CHAPTER 6
The Foramen Magnum
Albert L. Rhoton, Jr., M.D.
Department of Neurological Surgery, University of Florida, Gainesville, Florida
Key words: Cranial nerves, Craniovertebral junction, Foramen magnum, Microsurgery, Vertebral artery
T
he foramen magnum is located in the occipital bone,
which has three parts: a squamosal part located behind
the foramen magnum; a basal (clival) portion located
anterior to the foramen magnum; and a condylar part that
connects the squamosal and clival parts (Fig. 6.1). The suboc-
cipital approaches are directed through the squamosal part
and the anterior approaches through the clival part. The con-
dylar part, which includes the occipital condyle, posterior
margin of the jugular foramen, and hypoglossal canal, is
exposed in the far-lateral approach and its transcondylar,
retrocondylar, and supracondylar modifications described in
the chapter on the far lateral approach. Structures involved in
foramen magnum lesions include the lower cranial and upper
spinal nerves, the caudal brainstem and rostral spinal cord,
the vertebral artery and its branches, the veins and dural
sinuses at the craniovertebral junction, and the ligaments and
muscles uniting the atlas, axis, and occipital bone (5, 26). The
foramen magnum is most commonly approached from pos-
teriorly through the suboccipital and upper cervical region or
from anteriorly through the nasal and oral cavities, the phar-
ynx, or maxilla.
THE FORAMEN MAGNUM
Osseous relationships
The osseous structures that must be considered in planning
an approach to the region of the foramen magnum are the
occipital bone, the atlas, and the axis.
Occipital bone
The occipital bone surrounds the foramen magnum (Fig.
6.1). The foraminal opening is oval shaped and is wider
posteriorly than anteriorly. The wider posterior part transmits
the medulla, and the narrower anterior part sits above the
odontoid process. The occipital bone is divided into a squa-
mosal part located above and behind the foramen magnum, a
basal part situated in front of the foramen magnum, and
paired condylar parts located lateral to the foramen magnum.
The squamous part is an internally concave plate located
above and behind the foramen magnum. Its upper margins
articulate with the parietal bones at the lambdoid sutures and
its lower margins articulate with the mastoid portion of the
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temporal bones at the occipitomastoid sutures. The convex
external surface has several prominences on which the mus-
cles of the neck attach. The largest prominence, the external
occipital protuberance or inion, is situated at the central part
of the external surface. The inion is located an average of 1 cm
below the apex of the internal occipital protuberance and the
inferior margin of the confluence of the sagittal and transverse
sinuses. Two parallel ridges radiate laterally from the protu-
berance: the highest nuchal line is the upper and thinner
ridge, and the superior nuchal line is the lower and more
prominent one. The area below the nuchal lines is rough and
irregular and serves as the site of attachment of numerous
muscles. A vertical ridge, the external occipital crest, descends
from the external occipital protuberance to the midpoint of
the posterior margin of the foramen magnum. The inferior
nuchal lines run laterally from the midpoint of the crest.
The internal surface of the squamous part is concave and
has a prominence, the internal occipital protuberance, near its
center. The internal surface is divided into four unequal fos-
sae by the sulcus of the superior sagittal sinus that extends
upward from the protuberance, the internal occipital crest, a
prominent ridge that descends from the protuberance, and the
paired sulci for the transverse sinuses that extend laterally
from the protuberance. The sulcus for the right transverse
sinus is usually larger than the one on the left. The upper two
fossae are adapted to the poles of the occipital lobes. The
inferior two fossae conform to the contours of the cerebellar
hemispheres. The internal occipital crest bifurcates above the
foramen magnum to form paired lower limbs, which extend
along each side of the posterior margin of the foramen. A
depression between the lower limbs, the vermian fossa, is
occupied by the inferior part of the vermis. The falx cerebelli
is attached along the internal occipital crest.
The basilar part of the occipital bone, which is also referred
to as the clivus, is a thick quadrangular plate of bone that
extends forward and upward, at an angle of about 45° from
the foramen magnum. It joins the sphenoid bone at the sphe-
noccipital synchondrosis just below the dorsum sellae (7). The
superior surface of the clivus is concave from side to side and
is separated on each side from the petrous part of the tempo-
ral bone by the petroclival fissure. This fissure has the inferior
petrosal sinus on its upper surface and ends posteriorly at the
jugular foramen. On the inferior surface of the basilar part, in
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FIGURE 6.1. Occipital bone and foramen magnum. A, inferior view. B, posteroinferior view. C, anterior-inferior view. D,
superior view. E, posterosuperior view. F, oblique posterosuperior view. The occipital bone surrounds the oval-shaped fora-
men magnum, which is wider posteriorly than anteriorly. The narrower anterior part sits above the odontoid process and it
encroached on from laterally by the occipital condyles. The wider posterior part transmits the medulla. The occipital bone is
divided into a squamosal part located above and behind the foramen magnum; a basal (clival) part situated in front of the
foramen magnum; and paired condylar parts located lateral to the foramen magnum. The squamous part is internally con-
cave. Its upper margin articulates with the parietal bone at the lambdoid suture, and its lower margin articulates with the
mastoid portion of the temporal bone at the occipitomastoid suture. The convex external surface of the squamosal part has
several prominences. The largest prominence, the external occipital protuberance (inion), is situated at the central part of the

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front of the foramen magnum, a small elevation, the pharyn-
geal tubercle, gives attachment to the fibrous raphe of the
pharynx.
The paired lateral or condylar parts are situated at the sides
of the foramen magnum. The occipital condyles, which artic-
ulate with the atlas, protrude from the external surface of this
part. These condyles are located lateral to the anterior half of
the foramen magnum. They are oval in shape, convex down-
ward, face downward and laterally, and have their long axes
directed forward and medially. A tubercle that gives attach-
ment to the alar ligament of the odontoid process is situated
on the medial side of each condyle. The hypoglossal canal,
which transmits the hypoglossal nerve, is situated above the
condyle, and is directed forward and laterally from the pos-
terior cranial fossa. The canal may be partially or completely
divided by a bony septum. Septated hypoglossal canals were
found on one or both sides in 6% of the dry skulls (15).
The condylar fossa, a depression located on the external
surface behind the condyle, is often perforated to form the
posterior condylar canal through which an emissary vein
connects the vertebral venous plexus with the sigmoid sinus.
One or both condylar foramina may be absent or incompletely
perforated (9). The jugular process, a quadrilateral plate of
bone, extends laterally from the posterior half of the condyle
to form the posterior border of the jugular foramen. It serves
as a bridge between the condylar and squamosal portions of
the occipital bone. The jugular process articulates laterally
with the jugular surface of the temporal bone. On the intra-
cranial surface of the condylar part an oval prominence, the
jugular tubercle, sits just superior to the hypoglossal canal
and just medial to the lower extent of the petroclival fissure.
The caudal part of the tubercle often presents a shallow fur-
row above which the glossopharyngeal, vagus, and accessory
nerves course. The groove of the sigmoid sinus curves medi-
ally and forward around an upwardly directed, hook-shaped
process, on the superior surface of the jugular process, and
ends at the jugular foramen. The posterior condylar canal
opens into the posterior cranial fossa close to the medial end
of the groove for the sigmoid sinus.
The jugular foramen is situated lateral and slightly superior
to the anterior half of the condyles. It is bordered posteriorly
by the jugular process of the occipital bone, and anteriorly and
superiorly by the jugular fossa of the petrous portion of the
temporal bone (14). The foramen sits at the posterior end of
the petroclival suture. The jugular foramen is divided into
two parts by the intrajugular processes on the opposing edges
of the petrous and occipital bones, which either join directly
or are connected by a fibrous band. The smaller anteromedial
part, the petrous part, transmits the inferior petrosal sinus,
and the larger posterolateral part, the sigmoid part, transmits
the sigmoid sinus. The intrajugular part, situated along the
intrajugular processes, transmits the glossopharyngeal, vagus,
and accessory nerves. The enlarged part of the internal jugular
vein located within the foramen is referred to as the jugular bulb.
The jugular process also serves as the site of attachment of the
rectus capitis lateralis muscle behind the jugular foramen.
The atlas
The atlas, the first cervical vertebra, differs from the other
cervical vertebrae by being ring shaped and by lacking a
vertebral body and a spinous process (Fig. 6.2). It consists of
two thick lateral masses situated at the anterolateral parts of
the ring. The lateral masses are connected in front by a short
anterior arch and behind by a longer curved posterior arch.
The position of the usual vertebral body is occupied by the
odontoid process of the axis. The anterior arch is convexed
forward and has a median anterior tubercle. The posterior

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external surface. The superior nuchal line radiates laterally from the protuberance. A vertical ridge, the external occipital
crest, descends from the external occipital protuberance to the midpoint of the posterior margin of the foramen magnum.
The inferior nuchal lines run laterally on both sides from the midpoint of the crest. The internal surface of the squamous part
is concave and has a prominence, the internal occipital protuberance, near its center. The internal surface is divided into four
unequal fossae by the sulcus of the superior sagittal sinus, the internal occipital crest, and the sulci for the transverse sinuses.
The internal occipital crest bifurcates above the foramen magnum to form a V-shaped ridge between the limbs of which is
the vermian fossa. The basilar part of the occipital bone, which is also referred to as the clivus, is a thick quadrangular plate
of bone that extends forward and upward to join the sphenoid bone just below the dorsum sellae. The superior surface of the
clivus slopes upward from the foramen magnum and is concave from side to side. The clivus is separated on each side from
the petrous part of the temporal bone by the petroclival fissure that ends posteriorly at the jugular foramen. The occipitomas-
toid suture extends posterolateral from the jugular foramen. On the inferior surface of the basilar part, a small elevation, the
pharyngeal tubercle, gives attachment to the fibrous raphe of the pharynx. The condylar parts of the occipital bone, on which
the occipital condyles an located, are situated lateral to the foramen magnum on the external surface. The alar tubercle,
which gives attachment to the alar ligament, is situated on the medial side of each condyle. The hypoglossal canal is situated
above the condyle. The condylar fossa, which may be converted into a foramen for the passage of an emissary vein, is
located behind the condyle. The jugular process of the occipital bone extends laterally from the posterior half of the condyle
and articulates with the jugular surface of the temporal bone. The sulcus of the sigmoid sinus crosses the superior surface of
the jugular process. The jugular foramen is bordered posteriorly by the jugular process of the occipital bone and anteriorly
by the jugular fossa of the petrous temporal bone. The jugular tubercle lies on the internal surface above the hypoglossal
canal. A., artery; Ac., acoustic; Car., carotid; Cond., condyle; Digast., digastric; Ext., external; Fiss., fissure; For., foramen;
Hypogl., hypoglossal; Inf., inferior; Jug., jugular; Occipitomast., occipitomastoid; Occip., occipital; Petrocliv., petroclival;
Pharyng., pharyngeal; Proc., process; Protrub., protuberance; Sag., sagittal; Sig., sigmoid; Sup., superior; Trans., transverse.

