscope can help provide adequate visualization and illumi- face of tumor and a small corridor was created through which a
nation to access the anterior space without requiring substantial 30◦ 2.7 mm endoscope was inserted and angled inferiorly as a look
drilling of the condyle. around the corner to identify the 12th CN which is displaced ante-
A 52-year-old lady presented with headaches, numbness and rior and superior to the tumor (Fig. 3b). Also, the CNs 9th, 10th and
paresthesias of bilateral feet and decreased balance. Imaging 11th as they travel from the brainstem to the jugular foramen were
revealed a 9 mm enhancing lesion anterior to the medulla (Fig. 1). identified. The debulking was then continued and endoscope was
She underwent a right posterolateral suboccipital craniectomy inserted at frequent intervals to achieve dissection of tumor under
with right C1 hemilaminectomy in the semi-sitting position. A direct control of lower CNs. After tumor debulking the endoscope
2.7 mm 0◦ endoscope was inserted underneath the lower cranial was inserted again to look for tumor remnants.
nerves and allowed easy identification of the tumor, vertebral
artery, and posterior inferior cerebellar artery (Fig. 2). Resection
was performed using standard microsurgical technique and the 4.4. Case #4: vascular identification
endoscope was used several times to visualize the medial limits
of the tumor and ensure there were no gross remnants. The patient We have found the endoscope useful for identification of major
was neurologically intact postoperatively and MRI revealed a gross vessels and perforators prior to tumor resection. In larger lesions,
total resection (Fig. 2f). small corridors made inferiorly in the tumor can be created to
insert either a 0◦ or 30◦ endoscope with the lens directed supe-
riorly to look for the vertebral artery. Since most small branches
4.2. Case #2: anterolateral tumor with hypoglossal extension and perforators travel medially toward the brainstem, lateral cuts
in the tumor can be created to insert a 30◦ endoscope with the lens
Depending on the anatomy of the condyle and hypoglossal canal,
sometimes the entry into the hypoglossal canal can be difficult to
visualize. This occurs when the posterior condyle is oriented lon-
gitudinally rather than obliquely, when the hypoglossal canal is
further anterior, and when a dominant vertebral artery reduces
visualization. An anterolateral tumor that is intimately involved
with the hypoglossal nerve and even extending into the hypoglossal
canal may necessitate further lateral exposure to improve micro-
scopic illumination and visualization. Here, we have found utility
in the endoscope to “look around” the vertebral artery and increase
illumination and visualization along the anterolateral clivus.
A 54-year-old lady presented with progressive dysphagia and
gait imbalance. MRI demonstrated a 2.7 cm × 2.1 cm enhancing
lesion anterolateral to the medulla extending into the right
hypoglossal canal (Fig. 3). She underwent a right posterolateral sub-
occipital craniectomy and right C1 hemilaminectomy for resection
of the lesion in the semi-sitting position. Insertion of a 2.7 mm 0◦
endoscope allowed early identification of the hypoglossal nerve;
furthermore during resection, the endoscope was used to assess for
any tumor remnants in the hypoglossal canal. In clinic follow-up,
patient had complete resolution of her dysphagia and improvement
in her gait and MRI revealed gross total resection (Fig. 4).

4.3. Case #3: lateral tumor obscuring the lower cranial nerves

Tumor at the level vertebral artery dural entry can obscure

visualization of the hypoglossal nerve. To demonstrate the appli-
cation of an endoscope for this indication, an artificial tumor Fig. 4. Postoperative T1-weighted contrasted MRI demonstrating gross total
was implanted into the right lateral CVJ using Stratathane-ST504 resection.
