Introduction Removal of the odontoid process is a procedure often required for the treatment of the basilar impression with compression of the brain stem or cervical spinal cord due to irreducible atlanto-axial translocation. Different disorders may produce atlanto-axial dislocation such as congenital malformation, chronic inflammation, metabolic disorders and trauma. 6 9 11 13 15 16 22 26 3 17 1 2 4 5 10 14 18 21 This anatomic study describes the extended endoscopic endonasal approach to the cranio-vertebral junction, with particular attention to the reconstruction of the surgical route. Material and methods For this anatomic study, three fresh cadaver heads were dissected; an extended endoscopic endonasal approach to the cranio-vertebral junction was performed in all cases. Endoscopic dissections were performed using a rigid endoscope (Karl Storz GmbH, Tuttlingen, Germany), 4 mm in diameter, 18 cm in length, with 0 degree lenses. The endoscope was connected to a light source through a fiberoptic cable and to a camera fitted with 3CCD sensors. The video-camera was connected to a 21” monitor supporting the high resolution of the 3CCD technology. Results The procedure started with the introduction of the endoscope into a nasal vestibule through a lower trajectory as compared to the one employed for reaching the sellar region. Along such trajectory, the first structures to be visualized were the nasal septum medially, the inferior turbinate and the middle turbinate laterally. The inferior margin of the middle turbinate led to the choana which represented the main landmark of the approach. 1 Fig. 1 a b iwsphs ET Rphx  2 2 3 Fig. 2 a b ET Rphx NS iwsphs C aom C1 mmf  Fig. 3 iwsphs ET C1 mmf C2 D  4 Fig. 4 a b Ophx mmf T  This manoeuver permitted an adequate endonasal exposure of the cranio-vertebral junction without removing the mucosa of the rhinopharinx, which provides a useful autologous material for closure of the surgical field. 5 6 Fig. 5 a b C aom C1 dm al D  Fig. 6 a b iwsphs ET dm D  7 Fig. 7 iwsphs ET mmf  In this study, the endoscopic endonasal approach to the cranio-vertebral junction has been performed using both the one-nostril and the two-nostril technique, without removal of inferior and/or middle turbinate, nasal septum or other nasal structures. Although the procedure can be performed through only one nostril, the binostril technique provides, without any additional surgical trauma, a better manoeuverability of the surgical tools and the possibility to work with “three hands”. As a matter of fact, this technique permits a free-hand use of the endoscope in one nostril, held by the assistant, and the use of the other nostril or both nostrils for the insertion of the surgical instruments. Furthermore, in the case of a narrow nasal cavity, it is valuable to perform a unilateral middle turbinectomy and removal of the posterior third of the nasal septum to enlarge the surgical corridor. Discussion Different pathological disorders may produce atlanto-axial translocation with ventral compression of the brain stem or spinal cord. The most common are congenital malformations, such as Arnold Chiari malformation type II, chronic inflammation, such as rheumatoid arthritis, genetic transformation, such as Down’s syndrome and trauma, such as type II odontoid fracture. Some of these patients are candidate to the resection of the odontoid process for anterior decompression. The indication for odontoid resection is irreducible atlanto-axial subluxation, associated with severe spinal cord compression causing progressive myelopathy. 7 8 11 13 15 22 24 6 9 16 25 26 3 17 1 2 4 5 10 14 18 21 Thanks to the properties of the endoscope itself, the endonasal approach provides a wider view of the surgical field and a close-up vision, when compared with the transoral microscopic approach. Furthermore, the minimal invasiveness of the endoscopic endonasal route may reduce some morbidities related to the transoral approach. In fact, it is no longer necessary to use mouth retractors, prolonged compression of the tongue or split of the soft palate, and even considering the necessity of a middle turbinectomy or removal of the posterior portion of the nasal septum to enlarge the surgical corridor, these adjunctive manoeuvres do not usually produce morbidity to the patient. These manoeuvres are often performed in the endonasal extended approaches to the area around the sella in live patients and do not cause any respiratory problems. The possibility of performing an odontoidectomy through the nose is strictly related to the level of the C1–C2 junction. In fact, in the case of a low junction, below the level of the hard palate, it is virtually impossible to remove the odontoid process with an endonasal approach. On the contrary, in the case of a high position of the atlas-axis junction, the dens is more easily reached and removed through the nasal cavities. Odontoidectomy may be considered one of the most complicated manoeuvres for the transoral approach, in which the split of the soft and even hard palate is often necessary. Thus, this approach could be evaluated for those cases in which a transoral removal is considered more difficult. However, this kind of approach still presents some of the main problems of the transoral approach. The first problem concerns the risk of CSF leak and subsequent meningitis. Although the endoscope, thanks to its close-up and multi-angled vision, has a greater chance of detecting an occasional CSF leak, it is quite hard to suture the dura and the nasopharynx mucosa with conventional suturing tools through the nose. For this reason, in our anatomical study, we have created a muscle-mucosal flap, comprehensive of the entire muscular and mucosal tissue covering the ventral cranio-vertebral junction. This flap, as shown, is transposed into the oral cavity during the bone’s removal and replaced in its original site at the end of the procedure. Due to the difficulty of anchoring the flap with suture, it is only distended on the defect and its borders are apposed on the corresponding lines of incision. The mucosa of the inferior wall of the sphenoid sinus could be stripped to favour the adherence of the flap and fibrin glue could be used to seal the edges. The creation of a peduncolated muscle-mucosal flap permits a more physiological reconstruction of the surgical corridor and, furthermore, the vascularization of the flap that directly continues with the oropharynx, facilitates a rapid healing. An endoscopic control should be performed one month after surgery to check the recreating integrity of the rhinopharynx mucosa. The second problem of the transoral approach concerns the stability of the cranio-vertebral junction. The removal of the odontoid process with its ligaments can destabilize the cranio-vertebral junction. The third problem concerns the haemostasis that is often difficult in the extended endonasal approaches. Bleeding control may become difficult with bipolar coagulation because the endonasal approach presents a long and narrow corridor, with a limited working space between the tips of the bipolar forceps. Nevertheless, specific bipolar forceps (TAKE-APART bipolar forceps; Karl Storz GmbH, Tuttlingen, Germany) have been used to work through the nose in a safe and effective way as well. Conclusions This cadaver study has been performed to demonstrate the possibility of an anterior decompression of the upper cervical cord through an endoscopic endonasal approach. Similar to the transoral approach, the endoscopic endonasal approach provides a direct route to the surgical target, but it seems related to less morbidity. For clinical applications of this approach, the most common surgical problems are the risk of CSF leak and meningitis, the instability of the cervico-medullary junction and the bleeding control. The creation of a muscle-mucosal flap may represent a valid modality for closure of the surgical field. For application in live surgery, dedicate surgical instruments, such as endonasal bipolar forceps, high-speed low-profile drill and surgical guidance systems are needed. In selected cases this approach could be considered a valid alternative to the transoral microscopic approach for the resection of the odontoid process of C2. Obviously, it should be performed only by surgeons very skilled in endoscopic endonasal surgery and in endoscopic cadaver-dissections, while cooperation in a team with ENT surgeons is recommended.