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FIGURE 6.2. A–D. The atlas. A, superior view; B, inferior view; C, anterior view; D, posterior view. The atlas consists of two
thick lateral masses situated at the anteromedial part of the ring, which are connected in front by a short anterior arch and
posteriorly by a longer curved posterior arch. The anterior and posterior tubercles are at the anterior and posterior mid-
line. The superior articular facet is an oval, concave facet that faces upward and medially to articulate with the occipital con-
dyle. The inferior articular facet is a circular, flat, or slightly concave facet that faces downward, medially, and slightly back-
ward and articulates with the superior articular facet of the axis. The medial aspect of each lateral mass has a small tubercle
for the attachment of the transverse ligament of the atlas. The transverse process projects from the lateral masses. The trans-
verse foramina transmit the vertebral arteries. The upper surface of the posterior arch adjacent to the lateral masses has
paired grooves in which the vertebral arteries course. A., artery; Ant., anterior; Art., articular; For., foramen; Lat., lateral;
Mass., masses; Post., posterior; Proc., process; Trans., transverse; Vert., vertebral.
arch is convex backward and has a median posterior tubercle approximately 1-cm wide. On the front of the dens is an
and a groove on the lateral part of its upper-outer surface in articular facet that forms a joint with the facet on the back of
which the vertebral artery courses. The groove may be partly the anterior arch of the atlas. The dens has a pointed apex that
or fully converted into a foramen by a bridge of bone that is joined by the apical ligament, has a flattened side where the
arches backward from the posterior edge of the superior alar ligaments are attached, and is grooved at the base of its
articular facet of the atlas to its posterior arch. The first cer- posterior surface where the transverse ligament of the atlas
vical spinal nerve also lies in the groove, which is located passes. The dens and body are flanked by a pair of large oval
between the artery and the bone. The upper surface of each facets that extend laterally from the body onto the adjoining
lateral mass has an oval concave facet that faces upward and parts of the pedicles and articulate with the inferior facets of
medially and articulates with the occipital condyle that faces the atlas. The superior facets do not form an articular pillar
downward and laterally. The inferior surface of each lateral with the inferior facets, but are anterior to the latter. The
mass has a circular, flat, or slightly concave facet that faces anterior aspect of the body is hollowed out on each side of
downward, medially, and slightly backward, and it articu- the midline in the area where the longus colli muscles at-
lates with the superior articular facet of the axis. The medial tach. The lamina are thicker than on any other cervical verte-
aspect of each lateral mass has a small tubercle for the attach- brae, the pedicles are stout, and the spinous process is large.
ment of the transverse ligament of the atlas, which passes The transverse processes of the axis are small. Their blunt
behind the dens. Each transverse foramen, which transmits a tips present a single tubercle, the anterior tubercle, situated at
vertebral artery, and upon which the nerve root sits, is situ- or near the junction of the anterior root of the transverse
ated between the lateral mass and the transverse process. process and the body. Each transverse foramen faces supero-
laterally, thus permitting the lateral deviation of the vertebral
The axis artery as it passes up to the more widely separated transverse
The axis, the second cervical vertebra, more closely resem- foramina in the atlas. The inferior articular facets are situated
bles the typical vertebrae than the atlas, but is distinguished at the junction of the pedicles and laminae, and face down-
by the odontoid process (dens), which projects upward from ward and forward. The spade-shaped vertebral foramen is
the body (Fig. 6.2). The dens is 1.0- to 1.5-cm long, and relatively large.

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FIGURE 6.2. E–H. The axis. E, anterior view; F, lateral view; G, superior view; H, inferior view. The axis is distinguished by the
odontoid process (dens). On the front of the dens is an articular facet that forms a joint with the facet on the back of the anterior
arch of the atlas. The dens is grooved at the base of its posterior surface where the transverse ligament of the atlas passes. The oval
superior articular facets articulate with the inferior facets of the atlas. The superior facets are anterior to the inferior facets. The
pedicles and laminae are thicker than on the other cervical vertebra and the lamina fuse behind to form a large spinous process.
The transverse foramina are directed superolaterally, thus permitting the lateral deviation of the vertebral arteries as they pass up
to the more widely separated transverse foramina in the atlas. The inferior articular facets face downward and forward.

The atlantoaxial joints
The articulation of the atlas and axis comprises four syno-
vial joints: two median ones on the front and back of the dens,
and paired lateral ones between the opposing articular facets
on the lateral masses of the atlas and axis (Figs. 6.2-6.4). Each
of the median joints, situated on the front and back of the dens,
has its own fibrous capsule and synovial cavity. The anterior one
is situated between the anterior surface of the dens and the
posterior aspect of the anterior arch of the atlas. The posterior
one has an even larger synovial cavity and lies between the
cartilage-covered anterior surface of the transverse ligament of
the atlas and the posterior surface of the dens.
The atlas and axis are united by the cruciform ligament, the
anterior and posterior longitudinal ligaments, and the articu-
lar capsules surrounding the joints between the opposing
articular facets on the lateral masses. The cruciform ligament has
transverse and vertical parts that form a cross behind the dens.
The transverse part, called the transverse ligament, is a thick
strong band that arches across the ring of the atlas behind the
dens and divides the vertebral canal into a larger posterior
compartment containing the dura and the spinal cord and a
smaller anterior compartment containing the odontoid process.
The transverse ligament is broader in the middle behind the
dens than at the ends where it is attached to a tubercle on the
medial side of the lateral masses of the atlas. As it crosses
the dens, small longitudinal bands are directed upward and
downward from its posterior surface. The cranial extension is
attached to the upper surface of the clivus between the apical
ligament of the dens and the tectorial membrane. The lower
band is attached to the posterior surface of the body of the axis.
The neck of the dens is constricted where it is embraced poste-
riorly by the transverse ligament.

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FIGURE 6.3. A–D. Foramen

magnum. Posterior view. Stepwise
dissection. A, the cerebellar tonsils,
the foramen of Magendie, and lower
part of the fourth ventricle are
situated above the foramen magnum.
The vertebral artery penetrates the
dura below the foramen magnum and
ascends through the foramen in front
of the dentate ligament and accessory
nerves. The glossopharyngeal, vagus,
and accessory nerves pass through
the jugular foramen, which is located
lateral to the anterior half of the
foramen magnum. B, the cerebellum
has been removed. The vertebral
arteries pass through the foramen
magnum to reach the front of the
medulla. C, enlarged view of the left
half of the foramen magnum. The
vertebral artery passes behind and
below the atlanto-occipital joint,
penetrates the dura, and passes in
front of the dentate ligament and
accessory nerve. The rostral end of
the dentate ligament attaches to
the dura at the level of the foramen
magnum. The C1 nerve penetrates
the dura with the vertebral artery.
The hypoglossal nerve passes behind
the vertebral artery and enters the
hypoglossal canal. The hypoglossal
nerve is separated into several
bundles as it penetrates the dura. The
posterior spinal artery arises as the
vertebral artery enters the dura and
gives rise to ascending and
descending branches. D, a
longitudinal strip of the medulla and
floor of the fourth ventricle has been
removed to expose the
vertebrobasilar junction, the origin of
the anterior spinal artery, and
the median anterior medullary and
median anterior spinal veins. A.,
artery; A.I.C.A., anteroinferior
cerebellar artery; Ant., anterior; Asc.,
ascending; Atl., atlanto-; Bas., basilar;
Br., branch; Bridg., bridging; CN,
cranial nerve; Cruc., cruciform; Dent., dentate; Desc., descending; Flocc., flocculus; For., foramen; Horiz., horizontal; Lig.,
ligament; Med., median, medullary; Memb., membrane; Men., meningeal; Occip., occipital; P.I.C.A., posteroinferior cerebellar
artery; Post., posterior; Sp., spinal; Trans., transverse; V., vein; Vent., ventricle; Vert., vertebral.

In front, the atlas and axis are connected by the anterior
longitudinal ligament, which is a wide band fixed above to
the lower border of the anterior arch of the atlas and below
to the front of the body of the axis. The posterior longitudinal
ligament is attached below to the posterior surface of the body
of the axis, and above to the transverse part of the cruciform
ligament and the clivus. Posterior to the spinal canal, the atlas
and axis are joined by a broad, thin membrane in series with
the ligamentum flavum that is attached above to the lower
border of the posterior arch of the atlas, and below to the

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FIGURE 6.3. E–I. Foramen

magnum. Posterior view.
Stepwise dissection. E, the
right half of the medulla has
been removed. The anterior
spinal artery arises predomi-
nantly from the left vertebral
artery, but has a small contri-
bution from the right verte-
bral artery. Two bundles of
right hypoglossal rootlets
penetrate the dura. F, en-
larged view. The medulla has
been removed to expose the
vertebral and anterior spinal
arteries. The C1 nerve roots
penetrate the dura with the
vertebral artery. G, the intra-
dural segment of the verte-
bral arteries and the dura lining the anterior margin of the foramen magnum have been removed to expose the tectorial mem-
brane, a rostral extension of the posterior longitudinal ligament, and the vertebral venous plexus, which courses just outside the
dura. H, the tectorial membrane has been removed to expose the cruciform and alar ligaments. The horizontal portion of the cru-
ciform ligament, called the transverse ligament of the atlas, extends laterally to be attached to the medial edges of the lateral
masses of the atlas, and the vertical portion ascends to attach to the anterior margin of the foramen magnum deep to the tectorial
membrane. The alar ligaments pass upward and laterally and attach to the lateral edges of the foramen magnum. Anterior menin-
geal arteries pass along the dura and ligamentous structures in the anterior spinal canal. I, the vertical portion of the cruciform lig-
ament has been folded downward to expose the synovial joint between the anterior surface of the cruciform ligament and the pos-
terior surface of the dens. There is also another synovial joint between the anterior surface of the dens and the posterior surface of
the anterior atlantal arch. The apical ligament of the dens extends upward to be attached to the margin of the foramen magnum.

upper edges of the laminae of the axis. This membrane is
pierced laterally by the second cervical nerve.
The atlanto-occipital joints
The atlas and the occipital bone are united by the articular
capsules surrounding the atlanto-occipital joints and by the
anterior and posterior atlanto-occipital membranes (Figs. 6.2-
6.4). The articular capsules of the atlanto-occipital joints are
sometimes deficient medially where the synovial cavities may
communicate with the synovial bursa between the dens and
the transverse ligament of the atlas. The anterior atlanto-
occipital membrane is attached superiorly to the anterior edge

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FIGURE 6.4. Anterior view. Stepwise dissection of a cross section showing the relationship of the foramen magnum and cli-
vus to the nasal and oral cavities, pharynx, and infratemporal fossa. A, the soft palate, which has been preserved, is located
at the level of the foramen magnum. The infratemporal fossa, located below the greater sphenoid wing and middle cranial
fossa, contains the pterygoid muscles, maxillary artery, mandibular nerve branches, and the pterygoid venous plexus and
opens posteriorly into the area around the carotid sheath, as shown on the left side. B, enlarged view. The soft palate has
been divided in the midline and the leaves reflected laterally. The atlanto-occipital joints and the foramen magnum are
located at approximately the level of the hard palate. The anterior arch of C1 and the dens are located behind the orophar-
ynx, and the clivus is located behind the nasopharynx and sphenoid sinus. The prominence over the longus capitis and the