6 S. Chotai et al. / Clinical Neurology and Neurosurgery 121 (2014) 1–9

Fig. 5. Cadaveric artificial tumor model demonstrating endoscope utilization in a lateral CVJ tumor. (a) Tumor (red) at the lateral CVJ located above and below the proximal
intradural vertebral artery (VA). (b) The tumor was first debulked above the vertebral artery and along the superior surface of tumor to create a small corridor. (c) A 30◦
2.7 mm endoscope was inserted and angled inferiorly to look around the tumor. (d) Endoscopic view demonstrating the hypoglossal nerve on the anterior surface of the
tumor. Glossopharyngeal and vagus nerves also were identified. (e) The vertebral artery was followed and the origin of the posterior inferior cerebellar artery (PICA) was
identified. (f) After resection of the artificial tumor, the endoscope was inserted to visualize the clivus and anterior brainstem to look for tumor remnants. (For interpretation
of the references to color in figure legend, the reader is referred to the web version of the article.)

angled medially to identify branches and perforators prior to tumor
resection.
In this case example, a 75-year-old man presented with neck
pain, dysphagia, left greater than right extremity numbness and
paresis, and gait imbalance. He had a prior occipito-cervical syno-
vial cyst drained several years prior at another institution. MRI
revealed a 1.7 cm × 1.4 cm recurrent anterolateral synovial cyst at
the left cervicomedullary junction (Fig. 6). Patient underwent a left
C1 hemilaminectomy and resection of the cyst in the semi-sitting
position. Intraoperatively, significant scar tissue was encountered.
The endoscope was utilized after partial debulking to “look around”
the cyst to identify the vertebral artery as it crossed the O-C1 joint
(Fig. 7).
5. Discussion
5.1. Maximizing optical properties
EAM for resection of skull base tumors is a practical avenue that
combines the advantages of the operating microscope with those
of the endoscope [5,8–13,17,18,21,28,55–60]. The operating micro-
scope provides enhanced color fidelity and stereotactic vision for

Fig. 6. Preoperative axial (a) and sagittal (b) T2-weighted MRI showing a 1.7 cm × 1.4 cm left anterolateral cystic lesion at the cervicomedullary junction.
 S. Chotai et al. / Clinical Neurology and Neurosurgery 121 (2014) 1–9
Fig. 7. A 0◦ 2.7 mm endoscope was inserted after retraction of the cyst wall (black
arrow) to look around the cyst to identify the vertebral artery as it crosses atlanto-
occipital joint. Endoscopic view displayed using an image injection system into the
microscope oculars.
structures visible in the line of the light beam. In addition, the sur-
geon is looking directly into the lens of the microscope, allowing
the retinal sensor to produce image resolution that is better than
a high definition camera attached to the endoscope [6,17]. How-
ever, the microscope confines the surgeon to work within the light
beam. Structures that are not at the center are illuminated by a
decreasing intensity of light. For deep and narrow surgical corri-
dors, there is considerable loss of light even at the corridor entry
point. The endoscope can provide superior illumination in a deep
and narrow corridor and it also provides excellent depth of surgical
field. Angled endoscopes also allow illumination and visualization
of the surgical space behind structures. However, the image qual-
ity with the endoscopes is inferior compared to the microscope due
smaller lens diameter. The lack of stereoscopic vision and motion
parallax effect adds to the inferior image quality [61]. Employing
both technologies, one can take advantage of the optical advantages
of each modality [55].
5.2. Classification of endoscopic-assisted techniques
For EAM techniques, the major part of tumor resection is carried
out under microscopic visualization. The endoscope can be utilized
at various stages during the microscopic tumor resection. During
the initial stages of tumor resection, the endoscope can be used for
visualization of the structures in the shadow of microscope’s light
beam to look ahead or around a bony, dural, or neoplastic obstruc-
tion to assess the position of neurovascular structures in relation to
tumor. In particular at the CVJ, the displacement of the lower cranial
nerves, vertebral artery, and PICA must be predicted and verified
as early as possible to avoid inadvertent injury. This is usually
dictated by the origin and histological features of the tumor, which
determine the direction of tumor growth as well as its relation to
adjacent structures. For an anterolateral or anterior tumor located
below the VA, the lower CNs are generally pushed cranially and pos-
teriorly. With caudal to cranial resection of tumor, the CNs would
be exposed only while working on the superior part of tumor. For a
tumor arising above or encasing the VA, the displacement of lower
CNs, VA and its branches is more variable and these structures are at
greater risk of injury. After partial tumor debulking, the endoscope
7
can be inserted to identify the lower CNs prior to continuing with
further resection. In particular, we have found that the selective cre-
ation of corridors can be used to identify landmarks. For example,
lateral cuts in the tumor can be made to create a lateral clival cor-
ridor to insert an angled endoscope to identify the jugular foramen
and/or hypoglossal canal, which can then be used to further trace
the nerves proximally. In addition, targeted corridors can be created
to help visualize distal or proximal portions of the vertebral artery
and/or PICA. Various angled scopes (30, 45, and 70◦ ) scopes are
used [14]. In our experience, a 30◦ angle is sufficient to gain expo-
sure of the anterior clival space. When attempting to look around
a tumor superiorly or inferiorly, a 45◦ may be needed in some
cases.
