Background: Our objective was to develop a new, minimally invasive surgical technique for the resolution of craniovertebral junction pathologies, which can eliminate the complications of the previous methods, like liquor-leakage, velopharyngeal insufficiency and wound-dehiscence associated with the transoral or lateral approaches.

Methods: During the first stage of the operation, three patients underwent occipito-cervical dorsal fusion, while the fourth patient received C1-C2 fusion according to Harms. C1-C2 decompressive laminectomy was performed in all four cases. Ventral C1-C2 decompression with microscope assisted minimally invasive anterior submandibular retropharyngeal key-hole approach (MIS ASR) method was performed in the second stage. The MIS ASR similarly to the traditional anterior retropharyngeal surgery – preserves the hard and soft palates, yet can be performed through a 25 mm wide incision with the use of only one retractor.

Results: The MIS ASR approach was a success in all four cases, there were no intraand postoperative complications. This method, compared to the transoral approach, provided on average 23% (4.56 cm2 / 6.05 cm2) smaller dural decompression area; nonetheless, the entire pathology could be removed in all cases. After the surgery, all patients have shown significant neurological improvement.

Conclusion: Based on the outcome of these four cases we think that the MIS ASR approach is a safe alternative to the traditional methods while improving patient safety by reducing the risks of complications.