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of the foramen magnum, inferiorly to the superior edge of the
anterior arch of the atlas, and laterally to the capsule of
the atlanto-occipital joints.
The posterior atlanto-occipital membrane is a thin sheet con-
nected above to the posterior margin of the foramen magnum
and below to the upper border of the posterior arch of the atlas.
The lateral border of the membrane is free and arches behind the
vertebral artery and the first cervical nerve root. The lateral edge
of this membrane may be ossified in the area where it arches
over the posterior aspect of the vertebral artery, thus creating a
partial or complete osseous ring around the artery on the medial
side of the atlanto-occipital joint.
Axis and occipital bone
Four fibrous bands, the tectorial membrane, the paired alar
ligaments, and the apical ligament, connect the axis and the
occipital bone (Figs. 6.3 and 6.4). The tectorial membrane is a
cephalic extension of the posterior longitudinal ligament that
covers the dens and cruciform ligament. It is attached below
to the posterior surface of the body of the axis, above to the
upper surface of the occipital bone in front of the foramen
magnum, and laterally to the medial sides of the atlanto-
occipital joints. The alar ligaments are two strong bands that
arise on each side of the upper part of the dens and extend
obliquely superolateral to attach to the medial surfaces of the
occipital condyles. The apical ligament of the odontoid pro-
cess extends from the tip of the dens to the anterior margin of
the foramen magnum and is situated between the anterior
atlanto-occipital membrane and the superior prolongation of
the cruciform ligament.
Muscular relationships
The foramen magnum is surrounded by the muscles at-
tached to the occipital bone and upper cervical vertebrae (Figs.
6.4 and 6.5). The trapezius covers the back of the head and
neck. It extends from the medial half of the superior nuchal
line, the external occipital protuberance, and the spinous pro-
cesses of the cervical and thoracic vertebrae and converges on
the shoulder to attach to the scapula and the lateral third of
the clavicle. The sternocleidomastoid passes obliquely down-
ward across the side of the neck from the lateral half of the
superior nuchal line and mastoid process to the upper part of
the sternum and the adjacent part of the clavicle. This muscle
divides the side of the neck into an anterior triangle and a
posterior triangle. The anterior triangle is bounded posteri-
orly by the anterior border of the sternocleidomastoid, above
by the mandible, and anteriorly by the median line of the
neck; the posterior triangle is bounded in front by the poste-
rior border of the sternocleidomastoid, below by the middle
third of the clavicle, and behind by the anterior margin of the
trapezius. The splenius capitis, situated deep to and partially
covered by the trapezius and sternocleidomastoid, extends
from the bone below the lateral third of the superior nuchal
line to the spinous processes of the lower cervical and upper
thoracic vertebrae. Two muscles, both of which are situated
deep to the splenius capitis and sternocleidomastoid and at-
tach below to the upper thoracic and lower cervical vertebrae,
are the semispinalis capitis, which attaches above in the area
between the superior and inferior nuchal lines beginning
medially at the external occipital crest and extending laterally
to the occipitomastoid junction, and the longissimus capitis
muscle, which attaches above to the posterior margin of the
mastoid process.
The suboccipital muscles, located in the next layer, are a group
of muscles situated deep to the splenius, semispinalis, and lon-
gissimus capitis in the suboccipital area. This group includes the
superior oblique, which extends from the area lateral to the
semispinalis capitis between the superior and inferior nuchal
lines to the transverse process of the atlas; the inferior oblique,
which extends from the spinous process and lamina of the axis
to the transverse process of the atlas; the rectus capitis posterior
major, which extends from and below the lateral part of the
inferior nuchal line to the spine of the axis; and the rectus
capitis posterior minor, which is situated medial to and is
partially covered by the rectus capitis posterior major, extends

Š
anterior arch of C1 are seen through the pharyngeal mucosa. C, the mucosa lining the posterior pharyngeal wall has been
reflected to the right, exposing the longus capitis that attaches to the clivus and the part of the longus colli that attaches to
the anterior arch of C1. The eustachian tube has been divided. The rectus capitis anterior extends from the transverse process
of C1, posterolateral to the longus capitis, to attach to the occipital bone in front of the occipital condyle. D, the clivus and
anterior arch of C1 have been removed. The dura has been opened to expose the vertebral and basilar artery. The dens has
been preserved. The structures in the right infratemporal fossa and part of the right carotid artery and mandible have been
removed to expose the right vertebral artery ascending between the C2 and C1 transverse processes. E, enlarged view of the
step between C and D. The anterior arch of C1 has been removed to expose the odontoid process and the lower part of the
clivus. The left longus coli and longus capitis have been reflected out of the exposure. The atlanto-occipital joint is exposed at
the level of the odontoid apex. The transverse part of the cruciform ligament, also called the transverse ligament, extends
across the back of the dens and attaches to a tubercle on the medial side of each lateral mass of the axis. The tectorial mem-
brane, a cephalic extension of the posterior longitudinal ligament, lines the posterior clival surface. The alar ligaments attach
to the lateral edges of the foramen magnum. F, enlarged view of the exposure shown in D. G, exposure after opening of the
clivus. Both vertebral and anteroinferior cerebellar arteries (AICAs) and the anterior spinal artery are exposed. A., artery;
A.I.C.A., anteroinferior cerebellar artery; Ant., anterior; Atl., atlanto-; Cap., capitis; Car., carotid; CN, cranial nerve; Eust.,
eustachian; For., foramen; Infratemp., infratemporal; Int., internal; Jug., jugular; Lat., lateral; Lig., ligament; Long., longus; M.,
muscle; Mandib., mandibular; Max., maxillary; Med., medial; Memb., membrane; Occip., occipital; Pteryg., pterygoid; Rec.,
rectus; Sp., spinal; Sphen., sphenoid; Trans., transverse; Vert., vertebral.

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S164 Rhoton

FIGURE 6.5. Suboccipital muscles. Stepwise dissection. A, the right trapezius and sternocleidomastoid have been preserved.
The left trapezius and sternocleidomastoid have been reflected along with the galea aponeurotica to expose the underlying
semispinalis capitis, splenius capitis, and levator scapulae. B, the right sternocleidomastoid and trapezius have been reflected
to expose the splenius capitis. The left splenius capitis has been removed to expose the underlying semispinalis and longissi-
mus capitis. C, the right splenius capitis has been removed to expose the semispinalis and longissimus capitis. The left semi-
spinalis and longissimus capitis have been removed to expose the suboccipital triangle formed by the superior oblique, which
passes from the C1 transverse process to the occipital bone, the inferior oblique, which extends from the transverse process
of C1 to the spinous process of C2, and the rectus capitis posterior major, which extends from the occipital bone below the
inferior nuchal line to the spinous process of C2. The vertebral artery courses in the depths of the suboccipital triangle as it
passes behind the superior facet of C1 and across the upper edge of the posterior atlantal arch. D, both semispinalis capitis
muscles have been reflected laterally to expose the suboccipital triangles bilaterally. E, the muscles forming the left suboccipi-
tal triangle have been removed. The vertebral artery ascends slightly lateral from the transverse process of C2 to reach the

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 Foramen Magnum S165

from the medial part and below the inferior nuchal line to the
tubercle on the posterior arch of the atlas.
The suboccipital triangle is a region bounded above and
medially by the rectus capitis posterior major, above and
laterally by the superior oblique, and below and laterally by
the inferior oblique (Fig. 6.5). It is covered by the semispinalis
capitis medially and by the splenius capitis laterally. The floor
of the triangle is formed by the posterior atlanto-occipital
membrane and the posterior arch of the atlas. The structures
in the triangle are the terminal extradural segment of the
vertebral artery and the first cervical nerve.
The platysma is a broad sheet extending downward from
the lower part of the face and across the clavicle to the fascia
covering the pectoralis major and deltoid. The anterior verte-
bral muscles insert on the clival part of the occipital bone
anterior to the foramen magnum. This group includes the
longus colli, which attach to the anterior surface of the verte-
bral column between the atlas and the third thoracic vertebra;
the longus capitis, which extends from the clivus in front of
the foramen magnum to the transverse processes of the third
through the sixth cervical vertebrae; the rectus capitis ante-
rior, which is situated behind the upper part of the longus
capitis and extends from the occipital bone in front of the
occipital condyle to the anterior surface of the lateral mass
and transverse process of the atlas; and the rectus capitis
lateralis, which extends from the jugular process of the occip-
ital bone to the transverse process of the atlas.
The muscles described above are embedded in the cervical
fascia. This fascia is divided into superficial and deep layers.
The superficial layer is a lamina of loose connective tissue
below the dermis, which invests the platysma. The deep layer
lies internal to the platysma, invests the muscles, and con-
denses into fibrous sheaths that bind the arteries and accom-
panying veins together. The superficial lamina of the deep
fascia attaches in the posterior midline to the ligamentum
nuchae, thinly invests the trapezius, continues forward cov-
ering the posterior triangle of the neck, divides at the poste-
rior border of the sternocleidomastoid to enclose the muscle,
and at its anterior margin again forms a lamina that covers the
anterior triangle of the neck and reaches the median plane, to
be continuous with the corresponding lamina from the oppo-
site side. The carotid sheath is a condensation of the cervical
fascia, which invests the common and internal carotid arter-
ies, the internal jugular vein, and the vagus nerve. The pre-
vertebral lamina of the cervical fascia covers the prevertebral
muscles, extends laterally to connect with the carotid sheath,
and covers the scalene muscles to form a fascial floor for the
posterior triangle of the neck. Superiorly it is attached to the
base of the skull, and inferiorly it continues downward be-
hind the pharynx and in front of the longus colli into the
superior mediastinum. The deep fascia is fused above to
the superior nuchal line, mastoid process, zygomatic arch,
styloid process, and mandible, and below to the scapula,
clavicle, and sternum.
Neural relationships
The neural structures situated in the region of the foramen
magnum are the caudal part of the brainstem, cerebellum and
fourth ventricle, the rostral part of the spinal cord, and the lower
cranial and upper cervical nerves (Figs. 6.3 and 6.6) (5, 19).
Spinal cord
The spinal cord blends indistinguishably into the medulla
at a level arbitrarily set to be at the upper limit of the dorsal
and ventral rootlets forming the first cervical nerve (Figs. 6.3
and 6.6). It is easier to differentiate this level on the ventral
than on the dorsal surface because the ventral rootlets of the
first cervical nerve are always present, whereas the dorsal
rootlets are absent in many cases. The fact that the junction of
the spinal cord and medulla is situated at the rostral margin of
the first cervical root means that the medulla, and not the
spinal cord, occupies the foramen magnum.
The spinal cord immediately below the level of the foramen
magnum is round, and it is divided by one fissure and several
sulci. The anteromedian fissure and the posteromedian sulcus
divide the spinal cord into symmetrical halves. The antero-
median fissure reaches a depth of several millimeters. The pos-
teromedian sulcus is much shallower, and from it the postero-
median septum penetrates the spinal cord, almost reaching the
central canal. The posterior lateral sulcus is situated along the
line where the dorsal roots enter the spinal cord. The posterior
funiculus is situated between the posteromedian and poste-
rior lateral sulci. At the upper cervical level, the surface of
each posterior funiculus is divided by another shallow longi-
tudinal furrow, the posterior intermediate sulcus, into the
fasciculus gracilis medially and the fasciculus cuneatus later-
ally. The region of the spinal cord between the posterior
lateral sulcus and the anteromedian fissure is divided into
anterior and lateral funiculi by the exiting ventral rootlets of
the spinal nerves. The anterior funiculus includes the zone of
emergence of the ventral roots. The lateral funiculus lies between
the ventral roots and the posterior lateral sulcus. In the upper

Š
transverse process of C1 and turns medially behind the superior facet of C1 to reach the upper surface of the posterior arch of C1.
The C2 ganglion is located between the posterior arch of C1 and the lamina of C2. The dorsal ramus of C2 produces a medial
branch that forms the majority of the greater occipital nerve. F, the muscles forming both suboccipital triangles have been
removed. The rectus capitis posterior minor, which extends from the posterior arch of C1 to the occipital bone below the inferior
nuchal line, has been preserved. The vertebral arteries cross the posterior arch of the atlas and penetrate the posterior atlanto-
occipital membrane to reach the dura. A., artery; Atl., atlanto-; Cap., capitis; Car., carotid; CN, cranial nerve; Inf., inferior; Int.,
internal; Jug., jugular; Lev., levator; Longiss., longissimus; M., muscle; Maj., major; Memb., membrane; Min., minor; Obl., oblique;
Occip., occipital; Post., posterior; Proc., process; Rec., rectus; Scap., scapulae; Semispin., semispinalis; Spin., spinalis; Splen., sple-
nius; Sternocleidomast., sternocleidomastoid; Sup., superior; Trans., transverse; V., vein; Vert., vertebral.