After the initial tumor decompression, when additional visual
information of the target area is desired or when avoidance of
retraction of superficial structures is required, the endoscope can be
applied in deep and narrow surgical corridors to improve illumina-
tion and visualization. The endoscope can be used as a primary tool
of visualization during tumor dissection or as a tool to expand the
surgical working area. Finally, after tumor resection the endoscope
can be inserted for inspection and removal of tumor remnants with-
out cerebellar retraction and CN manipulation.
5.3. Utility of the semi-sitting position in CVJ surgery
We were able to use simple posterolateral approaches with
and without endoscopic assistance in dealing with different size
pathology at the CVJ. We were facilitated in our surgical expo-
sure/maneuvers by the availability of the inferior-to-superior line
of attack to the CVJ made possible by the use of the semisitting
position [52,62].
5.4. Limitations of endoscopic-assisted techniques
There are several limitations to endoscopic-assisted techniques
that warrant awareness. First, the endoscope occupies space in the
surgical corridor leaving less room for instruments. In addition,
insertion and removal of the endoscope risks damage to neurovas-
cular structures and must be done under microscopic visualization.
The amount of heat generated from endoscope light sources and
lens shaft needs to be further evaluated to prevent heat injury to
neurovascular structures. Use of endoscopic-controlled maneuvers
requires either an assistant to drive the endoscope or an endoscope
holder [63]. The recent introduction of pneumatic endoscope hold-
ers or hybrid integrated endoscope holder system (EndoArm) can
replace the mechanical holding system and allow bimanual dissec-
tion. In addition the steer device attached to the holding system
allows introduction of the endoscope away from the target area,
which can then be steered slowly to the desired position, thereby
minimizing risk of injury to the neurovascular structure. The intro-
duction of a built-in irrigation system in some endoscopes has
decreased the need for repeated insertion and removal of the endo-
scope to clean the lens [17]. Finally, the endoscope can sometimes
provide superior visualization without equivalent surgical maneu-
verability. It is important for one to understand the limitations in
surgical freedom when operating, particularly in a narrow curvi-
linear corridor between the lower cranial nerves for accessing the
anterior CVJ pathologies.
Above all there is a learning curve associated with endoscopic-
assisted techniques. This includes orientation to the endoscopic
anatomy, familiarity with an angled surgical orientation, and dex-
terity for inserting and removing the endoscope. Additionally,
dynamic movement using a two-surgeon technique requires expe-
rience and a close working relationship between surgeons.
8 S. Chotai et al. / Clinical Neurology and Neurosurgery 121 (2014) 1–9
5.5. Next steps
Further clinical studies are needed to demonstrate the util-
ity of EAM in practice. In addition, the risks of EAM including
direct mechanical or thermal injury to neurovascular structures
needs to be quantified. Technological advancements will likely
make the transition between microscope and endoscope visualiza-
tion more facile. Various technologies have been tested including
wall-mounted displays, microscope-mounted displays, and head
mounted liquid crystal display screens. In fact, several picture-
in-picture systems are available that integrate endoscopic and
microscopic visual information so that the neurosurgeon can eas-
ily go back and forth [64]. However, some neurosurgeons have
reported unsatisfactory visual quality of integrated endoscopic
views [64]. Further advancement of picture injection systems may
alleviate this problem. Finally, their needs to be further develop-
ment of endoscopic instrumentation specific to keyhole approaches
such that surgical maneuverability matches current visualization
afforded by the endoscope.