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S166 Rhoton

FIGURE 6.6. Foramen magnum. A–D, posterior views; E and F, anterior views. A, a suboccipital craniectomy and upper cer-
vical laminectomy exposes the dura. The vertebral arteries pass medially across the upper surface of the atlas where they give
off the posterior meningeal arteries that ascend to supply the dura on the posterior aspect of the foramen magnum and poste-
rior fossa. Insert, upper right. The upper margin of the left half of the arch of the atlas forms an osseous ring around the ver-
tebral artery just proximal to where it enters the dura. B, enlarged view of another foramen magnum after opening the dura.
The right PICA arises outside the dura and penetrates the dura with the vertebral artery. The rostral end of the dentate liga-
ment passes between the vertebral artery and the PICA to insert into the dura along the lateral margin of the foramen mag-
num. The accessory nerve ascends posterior to both the PICA and the vertebral artery. The vertebral artery gives rise to a
posterior spinal artery that passes along the posterolateral aspect of the spinal cord and medulla. The hypoglossal rootlets are
stretched over the posterior aspect of the vertebral artery. C, the right tonsil has been retracted to expose the caudal end of
the fourth ventricle, which is located above the foramen magnum. The right PICA ascends through the foramen magnum and

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 Foramen Magnum S167

cervical region, the rootlets that unite to form the spinal part of
the accessory nerve emerge through the lateral funiculus.
Dentate ligament
The dentate ligament is considered with the spinal cord
because it is attached to it (Figs. 6.3 and 6.6). This ligament is
a white fibrous sheet that is attached to the spinal cord me-
dially and to the dura mater laterally. The medial border of
the dentate ligament, which is attached to the pia mater
between the dorsal and ventral rootlets along the length of
each side of the spinal cord, presents a series of triangular
toothlike processes on each side that are attached at intervals
to the dura mater. At the craniocervical junction, the dentate
ligament is located between the vertebral artery and the ven-
tral roots of C1 anteriorly and the branches of the posterior
spinal artery and the spinal accessory nerve posteriorly; in
addition, it is often incorporated into the dural cuff around
the vertebral artery at the site of dural penetration. The most
rostral attachment of the dentate ligament is located at the
level of the foramen magnum, above where the vertebral
artery pierces the dura. The ligament courses behind the
accessory nerve at that level, although the dentate ligament is
located anterior to the accessory nerve at lower levels. The
second triangular process is attached to the dura below the
site at which the vertebral artery and the roots of C1 pierce the
dura. Sectioning the upper two triangular processes will in-
crease access anterior to the spinal cord. The first cervical
nerve courses along the posteroinferior surface of the verte-
bral artery as it pierces the dura. The ventral root is located
anterior to the dentate ligament, and the dorsal root, which is
infrequently present, passes posterior to the dentate ligament.
There are frequently communications between the C1 nerve
root and the spinal accessory nerve.
Brainstem
The lower medulla blends indistinguishably into the upper
spinal cord at the level of the C1 nerve roots (Figs. 6.3, 6.4, and
6.6). The anterior surface of the medulla is formed by the
medullary pyramids, which face the clivus, the anterior edge
of the foramen magnum, and the rostral part of the odontoid
process. The lateral surface is formed predominantly by the
inferior olives. The posterior surface of the medulla is divided
into superior and inferior parts. The superior part is com-
posed in the midline of the inferior half of the fourth ventricle,
and laterally by the inferior cerebellar peduncles. The inferior
part of the posterior surface is composed of the gracile fascic-
ulus and tubercle medially, and the cuneate fasciculus and
tubercle laterally.
Cerebellum
The suboccipital cerebellar surface rests above the posterior
and lateral edge of the foramen magnum. Only the lower part
of the hemispheres formed by the tonsils and the biventral
lobules, and the lower part of the vermis formed by the
nodule, uvula, and pyramid, are related to the foramen mag-
num. The biventral lobule sits above the lateral part of the
foramen magnum, and the tonsils rest above the level of the
posterior edge (Figs. 6.3 and 6.6). The cerebellar surface above
the posterior part of the foramen magnum has a deep vertical
depression, the posterior cerebellar incisura, which contains
the falx cerebelli and extends inferiorly toward the foramen
magnum. The tonsils, which sit above the posterior edge of
the foramen magnum, are commonly involved in herniations
through the foramen magnum. Each tonsil is an ovoid struc-
ture that is attached along its superolateral border to the
remainder of the cerebellum. The cerebellomedullary fissure
extends superiorly between the cerebellum and the medulla
and is situated rostral to the posterior margin of the foramen
magnum.
Cranial nerves
The accessory nerve is the only cranial nerve that passes
through the foramen magnum (Figs. 6.3 and 6.6). It has a
cranial part composed of the rootlets that arise from the
medulla and join the vagus nerve, and a spinal portion
formed by the union of a series of rootlets that arise from the
lower medulla and upper spinal cord. In the posterior fossa,
the accessory nerve is composed of one main trunk from the
spinal cord and three to six small rootlets that emerge from
the medulla. The most rostral medullary rootlets are function-
ally inferior vagal rootlets, since they arise from the vagal
nuclei (25). The lower medullary rootlets join the spinal por-
tion of the nerve. The upper medullary rootlets enter the
jugular foramen without joining the spinal portion, but once
inside the jugular foramen, they join either the vagus or
accessory nerve. The spinal contribution arises from the cer-
vical portion of the spinal cord as a series of rootlets situated
midway between the ventral and dorsal rootlets. The lowest
level of origin of the rootlets contributing to the accessory
nerves was at the C7 root level in 2 of the 50 nerves examined,

Š
along the posterior margin of the medulla to reach the cerebellomedullary fissure. D, another specimen. The rostral end of
the dentate ligament passes between the posterior spinal artery and vertebral artery and attaches to the dura at the level of
the foramen magnum. The accessory nerve ascends behind the posterior spinal artery. The C1 nerve root receives a contribu-
tion from the accessory nerve and passes through the dura with the vertebral artery and courses along the lower margin of
the artery. The posterior spinal artery arises inside the dura and passes between the dentate ligament and accessory nerve
and gives rise to ascending branches to the medulla and descending branches to the spinal cord. E, the anterior skull base has
been removed. The vertebral arteries ascend in front of the brainstem and give rise to the anterior spinal artery. F, enlarged
view. The C1 ventral roots penetrate the dura with the vertebral artery. The hypoglossal rootlets pass behind the vertebral
arteries. A., artery; Bas., basilar; Cer.Med., cerebellomedullary; CN, cranial nerve; Cond., condyle; Dent., dentate; Fiss., fis-
sure; Hypogl., hypoglossal; Lig., ligament; Men., meningeal; Occip., occipital; P.I.C.A., posteroinferior cerebellar artery; Post.,
posterior; Sp., spinal; Vert., vertebral.

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S168 Rhoton
C6 in 10, C5 in 13, C4 in 11, C3 in 7, C2 in 5, and Cl in 2 (5).
These rootlets unite to form a trunk with a diameter of ap-
proximately 1.0 mm, which ascends through the foramen
magnum between the dentate ligament and the dorsal spinal
roots to enter the posterior cranial fossa behind the vertebral
artery.
Of the 50 accessory nerves examined in our previous study,
all had connections with the dorsal roots of the upper cervical
nerves. The most common and largest anastomosis was with
the dorsal root of the first cervical nerve (5, 22). Twenty-eight
of the C1 dorsal roots arose solely from the accessory nerve
without there being a contribution from the C1 level of the
spinal cord. All of the 15 Cl dorsal roots that received rootlets
arising from the spinal cord at the C1 level also had anasto-
motic fibers from the accessory nerve. Four of the 50 accessory
nerves had an anastomotic connection with the C2 nerve root,
10 with the C3, 8 with the C4, and 2 with the C5.
The lower four cranial nerves are sufficiently close to the
foramen magnum that they may be involved by lesions aris-
ing there (Figs. 6.3 and 6.6). Their intradural anatomy is de-
scribed in the chapter of this issue on the cerebellopontine
angle and posterior fossa cranial nerves.
Cervical nerve roots
Each dorsal and ventral root is composed of a series of six
to eight rootlets that fan out to enter the posterolateral and
anterolateral surfaces of the spinal cord, respectively (Figs. 6.3
and 6.6). The dorsal and ventral roots cross the subarachnoid
space and transverse the dura mater separately, then unite
close to the intervertebral foramen to form the spinal nerves.
The rootlets in the region of the foramen magnum pass almost
directly lateral to reach their dural foramina. The neurons of
the dorsal roots collect to form ganglia located just proximal
to the union of the dorsal and ventral root in the intervertebral
foramina, however the first cervical dorsal root and associated
ganglion may be absent. The C1, C2, and C3 nerves, distal to
the ganglion, divide into dorsal and ventral rami. The dorsal
rami divide into medial and lateral branches that supply the
skin and muscles of the posterior region of the neck. The C1
nerve, termed the suboccipital nerve, leaves the vertebral
canal between the occipital bone and atlas and has a dorsal
ramus that is larger than the ventral ramus. The dorsal ramus
courses between the posterior arch of the atlas and the verte-
bral artery to reach the suboccipital triangle, where it sends
branches to the rectus capitis posterior major and minor,
superior and inferior oblique, and the semispinalis capitis,
and occasionally has a cutaneous branch that accompanies the
occipital artery to the scalp. The C1 ventral ramus courses
between the posterior arch of the atlas and the vertebral artery
and passes forward, lateral to the lateral mass of the atlas and
medial to the vertebral artery, and supplies the rectus capitis
lateralis. The C2 nerve emerges between the posterior arch of
the atlas and the lamina of the axis where the spinal ganglion
is located extradurally, medial to the inferior facet of C1 and
the vertebral artery. Distal to the ganglion, the nerve divides
into a larger dorsal and a smaller ventral ramus. After passing
below and supplying the inferior oblique muscle, the dorsal
Neurosurgery, Vol. 47, No. 3, September 2000 Supplement
ramus divides into a large medial and a small lateral branch.
It is the medial branch that is most intimately related to this
suboccipital operative field and that forms the greater occip-
ital nerve. It ascends obliquely between the inferior oblique
and the semisplenius capitis, pierces the latter and the trape-
zius muscle near their attachments to the occipital bone, and
is joined by a filament from the medial branch of C3. It
supplies the semispinalis capitis muscle, ascends with the
occipital artery, and supplies the scalp as far forward as the
vertex, and occasionally the back of the ear. The lateral branch
sends filaments that innervate the splenius, longissimus, and
semisplenius capitis, and is often joined by the corresponding
branch from the C3 nerve. The C2 ventral ramus courses
between the vertebral arches and transverse processes of the
atlas and axis and behind the vertebral artery to leave this
operative field. Two branches of the C2 and C3 ventral rami,
the lesser occipital and greater auricular nerves, curve around
the posterior border and ascend on the sternocleidomastoid
muscle to supply the skin behind the ear.
The first cervical nerve, located just below the foramen
magnum, deserves special attention (Figs. 6.3 and 6.6). It
differs from the other cervical nerves in the consistency and
origin of the dorsal rootlets forming the nerve. The C1 ventral
root is composed of four to eight rootlets that joined and
coursed laterally. Before entering the dural foramina, the C1
ventral root, and the corresponding dorsal root if present,
attaches to the posteroinferior surface of the initial intradural
part of the vertebral artery, and both exit the dural sac
through the funnel-shaped dural foramen around the verte-
bral artery. The ventral root joins the dorsal root in or external
to the dural foramen.
The dorsal root of the first cervical nerve is more compli-
cated than the ventral root because of the variations in its
composition and its connections with the accessory nerve. In
the 25 cervical spinal cords examined, in which one would
expect to find 50 C1 dorsal roots arising from the posterior
lateral sulcus, only 15 were found (5). The accessory nerve
contributed a root to the C1 nerve in 28 of the 35 roots lacking
a dorsal root arising from the spinal cord. In the remaining 7
cases, the C1 dorsal root was absent. Each of the 15 dorsal
roots that arose from the spinal cord also had a contribution
from the accessory nerve.
Arterial relationships
The major arteries related to the foramen magnum are the
vertebral and posteroinferior cerebellar arteries (PICA), and
the meningeal branches of the vertebral, and external and
internal carotid arteries (Figs. 6.3, 6.4, and 6.6) (16, 20, 21).
Vertebral artery
The paired vertebral arteries arise from the subclavian ar-
teries, ascend through the transverse processes of the upper
six cervical vertebrae, pass behind the lateral masses of the
axis, enter the dura mater behind the occipital condyles, as-
cend through the foramen magnum to the front of the me-
dulla, and join to form the basilar artery at the pontomedul-

lary junction. Each artery is divided into intradural and
extradural parts (Figs. 6.3-6.6).
The extradural part is divided into three segments. The first
segment extends from the origin at the subclavian artery to
the entrance into the lowest transverse foramen, usually at the
C6 level. The second segment ascends through the transverse
foramina of the upper six cervical vertebrae in front of the
cervical nerve roots. This segment deviates laterally just above
the axis to reach the laterally placed transverse foramen of the
atlas. The third segment, the one most intimately related to
the foramen magnum, extends from the foramen in the trans-
verse process of the atlas to the site of passage through the
dura mater. The artery, after passing through the transverse
process of the atlas, is located on the medial side of the rectus
capitis lateralis. The third segment passes medially behind the
lateral mass of the atlas and atlanto-occipital joint and is
pressed into the groove on the upper surface of the lateral part
of the posterior arch of the atlas, where it courses along the
floor of the suboccipital triangle. It enters the vertebral canal
by passing anterior to the lateral border of the atlanto-
occipital membrane. It is partially covered by the posterior
atlanto-occipital membrane and semispinalis capitis, the rec-
tus capitis posterior major, and the superior and inferior
oblique muscles. It is surrounded by a venous plexus com-
posed of anastomoses between the deep cervical and epidural
veins. The C1 nerve root passes through the dura mater on the
lower surface of the vertebral artery between the artery and
the groove on the posterior arch of the atlas with the vertebral
artery. This bony groove is frequently transformed into a
bony canal that completely surrounds a short segment of the
artery. Of the 50 arteries we examined, 24 (48%) were in a
shallow groove, 12 (24%) were partially, but incompletely,
surrounded by bone, and 14 (28%) coursed through a bony
ring that completely surrounded the artery (Fig. 6.6) (5). The
terminal extradural segment of the vertebral artery gives rise
to the posterior meningeal and posterior spinal arteries,
branches to the deep cervical musculature, and infrequently
the PICA.
The intradural segment begins at the dural foramina just
inferior to the lateral edge of the foramen magnum. The dura
in this region is much thicker than in other areas, and it forms
a funnel-shaped foramen around a 4- to 6-mm length of the
artery. The first cervical nerve exits the spinal canal, and the
posterior spinal artery enters the spinal canal through this
dural foramen with the vertebral artery. These three struc-
tures are bound together at the foramen by fibrous dural
bands. The initial intradural segment of the vertebral artery
passes just superior to the dorsal and ventral roots of the first
cervical nerve, and just anterior to the posterior spinal artery,
the dentate ligament, and the spinal portion of the accessory
nerve.
Once inside the dura mater, the artery ascends from the
lower lateral to the upper anterior surface of the medulla. The
intradural part of the artery is divided into lateral and anterior
medullary segments (5, 16). The lateral medullary segment
begins at the dural foramen and passes anterior and superior
along the lateral medullary surface to terminate at the preo-
livary sulcus. The anterior medullary segment begins at the
Neurosurgery, Vol. 47, No. 3, September 2000 Supplement
Foramen Magnum S169
preolivary sulcus, courses in front of, or between, the hypo-
glossal rootlets, and crosses the pyramid to join with the other
vertebral artery at or near the pontomedullary sulcus to form
the basilar artery. In its ascending course, the anterior and
lateral surfaces of the lateral medullary segments face the
occipital condyles, the hypoglossal canals, and the jugular
tubercles. The anterior medullary segment rests on the clivus.
The branches arising from the vertebral artery in the region of
the foramen magnum are the posterior spinal, anterior spinal,
PICA, and anterior and posterior meningeal arteries.
Posterior spinal artery
The paired posterior spinal arteries usually arise from the
posteromedial surface of the vertebral arteries, just outside
the dura mater, but they may also arise from the initial intra-
dural part of the vertebral arteries, or from the PICA (Figs. 6.3
and 6.6) (5, 16, 21). Care should be taken to preserve the
posterior spinal artery during dural opening because it may
be incorporated into the dural cuff around the vertebral artery.
As each posterior spinal artery passes through the dura mater, it
is surrounded by the same fibrous tunnel as the vertebral artery
and the first cervical nerve root. In the subarachnoid space, it
courses medially behind the rostral-most attachments of the
dentate ligament, and on reaching the lower medulla, it divides
into ascending and descending branches. The ascending branch
courses through the foramen magnum and supplies the resti-
form body, the gracile and cuneate tubercles, the rootlets of the
accessory nerve, and the choroid plexus near The foramen of
Magendie, and may give rise to branches that anastomose with
branches of the PICA. The descending branch passes downward
between the dorsal rootlets and the dentate ligament on the
posterolateral surface of the spinal cord, and supplies the super-
ficial part of the dorsal half of the cervical spinal cord. It anas-
tomoses with the posterior branches of the radicular arteries that
enter the vertebral foramen at lower levels. The descending
branch gives rise to collateral branches, each lower one being
smaller and less constant than the last one, which course medi-
ally across the posterior surface of the spinal cord, and join to
form an artery that courses in the midline, parallel to the poste-
rior spinal arteries.
Posteroinferior cerebellar artery
The PICA is the largest branch of the vertebral artery (Figs.
6.3 and 6.6). It usually originates with the dura mater, but it
may infrequently originate from the terminal extradural part
of the vertebral artery. It may arise at, above, or below the
level of the foramen magnum; of the 42 arteries found in 50
cerebellae examined, 35 arose above and 7 arose below the
foramen (16). The tonsillomedullary PICA segment, which
forms the caudal loop related to the lower part of the tonsil, is
most intimately related to the foramen magnum. The lower
end of the caudal loop was found to be above the edge of the
foramen magnum in 37 of the 42 arteries examined, below the
edge in 4, and at the level of the edge of the foramen in 1.
Anterior spinal artery
The anterior spinal artery is formed by the union of the
paired anterior ventral spinal arteries, which originate from
S170 Rhoton
the anterior medullary segment of the vertebral arteries near
the origin of the basilar artery (Figs. 6.3, 6.4, and 6.6). The
junction of the anteroventral spinal arteries was located above
the level of the foramen magnum near the lower end of the
olives in 84% of our specimens (5). In some cases, one of
the anterior ventral spinal arteries continued inferiorly as the
anterior spinal artery, and the other terminated on the ante-
rior surface of the medulla or in a rudimentary channel con-
nected the smaller anterior ventral spinal artery with a dom-
inant one.
The anterior spinal artery descends through the foramen
magnum on the anterior surface of the medulla and the spinal
cord in or near the anteromedian fissure. On the medulla, it
supplies the pyramids and their decussation, the medial lem-
niscus, the interolivary bundles, the hypoglossal nuclei and
nerves, and the posterior longitudinal fasciculus (17). It anas-
tomoses with the anterior branches of the radicular arteries
entering the cervical foramina. There are few anastomoses
with the anterior radicular branches if the descending channel
is large, but it has frequent connections with the anterior
radicular arteries if it is small.
Meningeal arteries
The dura mater around the foramen magnum is supplied
by the anterior and posterior meningeal branches of the ver-
tebral artery, and the meningeal branches of the ascending
pharyngeal and occipital arteries (Figs. 6.3 and 6.6) (5, 20).
These arteries, plus the dorsal meningeal branch of meningo-
hypophyseal trunk that arises from the intracavernous seg-
ment of the internal carotid artery, supply all of the dura
lining the posterior cranial fossa. Infrequently, the PICA, the
posterior spinal artery, and the intradural part of the vertebral
artery give rise to meningeal branches.
The anterior meningeal branch of the vertebral artery arises
from the medial surfaces of the extradural part of the verte-
bral artery immediately above the transverse foramen of the
third cervical vertebra (Fig. 6.3). The artery enters the spinal
canal through the intervertebral foramen between the second
and third cervical vertebrae, and ascends between the poste-
rior longitudinal ligament and the dura mater. At the level of
the apex of the dens, each artery courses medially to join its
mate from the opposite side and forms an arch over the apex
of the dens. Its branches supply the dura mater in the region
of the clivus and the anterior part of the foramen magnum
and upper spinal canal, and they anastomose with the
branches of the ascending pharyngeal and dorsal meningeal
arteries that supply the dura mater covering the anterior and
anterolateral part of the posterior fossa. The anterior menin-
geal artery also gives rise to muscular and osseous branches
that supply the body and odontoid process of the axis and the
articulate plate of the atlanto-occipital and atlantoaxial joints.
The posterior meningeal artery arises from the posterosu-
perior surface of the vertebral artery as it courses around the
lateral mass of the atlas, above the posterior arch or just before
penetrating the dura; however, it may have an intradural
origin, in which case, it penetrates the arachnoid to reach the
dura (Fig. 6.6) (5). It pursues a tortuous ascending course and
Neurosurgery, Vol. 47, No. 3, September 2000 Supplement
penetrates the dura before reaching the posterior edge of the
foramen magnum. After passing through the foramen mag-
num, it ascends near the falx cerebelli and divides near the
torcula into several branches that terminate in the posterior
part of the tentorium and cerebral falx. It supplies the dura
mater lining the posterolateral and posterior part of the pos-
terior cranial fossa, and anastomoses with the meningeal
branches of the ascending pharyngeal and occipital arteries.
The ascending pharyngeal branch of the external carotid
artery usually sends two branches to the dura above the
foramen magnum. One branch passes through the hypoglos-
sal canal and the other enters through the jugular foramen
(14). The branch passing through the hypoglossal canal di-
vides into an ascending branch that passes upward in the
dura covering the clivus and anastomoses with the branches
of the dorsal meningeal artery, and a descending branch that
courses inferomedially toward the anterior edge of the fora-
men magnum and anastomoses with branches of the arcade
above the odontoid process formed by the anterior meningeal
arteries. This anastomotic rete in the dura anterior to the
foramen magnum and on the clivus gives osseous branches to
the clivus. The branches that enter through the jugular fora-
men divide into branches that course posteriorly and postero-
superiorly to anastomose with the meningeal branches of the
occipital and posterior meningeal arteries, and supply the dura
mater in the posterior and posterolateral parts of the posterior
cranial fossa.
The meningeal branch of the occipital artery is inconstant
and, if present, it penetrates the cranium through the mastoid
emissary foramen. It divides into one branch that courses
posterosuperiorly to join the branches of the posterior men-
ingeal artery that supplies the dura mater in the posterior part
of the posterior fossa, and another branch that courses antero-
laterally and joins the meningeal branches of the ascending
pharyngeal artery.
Venous relationships
The venous structures in the region of the foramen magnum
are divided into three groups: one composed of the extradural
veins, another formed by the intradural (neural) veins, and a
third constituted by the dural venous sinuses (13, 18). The three
groups anastomose through bridging and emissary veins.
Extradural groups
Venous flow in this area empties into two systems: one
drained by the internal jugular vein and another draining into
the vertebral venous plexus. The internal jugular vein and its
tributaries form the most important drainage system in the
craniocervical area. The internal jugular vein originates at the
jugular foramen by the confluence of the sigmoid and inferior
petrosal sinuses (14, 18, 25). The venous plexus surrounding
the vertebral artery in the suboccipital triangle is formed by
numerous small channels that empty into the internal verte-
bral plexuses (between the dura and the vertebrae), which
issue from the vertebral canal above the posterior arch of the