6. Conclusion
Endoscopic-assisted microsurgical techniques can improve illu-
mination and visualization of the surgical field at the CVJ. Its
use is particularly evident in visualizing down narrow surgical
corridors and looking around bony, vascular, and neoplastic struc-
tures to visualize the surgical space around these structures. EAM
techniques can help to minimize the need for brain retraction
or extensive exposures. Utilizing both the endoscope and micro-
scope allows the surgeon to benefit from the advantages from
each modality. The utility of the endoscope has been demonstrated
in transoral, transcervical, lateral, far lateral and posterolateral
approaches. We have particularly found it useful in the posterolat-
eral approach to obviate the need for extensive condyle resection, to
look around the tumor using surgically created corridors to identify
the lower cranial nerves, to help identify vascular structures, and
to ensure there are no tumor remnants after microscopic resection.
We believe that EAM at the CVJ will become more widespread and
future technological advancements will further expand the benefit
of EAM at the CVJ.
Funding
None.
References
[1] Gieger MCA. The history of neuroendsocopy. In: Cohen AHS, editor. Minimally
invasive techniques in neurosurgery. Baltimore: Williams & Wilkins; 1995. p.
1–5.
[2] Cohen A. Endoscopic neurosurgery. In: Wilkins RRS, editor. Neurosurgery. New
York: McGraw Hill; 1996. p. 539–46.
[3] Kalavakonda C, Sekhar LN, Ramachandran P, Hechl P. Endoscope-assisted
microsurgery for intracranial aneurysms. Neurosurgery 2002;51(1119–1126),
discussion 1126-1117.
[4] Fries G, Perneczky A. Endoscope-assisted brain surgery: part 2 – analysis of 380
procedures. Neurosurgery 1998;42:226–31, discussion 231-222.
[5] Hopf NJ, Perneczky A. Endoscopic neurosurgery and endoscope-assisted
microneurosurgery for the treatment of intracranial cysts. Neurosurgery
1998;43:1330–6, discussion 1336-1337.
[6] Perneczky A, Fries G. Endoscope-assisted brain surgery: part 1 – evolution,
basic concept, and current technique. Neurosurgery 1998;42:219–24, discus-
sion 224-215.
[7] Perneczky A, Boecher-Schwarz HG. Endoscope-assisted microsurgery for cere-
bral aneurysms. Neurol Med Chir 1998;38(Suppl.):33–4.
[8] Cheng WY, Chang CS, Shen CC, Wang YC, Sun MH, Hsieh PP. Endoscope-assisted
microsurgery for treatment of a suprasellar craniopharyngioma presenting pre-
cocious puberty. Pediatr Neurosurg 2001;34:247–51.
[9] Kadri H, Mawla AA. Endoscopy-assisted microsurgical total resection of cran-
iopharyngioma in childhood. Minim Invasive Neurosurg 2006;49:369–72.
[10] Rak R, Sekhar LN, Stimac D, Hechl P. Endoscope-assisted microsurgery for
microvascular compression syndromes. Neurosurgery 2004;54:876–81, dis-
cussion 881-873.
[11] Teo C, Nakaji P, Mobbs RJ. Endoscope-assisted microvascular decompres-
sion for trigeminal neuralgia: technical case report. Neurosurgery 2006;59.
ONSE489–490; discussion ONSE490.
[12] Cardia A, Caroli M, Pluderi M, Arienta C, Gaini SM, Lanzino G, et al. Endoscope-
assisted infratentorial-supracerebellar approach to the third ventricle: an
anatomical study. J Neurosurg 2006;104:409–14.