atlas. This vertebral venous plexus and multiple small veins
from the deep muscles communicate with the dense venous
plexus, which accompanies the vertebral artery into the fora-
men in the transverse process of the atlas and descends
through the transverse foramina of successive cervical verte-
brae into the brachiocephalic vein. The posterior condylar
emissary vein, which passes through the posterior condylar canal,
forms a communication between the vertebral venous plexus and
the sigmoid sinus. The venous plexus of the hypoglossal canal
passes along the hypoglossal canal to connect the basilar venous
plexus with the marginal sinus, which encircles the foramen
magnum. Obliteration of a portion of the venous plexus exposes
the upper extradural segment of the vertebral artery.
Dural venous sinuses
The venous channels in the dura mater surrounding the
foramen magnum are the marginal, occipital, sigmoid, infe-
rior petrosal, and basilar venous plexus. The marginal sinus is
located between the layers of the dura in the rim of the
foramen magnum. It communicates anteriorly, through a se-
ries of small sinuses, with the basilar sinus on the clivus, and
posteriorly with the occipital sinus. It is usually connected to
the sigmoid sinus or jugular bulb, by a sinus that passes
across the intracranial surface of, and communicates with, the
veins in the hypoglossal canal. These anastomoses provide an
alternative route for venous drainage in the case of obstruc-
tion of the internal jugular vein. The occipital sinus courses in
the cerebellar falx. Its lower end divides into paired limbs
each of which courses anteriorly around the foramen mag-
num to join the sigmoid sinus or the jugular bulb and its
upper end joins the torcula.
The basilar venous plexus is located between the layers of
the dura mater on the upper clivus. It is formed by intercon-
necting venous channels that anastomose with the inferior
petrosal sinuses laterally, the cavernous sinuses superiorly,
and the marginal sinus and epidural venous plexus inferi-
orly. The inferior petrosal sinuses extend along the petroclival
fissure and communicate above with the basilar sinus and
below with the jugular bulb. The sigmoid sinus descends
along the sigmoid groove and exits the cranium through the
sigmoid part of the jugular foramen, and descends anterolat-
eral to the occipital condyle, and anterior to the transverse
process of the atlas.
Intradural (neural) veins
The intradural veins in the region of the foramen magnum
drain the lower part of the cerebellum and brainstem, the
upper part of the spinal cord, and the cerebellomedullary
fissure. The veins of the medulla and spinal cord form longi-
tudinal plexiform channels that anastomose at the foramen
magnum. The median anterior spinal vein that courses in the
anteromedian spinal fissure deep to the anterior spinal artery
is continuous with the median anterior medullary vein that
courses on the anteromedian sulcus of the medulla. The lat-
eral anterior spinal vein courses longitudinally along the or-
igin of the ventral roots and superiorly joins the lateral ante-
rior medullary vein that courses longitudinally in the
Neurosurgery, Vol. 47, No. 3, September 2000 Supplement
Foramen Magnum S171
anterolateral medullary (preolivary) sulcus along the line of
origin of the hypoglossal rootlets. The lateral posterior spinal
vein, which courses along the line of origin of the dorsal roots
in the posterior lateral spinal sulcus, is continuous above with
the lateral medullary vein that courses along the retro-olivary
sulcus, dorsal to the olive. The median posterior spinal vein,
which courses along the posteromedian spinal sulcus, is con-
tinuous above with the main vein on the posterior surface of
the medulla, the median posterior medullary vein that
courses along the posteromedian medullary sulcus. The trans-
verse medullary and transverse spinal veins cross the medulla
and spinal cord at various levels, interconnecting the major
longitudinal channels. Bridging veins may connect the neural
veins with the dural sinus in the region of the foramen
magnum.
DISCUSSION
Herniations
Herniation of cerebellar tissue into the foramen magnum
may cause neural compression and even death. These hernia-
tions are commonly referred to as tonsillar herniations (8, 27),
but the herniation usually involves the tonsils and biventral
lobules, both of which are deeply grooved by the edge of the
foramen magnum. The herniation may compress the medulla
and be so severe that the herniated tissue undergoes necrosis.
Patients with herniation at the foramen magnum may be asymp-
tomatic; or may present with pain, signs of neural compression,
increased intracranial pressure, and sudden unexpected death.
Symptoms caused by dysfunction of the cerebellum, brainstem,
and lower cranial and upper spinal nerves include pain in the
neck and upper arms, dizziness, ataxia, disturbances of gait,
diplopia, dysphagia, tinnitus, decreased hearing, nystagmus,
weakness up to the degree of quadriparesis, and sensory deficit in
the extremities. Coughing or sneezing may aggravate the symp-
toms and cause syncope. Some patients without previous
symptoms who die suddenly are found to have herniations
through the foramen magnum at autopsy. The occurrence of
sudden death in these patients means that herniation at the
foramen magnum is a precarious situation that can be aggra-
vated by minor stresses (8). The common denominator in
these cases with sudden death is herniation of the tonsils and
adjacent part of the biventral lobule into the foramen mag-
num. The herniation may be bilateral and symmetrical, al-
though more commonly it is not strictly symmetrical and may
be unilateral. The herniated tonsils are tightly pressed against
the medulla. Acute or chronic herniations may be seen with
space-occupying lesions, such as cerebellar astrocytomas or
cystic tumors. Chronic herniation is seen with the Arnold-
Chiari malformation.
Tumors
Tumors arising in the region of the foramen magnum are
divided by Cushing and Eisenhardt (4) into a craniospinal
group that arises above and grows downward toward the
foramen magnum, and a spinocranial group that arises below
S172 Rhoton

FIGURE 6.7. Surgical approaches to the foramen magnum. The posterior operative approach is commonly selected for intra-
dural lesions. An anterior approach is frequently selected for extradural lesions situated anterior to the foramen magnum. A
lateral approach may be selected for intradural lesions located lateral to and/or in front of the brainstem, especially if they
involve or are contiguous with the temporal bone. The lateral approaches directed through the temporal bone are considered
in a later section of this issue.

and grows upward toward the foramen magnum. The intra-
dural extramedullary tumors in this region are usually be-
nign, with meningiomas and schwannomas being the most
frequent. The intramedullary tumors are represented mainly
by astrocytomas and ependymomas. Cerebellar tumors, espe-
cially those originating in the fourth ventricle and those aris-
ing in the lower part of the cerebellar hemisphere or vermis,
may extend into or through the foramen magnum into the
upper spinal canal. Chordomas and metastases are the most
common extradural tumors. The chordomas usually arise at
the level of the clivus and may extend caudally into the
foramen magnum.
Foramen magnum tumors have frequently eluded early
diagnosis because they cause bizarre symptoms that simulate
cervical, spondylosis, multiple sclerosis, or degenerative dis-
eases (1, 23, 30). Symptoms or signs, common in other disor-
ders that should also suggest the presence of a tumor in the
region of the foramen magnum include neck stiffness and
pain, involvement of the lower cranial nerves, especially the
spinal accessory nerve, unilateral upper extremity weakness
and atrophy, incoordination of the hands, gait disturbances,
vague sensory disturbances or paresthesia in the extremities,
objective sensory loss in a nonanatomic pattern, incoordina-
tion in the upper extremities, and pyramidal tract findings
with spastic gait. Those tumors arising in the caudal part of
the fourth ventricle or cerebellum may cause increased intra-
cranial pressure by obstructing cerebrospinal fluid drainage
at the level of the fourth ventricle.

Neurosurgery, Vol. 47, No. 3, September 2000 Supplement

 Foramen Magnum S173

FIGURE 6.8. Suboccipital

approaches. Either a vertical
midline or hockey-stick
incision is used, depending
on the site of the lesion. A,
the patient is most
commonly placed in the
three-quarter prone position.
B, the vertical midline
incision is selected for
lesions situated in the upper
spinal canal and for those
located posteriorly or
posterolaterally in the area
above the foramen magnum.
The subcutaneous tissues are
separated from the
underlying fascia near the
inion to gain room for a Y-
shaped incision in the
muscles. The upper limbs of
the “Y” begin at the level
of the superior nuchal line
and join below the inion. C,
the incision is of sufficient
length to complete a
suboccipital craniectomy and
a laminectomy of the axis
and atlas (oblique lines). D,
the dural incision is outlined
(interrupted lines). E,
intradural exposure. The
major extracranial hazard is
injury to the vertebral artery
as it courses below the
atlantoaxial joint and across
the posterior arch of the
atlas. The vertebral arteries
and PICAs are in the lower
part of the exposure. The
accessory nerve ascends
posterior to the dentate
ligament. The
glossopharyngeal, vagus, and
accessory nerves pass toward the jugular foramen. F, upper left. Hockey-stick retrosigmoid exposure. Skin incision (solid line)
and bone removal (oblique lines). Lower right. Intradural exposure. The hockey-stick incision extends superomedial from the
mastoid process along the superior nuchal line to the inion and downward in the midline. This incision is selected if the
lesion extends anterolateral or anterior to the brainstem toward the jugular foramen or cerebellopontine angle. This exposure
permits the removal of the full posterior rim of the foramen magnum, the posterior elements of the atlas and axis, and, in
addition, the ability to complete a unilateral suboccipital craniectomy of sufficient size to expose the anterolateral surface of
the brainstem and the nerves in the cerebellopontine angle. Tumors in this area may extend upward through the
cerebellomedullary fissure to be attached to the roof or floor of the fourth ventricle. Laterally situated tumors may be
attached to the initial intradural segment of the vertebral artery and the thick dural cuff around the artery, which also
incorporates the posterior spinal arteries and the C1 nerve root in fibrous tissue. As one moves superiorly along the lateral
surface of the medulla, the origin of the PICA and the glossopharyngeal, vagus, accessory, facial, vestibulocochlear, and
trigeminal nerves are encountered. The dura is closed with a dural substitute if closure of the patient’s dura constricts the
cerebellar tonsils or the cervicomedullary junction. A., artery; A.I.C.A., anteroinferior cerebellar artery; Lig., ligament;
P.I.C.A., posteroinferior cerebellar artery; Vert., vertebral.