[13] Gore PA, Gonzalez LF, Rekate HL, Nakaji P. Endoscopic supracerebellar infraten-
torial approach for pineal cyst resection: technical case report. Neurosurgery
2008;62:108–9 [discussion 109].
[14] Gerganov VM, Romansky KV, Bussarsky VA, Noutchev LT, Iliev IN. Endoscope-
assisted microsurgery of large vestibular schwannomas. Minim Invasive
Neurosurg 2005;48:39–43.
[15] King WA, Wackym PA. Endoscope-assisted surgery for acoustic neuromas
(vestibular schwannomas): early experience using the rigid Hopkins telescope.
Neurosurgery 1999;44:1095–100, discussion 1100-1092.
[16] Pillai P, Sammet S, Ammirati M. Image-guided, endoscopic-assisted drilling and
exposure of the whole length of the internal auditory canal and its fundus with
preservation of the integrity of the labyrinth using a retrosigmoid approach: a
laboratory investigation. Neurosurgery 2009;65:53–9, discussion 59.
[17] Schroeder HW, Hickmann AK, Baldauf J. Endoscope-assisted microsurgical
resection of skull base meningiomas. Neurosurg Rev 2011;34:441–55.
[18] Schroeder HW, Oertel J, Gaab MR. Endoscope-assisted microsurgical
resection of epidermoid tumors of the cerebellopontine angle. J Neurosurg
2004;101:227–32.
[19] Hayashi N, Cohen AR. Endoscope-assisted far-lateral transcondylar approach
to the skull base. Minim Invasive Neurosurg 2002;45:132–5.
[20] Komatsu F, Komatsu M, Di Ieva A, Tschabitscher M. Endoscopic far-lateral
approach to the posterolateral craniovertebral junction: an anatomical study.
Neurosurg Rev 2013;36:239–47, discussion 247.
[21] Martins C, Cardoso AC, Alencastro LF, Leao CS, Rhoton Jr AL. Endoscopic-assisted
lateral transatlantal approach to craniovertebral junction. World Neurosurg
2010;74:351–8.
[22] Pillai P, Baig MN, Karas CS, Ammirati M. Endoscopic image-guided transoral
approach to the craniovertebral junction: an anatomic study comparing sur-
gical exposure and surgical freedom obtained with the endoscope and the
operating microscope. Neurosurgery 2009;64:437–42, discussion 442-434.
[23] Russo VM, Graziano F, Quiroga M, Russo A, Albanese E, Ulm AJ. Minimally inva-
sive supracondylar transtubercular (MIST) approach to the lower clivus. World
Neurosurg 2012;77:704–12.
[24] Russo VM, Graziano F, Russo A, Albanese E, Ulm AJ. High anterior cervical
approach to the clivus and foramen magnum: a microsurgical anatomy study.
Neurosurgery 2011;69, ons103–114; discussion ons115-106.
[25] Crockard HA, Sen CN. The transoral approach for the management of intradu-
ral lesions at the craniovertebral junction: review of 7 cases. Neurosurgery
1991;28:88–97, discussion 97-88.
[26] El-Sayed IH, Wu JC, Ames CP, Balamurali G, Mummaneni PV. Combined
transnasal and transoral endoscopic approaches to the craniovertebral junc-
tion. J Craniovertebr Junction Spine 2010;1:44–8.
[27] Husain M, Rastogi M, Ojha BK, Chandra A, Jha DK. Endoscopic transoral surgery
for craniovertebral junction anomalies. Technical note. J Neurosurg Spine
2006;5:367–73.
[28] Jung SH, Jung S, Moon KS, Park HW, Kang SS. Tailored surgical approaches
for benign craniovertebral junction tumors. J Korean Neurosurg Soc
2010;48:139–44.
[29] Miller E, Crockard HA. Transoral transclival removal of anteriorly placed menin-
giomas at the foramen magnum. Neurosurgery 1987;20:966–8.
[30] Singh H, Harrop J, Schiffmacher P, Rosen M, Evans J. Ventral surgical approaches
to craniovertebral junction chordomas. Neurosurgery 2010;66:96–103.
[31] Banerji D, Behari S, Jain VK, Pandey T, Chhabra DK. Extreme lateral transcondy-
lar approach to the skull base. Neurol India 1999;47:22–30.
[32] George B, Dematons C, Cophignon J. Lateral approach to the anterior portion
of the foramen magnum. Application to surgical removal of 14 benign tumors:
technical note. Surg Neurol 1988;29:484–90.
[33] Heros RC. Lateral suboccipital approach for vertebral and vertebrobasilar artery
lesions. J Neurosurg 1986;64:559–62.
[34] Margalit NS, Lesser JB, Singer M, Sen C. Lateral approach to anterolateral tumors
at the foramen magnum: factors determining surgical procedure. Neurosurgery
2005;56:324–36, discussion 324-336.
[35] Menezes AH, Traynelis VC, Gantz BJ. Surgical approaches to the craniovertebral
junction. Clin Neurosurg 1994;41:187–203.
[36] Salas E, Sekhar LN, Ziyal IM, Caputy AJ, Wright DC. Variations of the extreme-
lateral craniocervical approach: anatomical study and clinical analysis of 69
patients. J Neurosurg 1999;90:206–19.
[37] Ayoub B. The far lateral approach for intra-dural anteriorly situated tumours
at the craniovertebral junction. Turk Neurosurg 2011;21:494–8.
[38] Baldwin HZ, Miller CG, van Loveren HR, Keller JT, Daspit CP, Spetzler RF. The
far lateral/combined supra- and infratentorial approach. A human cadaveric
prosection model for routes of access to the petroclival region and ventral brain
stem. J Neurosurg 1994;81:60–8.
[39] Karam YR, Menezes AH, Traynelis VC. Posterolateral approaches to the cran-
iovertebral junction. Neurosurgery 2010;66:135–40.
[40] Lanzino G, Paolini S, Spetzler RF. Far-lateral approach to the craniocervical
junction. Neurosurgery 2005;57:367–71, discussion 367-371.
 S. Chotai et al. / Clinical Neurology and Neurosurgery 121 (2014) 1–9
[41] Sekhar LN, Ramanathan D. Evolution of far lateral and extreme lateral
approaches to the skull base. World Neurosurg 2012;77:617–8.
[42] Wanebo JE, Chicoine MR. Quantitative analysis of the transcondylar approach
to the foramen magnum. Neurosurgery 2001;49:934–41, discussion 941-933.
[43] Wen HT, Rhoton Jr AL, Katsuta T, de Oliveira E. Microsurgical anatomy of the
transcondylar, supracondylar, and paracondylar extensions of the far-lateral
approach. J Neurosurg 1997;87:555–85.
[44] Visocchi M, Doglietto F, Della Pepa GM, Esposito G, La Rocca G, Di Rocco C,
et al. Endoscope-assisted microsurgical transoral approach to the anterior cran-
iovertebral junction compressive pathologies. Eur Spine J 2011;20:1518–20.
[45] McGirt MJ, Attenello FJ, Sciubba DM, Gokaslan ZL, Wolinsky JP. Endoscopic tran-
scervical odontoidectomy for pediatric basilar invagination and cranial settling.
Report of 4 cases. J Neurosurg Pediatr 2008;1:337–42.
[46] Dasenbrock HH, Clarke MJ, Bydon A, Sciubba DM, Witham TF, Gokaslan ZL,
et al. Endoscopic image-guided transcervical odontoidectomy: outcomes of 15
patients with basilar invagination. Neurosurgery 2012;70:351–9, discussion
359-360.
[47] Hsu W, Kosztowski TA, Zaidi HA, Gokaslan ZL, Wolinsky JP. Image-guided,
endoscopic, transcervical resection of cervical chordoma. J Neurosurg Spine
2010;12:431–5.
[48] Wolinsky JP, Sciubba DM, Suk I, Gokaslan ZL. Endoscopic image-guided odon-
toidectomy for decompression of basilar invagination via a standard anterior
cervical approach. Technical note. J Neurosurg Spine 2007;6:184–91.