Neurosurgery, Vol. 47, No. 3, September 2000 Supplement

S174 Rhoton

FIGURE 6.9. Transnasal route to the upper clivus. A, the section of the facial structures extends across the nasal cavity,
superior and middle turbinates, maxillary sinuses, the orbits near the apex, and the ethmoid sinuses in front of the sphenoid
sinus. The zygomatic and infraorbital nerves arise from the mandibular nerve in the pterygopalatine fossa, which is located
behind the posterior wall of the maxillary sinus. B, the turbinates and posterior ethmoid air cells have been removed to
expose the vomer and the anterior face of the sphenoid sinus. The nasolacrimal duct descends along the lateral wall of the
nasal cavity and opens below the inferior turbinate into the inferior meatus. C, the anterior face of the sphenoid sinus has
been removed to expose the multiseptated sphenoid sinus and the anterior wall of the sella. The bony prominences over the
optic canals are situated in the superolateral margins of the sphenoid sinus. D, the anterior wall of the sella and the lateral
walls of the sphenoid sinus have been removed to expose the petrous and cavernous carotid and the pituitary gland. The pos-
terior wall of the sphenoid sinus, which forms the anterior surface of the upper clivus, has been preserved. A., artery; Car.,
carotid; Cav., cavernous; CN, cranial nerve; Gang., ganglion; Gl., gland; Inf., inferior; Infraorb., infraorbital; M., muscle;
Max., maxillary; M.C.A., middle cerebral artery; Med., medial; Mid., middle; N., nerve; Nasolac., nasolacrimal; Pet., petrous;
Rec., rectus; Sphen., sphenoid; Sup., superior; Turb., turbinates.

Surgical approaches Posterior approaches

The foramen magnum is most commonly approached from
posteriorly or anteriorly, and less frequently from laterally
(Fig. 6.7). The posterior operative approach is commonly se-
lected for intradural lesions, and an anterior approach is
frequently selected for extradural lesions situated anterior to
the foramen magnum. A lateral approach may be selected for
lesions located lateral to or in front of the brainstem, espe-
cially if they involve, or are located contiguous to the tempo-
ral bone and clivus. The lateral approaches directed through
the temporal bone are reviewed in the chapter on the tempo-
ral bone.
The vertical midline incision is used for lesions situated in
the upper spinal canal and posterior or posterolateral at the
level of or above the foramen magnum (Figs. 6.3, 6.6, and 6.8).
The vertical midline skin incision is of sufficient length to
complete a craniectomy above the foramen magnum and a
laminectomy of the axis and atlas. The subcutaneous tissues
are separated from the underlying fascia near the inion to gain
room for a Y-shape muscle incision. The upper limbs of the
“Y” begin at the level of the superior nuchal line, lateral to the
external occipital protuberance, and join several centimeters
below the inion, leaving a musculofascial flap along the su-

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 Foramen Magnum S175

FIGURE 6.10. Nasal pathway to the clivus. Stepwise dissection showing the structures that form the lateral limit of the trans-
nasal route to the clivus. A, the entire clivus is located above the level of the hard palate and, in most cases, can be accessed
through the nasal cavity and nasopharynx. The nasal turbinates and meati and the eustachian tubes are in the lateral margin
of the exposure. B, a portion of the superior, middle, and inferior turbinates has been removed and the area between the sphenoid
pterygoid process and the posterior wall of the maxilla has been opened to expose the pterygopalatine fossa in the lateral wall of
the nasal cavity. The ostia of the maxillary and frontal sinuses opens into the middle meatus located below the middle turbinate.
The nasolacrimal duct opens below the lower turbinate into the inferior meatus. The eustachian tube, located in front the foramen
magnum and lower edge of the clivus, opens into the nasopharynx at the posterior edge of the pterygoid process. Accessing the
clivus plus the atlas and axis requires an approach that can be directed above and below the level of the palate. Rosenmuller’s
fossa is located behind the eustachian tube. C, the medial wall of the maxillary sinus has been opened to expose the infraorbital
nerve, which arises in the pterygopalatine fossa and passes forward in the sinus roof. The maxillary nerve passes through the fora-
men rotundum to enter the pterygopalatine. The upper cervical carotid and eustachian tube form the lateral limit of the exposure
of the lower clivus and the junction of the petrous and cavernous carotid limits the lateral exposure of the upper clivus. D,
enlarged view. The bone and dura covering the optic canal in the superolateral part of the sphenoid sinus has been opened to
expose the optic nerve and ophthalmic artery in the optic canal. The junction of the petrous and cavernous carotid limits the expo-
sure below the level of the sella. The maxillary nerve exits the foramen rotundum and enters through the pterygopalatine fossa
where it gives rise to the infraorbital, zygomatic, and greater palatine nerves, plus communicating rami to the pterygopalatine gan-
glion. Terminal branches of the maxillary artery intermingle with the neural structures in the pterygopalatine fossa. A., artery; Ant.,
anterior; Car., carotid; Cav., cavernous; Eust., eustachian; For., foramen; Gang., ganglion; Gr., greater; Inf., inferior; Infraorb.,
infraorbital; Max., maxillary; Mid., middle; N., nerve; Ophth., ophthalmic; Palat., palatine; Pet., petrosal; Proc., process; Pteryg.,
pterygoid; Pterygopal., pterygopalatine; Sup., superior.

perior nuchal line for closure. The inferior limb of the “Y”
incision extends downward in the midline. The major ex-
tracranial hazard is injury to the vertebral artery as it courses
along the lateral part of the posterior arch of the atlas. This
artery is not encountered if the incision is strictly midline, but
it is frequently encountered in the floor of the suboccipital
triangle if the muscle incision deviates laterally, or when the
muscles are stripped from the lateral part of the posterior arch
of the atlas. The emissary veins and vertebral venous plexus
should be obliterated quickly if they are opened.
The hockey-stick incision is selected if the lesion extends
anterior or anterolateral to the brainstem toward the jugular
foramen or the cerebellopontine angle. The skin incision ex-
tends from the mastoid process along the superior nuchal line to

Neurosurgery, Vol. 47, No. 3, September 2000 Supplement

S176 Rhoton

FIGURE 6.11. Nasal route to the clivus. A, this cross section extends through the nasal cavity, orbits, and maxillary and eth-
moid sinuses. The ethmoid sinuses are situated in front of the sphenoid sinus. The middle and inferior turbinates have been
preserved. B, the anterior wall of the sphenoid sinus has been opened to expose a multiseptated sinus and the anterior sellar
wall. The left turbinates have been removed. Part of the posterior wall of the left maxillary sinus has been removed to expose
the greater palatine artery which arises from the maxillary artery in the pterygopalatine fossa. The internal carotid arteries

Neurosurgery, Vol. 47, No. 3, September 2000 Supplement

 Foramen Magnum S177

the inion, and downward in the midline. A muscular cuff is left
attached along the superior nuchal line to facilitate the closure.
This incision permits removal of the full posterior rim of the
foramen magnum, the posterior elements of the atlas and axis,
and, in addition, to complete a unilateral suboccipital craniec-
tomy of sufficient size to expose the anterolateral surface of the
brainstem and the nerves in the cerebellopontine angle.
In opening the dura mater, using either the midline or
hockey-stick approach, the marginal and occipital sinuses,
along with the bridging veins passing from the neural sur-
faces to these and the sigmoid sinus, are encountered. Poste-
rior intradural lesions may separate easily from the surface of
the brain and spinal cord. On the other hand, they may be
attached to the nerve roots and spinal cord, or they may
extend upward through the cerebellomedullary fissure to be
attached to the inferior medullary velum, choroid plexus, or
the floor of the fourth ventricle. Opening the tela choroidea
and inferior medullary velum may facilitate the exposure of
tumors in this area. Care is required to avoid injury to the
PICA as it courses around the tonsil and through the cleft
between the superior pole of the tonsil and inferior medullary
velum and tela choroidea.
Laterally situated tumors may be attached to the initial
intradural segment of the vertebral artery and the thick dural
cuff around the artery, which also incorporates the posterior
meningeal and posterior spinal arteries, Cl nerve root, acces-
sory nerve, and the dentate ligament. Dealing with these
lesions may be facilitated by using a far-lateral approach,
which is extended to include exposure of the atlanto-occipital
joint, extradural vertebral artery, and transverse process of
C1, combined with drilling of the occipital condyle, as de-
scribed in detail in the chapter on the far lateral approach (29,
33). Dividing the attachments of the upper triangular pro-
cesses of the dentate ligaments may facilitate the exposure of
anteriorly situated lesions. Structures encountered in expos-
ing superiorly along the lateral surface of the medulla include
the PICA and the glossopharyngeal, vagus, accessory, and
hypoglossal nerves. The vertebral artery may be followed
upward to its junction with the basilar artery through the
hockey-stick exposure. The most difficult lesions to remove
are those situated anterior to the glossopharyngeal, vagus,
and accessory nerves and the lateral medullary segment of the
vertebral artery. Before sacrificing any rootlets of these
nerves, an attempt should be made to gently separate the
rootlets and to operate through the interval between the root-
lets. Often, tumors expand and widen the interval between
the rootlets, thus providing some access to medially placed
lesions. Another route through which it may be easier to reach
a lesion anterior to the medulla and pons is the interval
between the lower margin of the vestibulocochlear and facial
nerves and the upper margin of the glossopharyngeal nerve.
It is uncommon to be able to work between the vagal rootlets;
however, the lower cervical rootlets of the accessory nerve are
very fine and are often separated by a wide interval. Consid-
eration might be given to sacrificing a few of the lower acces-
sory rootlets if it will make an otherwise incurable lesion
curable. The intracapsular contents of the tumor are removed,
and the remaining tumor capsule is separated from the sur-
face of the brainstem and nerves rather than attempting to
deliver the whole intact tumor through the limited exposure.
Extreme care should be used when cutting into tumors situ-
ated anterolateral to the brainstem, since these tumors, espe-
cially meningiomas, may encase a segment of the vertebral
artery or the PICA. The dura mater is closed with a dural
substitute if closure of the patient’s dura mater constricts the
cerebellar tonsils or the cervicomedullary junction. A pseudo-
meningocele may form at the operative site if there is any
tendency toward the development of hydrocephalus. Spinal drain-
age, repeated spinal punctures, or a shunting procedure may be
required to decompress a postoperative pseudomeningocele.
Anterior operative approaches
The anterior approach was first used to reach lesions ante-
rior to the spinal cord, and was subsequently used to expose
lesions anterior to the brainstem (Figs. 6.4, 6.5, and 6.9-6.11).
The greatest advantage of the anterior approach is the direct
route to the lesion, and the major disadvantages are the con-
taminated field and the frequency of cerebrospinal fluid fis-
tula, pseudomeningocele, and meningitis after the exposure
of intradural lesions by this approach. The depth of the op-
erative field was once considered a disadvantage, but the use
of the operating microscope has reduced the importance of
that factor.