[49] Ture U, Pamir MN. Extreme lateral-transatlas approach for resection of the dens
of the axis. J Neurosurg 2002;96:73–82.
[50] Guan MW, Wang JY, Feng DX, Fu P, Chen LH, Li MC, et al. Anatomical study of
endoscope-assisted far lateral keyhole approach to the ventral craniocervical
region with neuronavigational guidance. Chin Med J (Engl) 2013;126:1707–10.
[51] Anichini GBD, Evins A, Santoro A, Stieg PE, Bernardo A. 3D Endoscope-assisted
anatomy of the foramen magnum and cranio-vertebral junction through a far
lateral approach – a technical note. In: Congress of Neurological Surgeons –
Annual meeting. 2012.
[52] Kshettry VR, Chotai S, Hou J, Lamki T, Ammirati M. Successful resection of ante-
rior and anterolateral lesions at the craniovertebral junction using a simple
posterolateral approach. J Clin Neurosci 2013;4:616–22.
9
[53] Velat GJ, Spetzler RF. The far-lateral approach and its variations. World Neuro-
surg 2012;77:619–20.
[54] Gragnaniello C, Nader R, Doormaal Tv, Kamel M, Voormolen EHJ, Lasio G, et al.
Skull base tumor model. J Neurosurg 2010;113:1106–10.
[55] Ebner FH, Roser F, Thaher F, Schittenhelm J, Tatagiba M. Balancing the
shortcomings of microscope and endoscope: endoscope-assisted technique in
microsurgical removal of recurrent epidermoid cysts in the posterior fossa.
Minim Invasive Neurosurg 2010;53:218–22.
[56] Iacoangeli M, Salvinelli F, Di Rienzo A, Gladi M, Alvaro L, Greco F, et al.
Microsurgical endoscopy-assisted presigmoid retrolabyrinthine approach as
a minimally invasive surgical option for the treatment of medium to large
vestibular schwannomas. Acta Neurochir (Wien) 2013;155:663–70.
[57] Kassam A, Horowitz M, Welch W, Sclabassi R, Carrau R, Snyderman C, et al.
The role of endoscopic assisted microneurosurgery (image fusion technology)
in the performance of neurosurgical procedures. Minim Invasive Neurosurg
2005;48:191–6.
[58] Kassam A, Snyderman CH, Mintz A, Gardner P, Carrau RL. Expanded endonasal
approach: the rostrocaudal axis, Part II. Posterior clinoids to the foramen mag-
num. Neurosurg Focus 2005;19:E4.
[59] Reisch R, Stadie A, Kockro RA, Hopf N. The keyhole concept in neurosurgery.
World Neurosurg 2013;79(S17), e19–13.
[60] Taniguchi M, Kato A, Taki T, Tsuzuki T, Hashimoto N, Fujimoto Y, et al. Endo-
scope assisted removal of jugular foramen schwannoma; report of 3 cases.
Minim Invasive Neurosurg 2005;48:365–8.
[61] Schroeder Henry WS. Transcranial endoscope-assisted skull base surgery –
posterior fossa. Innov Neurosurg 2013;Vol1:5.
[62] Ammirati M, Lamki TT, Shaw AB, Forde B, Nakano I, Mani M. A streamlined
protocol for the use of the semi-sitting position in neurosurgery: a report on
48 consecutive procedures. J Clin Neurosci 2013;20:32–4.
[63] de Divitiis O, Cavallo LM, Dal Fabbro M, Elefante A, Cappabianca P. Freehand
dynamic endoscopic resection of an epidermoid tumor of the cerebellopontine
angle: technical case report. Neurosurgery 2007;61:E239–40, discussion E240.
[64] Salma A, Ammirati M. Real time parallel intraoperative integration of endo-
scopic, microscopic, and navigation images: a proof of concept based on
laboratory dissections. J Neurol Surg B Skull Base 2012;73:36–41.