Š
form serpiginous prominences in the lateral wall of the sphenoid sinus. C, the mucosa and bony wall of the sphenoid sinus
have been removed to expose both the internal carotid arteries, which form the lateral limit of the transnasal exposure of the
upper clivus. The pituitary gland has been exposed. Additional posterior wall of the left maxillary sinus has been removed to
expose the infratemporal fossa, which contains the branches of the maxillary artery, the pterygoid muscles, pterygoid venous
plexus, and branches of the mandibular nerve. The nasopharyngeal mucosa covering the longus capitis and the lower clivus is
exposed in the interval between the palate and the vomer. D, enlarged view of the sphenoid sinus and sellar region. The
anterior surface of the upper clivus is exposed below the pituitary gland. The lateral clival exposure is limited at this level by
the internal carotid arteries. E, oblique view. The medial wall of the left cavernous sinus has been opened to expose the
abducens and oculomotor nerves. The pterygopalatine fossa is located below the orbital apex. The maxillary nerve passes
through the foramen rotundum and gives rise to the communicating rami to the pterygopalatine ganglion and the infraorbital
nerve that courses along the floor of the orbit. F, enlarged view of the structures in the medial cavernous sinus. The ophthal-
mic artery courses below the optic nerve in the optic canal. A., artery; Car., carotid; Cav., cavernous; CN, cranial nerve; Gl.,
gland; Gr., greater; Inf., inferior; Infratemp., infratemporal; Max., maxillary; Mid., middle; Ophth., ophthalmic; Palat., pala-
tine; Pterygopal., pterygopalatine; Sphen., sphenoid; Turb., turbinates.

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S178 Rhoton

FIGURE 6.12. A–F. Transoral,

transpalatal, and transmaxillary
approaches to the clivus and foramen
magnum. A, forced opening of the mouth
permits the clivus to be exposed below
the palate. B, anterior view through the
open mouth. The soft palate, which
extends backward from the hard palate,
will block the view of the upper clivus. C,
an incision has been outlined in the
midline of the soft palate. D, the soft
palate has been divided to expose the
mucosa lining the lower clivus. E, the
pharyngeal mucosa has been opened in
the midline and the longus capitis and
longus coli have been exposed and
the longus capitis reflected laterally.
F, the left longus capitis and longus coli
have been reflected laterally. A., artery;
A.I.C.A., anteroinferior cerebellar artery; Ant., anterior; Bas., basilar; Cap., capitis; CN, cranial nerve; For., foramen; Gr.,
greater; Infratemp., infratemporal; Jug., jugular; Long., longus; M., muscle; Max., maxillary; N., nerve; P.I.C.A., posteroinferior
cerebellar artery; Sp., spinal; Sphen., sphenoid; Temp., temporal; Vert., vertebral; Vert., vertebral; Zygom., zygomatic.

Anterior approaches have been used to reach tumors of the such as basilar invagination, which compress the medulla or
atlas, axis, and clivus; for the resection and fixation of the odon- spinal cord from anteriorly; and for approaching aneurysms of
toid process after ligamentous and osseous injury; for decom- the lower third of the basilar artery, the vertebrobasilar junction,
pressing bony malformations of the craniovertebral junction, and the upper part of the vertebral arteries.

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 Foramen Magnum S179

FIGURE 6.12. G–J. Transoral, transpalatal, and transmaxillary approaches to the clivus and foramen magnum. G, the lower clivus
has been opened to expose both vertebral arteries, lower part of the basilar artery, right PICA, left AICA, and the abducens and
hypoglossal nerves. H, the anterior arch of C1 has been removed to expose the odontoid process. I, a degloving subperiosteal dis-
section exposes the anterior face of the maxilla and the lower part of the anterior piriform aperture. J, the transverse maxillary
(LeFort I) osteotomy extends through the maxillary sinus above the apex of the teeth and below the infraorbital canals.

The transoral route through the mouth and the posterior
pharyngeal wall, referred to as the buccopharyngeal ap-
proach, is the anterior approach most commonly selected. The
basic transoral approach may be modified to include a trans-
palatine approach in which the soft palate, or both the soft
and hard palates, are opened, and a labiomandibular or la-
bioglossomandibular approach in which the lip, mandible,
and possibly the tongue and floor of the mouth are split to
increase the exposure. Other types of anterior approaches are:
the transcervical approach directed through the submandib-
ular area along the anterior border of the sternocleidomastoid
muscle (31); the transcranial-transbasal approach in which the
clivus is reached through a bifrontal craniotomy after resection
of the sphenoid and ethmoid sinuses (6); the extended frontal
approach in which the bifrontal craniotomy is combined with an
osteotomy of the orbital rims; and the transsphenoidal approach
directed under the lip, along the nasal septum, and through the
sphenoid sinus to the upper part of the clivus.
Transoral approaches
For the transoral approach, the soft palate is retracted to
reach the anterior part of the atlas and axis, and the posterior
pharyngeal wall is incised longitudinally in the midline (Figs.
6.4, 6.12, and 6.13). The mucosa and prevertebral muscles are
elevated as a single mucoperiosteal layer using subperiosteal
dissection, and are retracted laterally. To expose the clivus, it
is often necessary to split the soft palate in the midline. If
added craniad exposure is needed, laterally based mucoperi-
osteal flaps may be elevated from the lower surface of the
hard palate, and the posterior part of the hard palate may be
removed. The mucosa covering the upper surface of the hard
palate should be retracted and not opened. This permits the
pharyngeal incision to be extended upward through the vault
of the nasopharynx to the posterior border of the vomer.
When elevating the mucoperiosteal layer from the clivus, the
lateral margins slope dorsally into “gutter-like” depressions
in which the tissue becomes thicker and more adherent. De-
pending on the lesion, the clivus, the anterior arch of the atlas,
the dens, and bodies of C2 and C3 may be removed with a
drill and rongeurs. The clival exposure between the occipital
condyles is 2- to 2.5-cm wide and 2.5- to 3.0-cm long. Care
must be taken to avoid the sixth through the twelve cranial
nerves, the internal carotid arteries, the internal jugular veins,
and the inferior petrosal sinuses that are on the periphery of

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S180 Rhoton

FIGURE 6.12. K–N. Transoral, transpalatal, and transmaxillary approaches to the clivus and foramen magnum. K, the lower
maxilla has been displaced downward. The clival window and vertebral arteries can be seen through the exposure. L,
enlarged view of the clival opening. M, the maxilla has been split vertically in the midline and the halves reflected laterally,
allowing the clival opening to be extended upward. N, enlarged view of the clival exposure. The right AICA passes behind the
right abducens nerve and the left AICA passes in front of the left abducens nerve.

the exposure. The most common lesions approached by this
route are in an extradural location. Opening the dura mater
will expose both vertebral arteries and the lower part of the
basilar artery.
To increase the exposure and reduce the operative depth,
the lip and chin may be incised vertically and a step-like
mandibular osteotomy accomplished in the midline after re-
moval of a central incisor tooth. Spreading the mandibular
edges laterally, without splitting the tongue, permits the
tongue to be depressed downward between the mandibular
halves. If the exposure is still inadequate, the tongue and floor
of the mouth may be split in the midline. Spreading the

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 Foramen Magnum S181

FIGURE 6.13. The transoral approach is the anterior approach most commonly selected. Variants of the transoral approach include the
transpalatal variant in which the soft palate or both the soft and hard palates are opened, and the labiomandibular or labioglossoman-
dibular variants in which the lip, chin, mandible, and possibly the tongue and floor of the mouth are split in the midline to increase the
exposure. The transoral approach and its variants permit removal of the clivus, the anterior arch of the atlas, the odontoid process, and
the bodies of C2 and C3. A, transoral approach. The patient is positioned with the head fixed so that lateral x-ray or image intensification
is available to verify the location. A tracheostomy is commonly performed. Catheters inserted through the nasal passages and brought
behind the soft palate and out the mouth or a silk suture brought through the base of the uvula and attached to a nasal catheter may be
used to retract the soft palate. The posterior pharyngeal wall is incised longitudinally in the midline (interrupted line). B, the mucosa and
muscles are retracted laterally as a single layer, using subperiosteal dissection to reach the atlas, axis, and lower clivus. The anterior arch
of the atlas, the odontoid process, and the body of the atlas may be removed (interrupted line) to expose the dura. C, it may be necessary
to split the soft palate in the midline to expose the clivus (palatal incision, continuous line; pharyngeal incision, interrupted line). D, the
anterior surface of the clivus has been exposed through the transpalatal approach. The anterior arch of the atlas and the odontoid process
may be removed and an opening made in the clivus (interrupted line). E, if further craniad exposure is needed, laterally based mucoperi-
osteal flaps may be elevated from the lower surface of the hard palate (interrupted line), and the soft palate split in the midline (continu-
ous line). The posterior part of the hard palate may be removed (oblique lines). F, care is taken to retract rather than open the mucosa
lining the upper surface of the hard palate. The pharyngeal incision is extended upward through the vault of the nasopharynx to the pos-
terior border of the vomer. When elevating the mucoperiosteal layer from the clivus, the lateral margins slope dorsally into gutter-like
depressions where the tissue becomes more adherent. The clivus, anterior arch of the atlas, dens, and bodies of C2 and C3 may be
removed. The clival defect is packed with muscle or fat and may be reinforced with a bone graft. The prevertebral muscle and mucosal
layers and the palatal openings are closed with absorbable sutures. G, the lower lip and mandible may be split (interrupted line) to
increase the exposure and reduce the operative depth. H, a step-like mandibular osteotomy (interrupted line) is accomplished in the mid-
line after removal of a central incisor tooth. I, spreading the mandibular halves laterally without splitting the tongue permits the tongue to
be depressed downward between the mandibular halves. J, if the exposure is still inadequate, the tongue and floor of the mouth may be
split in the midline. Spreading the mandibular-lingual halves exposes the pharynx down to the C3 level. The mucosa and musculature of
the tongue and floor of the mouth are reapproximated; the mandibular osteotomy is closed with plates; and the lip, chin, and submandib-
ular region are carefully closed after dealing with the lesion. (From, Rhoton AL Jr, de Oliveira E: Anatomical basis of surgical approaches
to the region of the foramen magnum, in Dickman CA, Spetzler RF, Sonntag VKH (eds): Surgery of the Craniovertebral Junction. New
York, Thieme, 1998, pp 13–57 [26].)

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S182 Rhoton

FIGURE 6.14. A–D. Lower maxillotomy route to the clivus and foramen magnum. A, the approach can be made through a
degloving incision inside the mouth; however, in this case, to more fully show the anatomy, a Weber-Fergusson paranasal
incision with an infraorbital extension is used to expose the anterior face of the maxilla. The infraorbital nerve has been
divided, although it can usually be preserved with the degloving incision. The masseter is attached along the lower margin of
the zygoma. B, the mucosal lining the maxillary sinus is exposed below the zygomatic arch. The coronoid process of the man-
dible is removed or reflected with the temporalis muscle to expose the medial and lateral pterygoid muscles and the maxil-
lary artery in the infratemporal fossa. C, the lateral pterygoid muscles and a segment of the maxillary artery have been
removed. Removal of the lateral pterygoid exposes the mandibular nerve and its branches in the medial part of the infratem-
poral fossa. D, a lower maxillectomy has been completed. In this approach, the maxilla can be folded on a vascularized pedicle of
soft palate into the floor of the mouth. The pterygoid process, which forms the posterior wall of the pterygopalatine fossa, has been
preserved. The nasal mucosa remains intact. The maxillary artery exits the infratemporal fossa to enter the pterygopalatine fossa.
A., artery; A.I.C.A., anteroinferior cerebellar artery; Alv., alveolar; Ant., anterior; Bas., basilar; Cap., capitis; Car., carotid; Cav., cav-
ernous; CN, cranial nerve; Eust., eustachian; Gl., gland; Inf., inferior; Infraorb., infraorbital; Int., internal; Intercav., intercavernous;
Lat., lateral; Long., longus; M., muscle; Max., maxillary; Med., medial; N., nerve; Pal., palatini; Pet., petrous; Pteryg., pterygoid;
Pterygopal., pterygopalatine; Tens., tensor; TM., temporomandibular; Vert., vertebral.

mandibular-lingual halves exposes the pharyngeal wall down
to the level of the arytenoid cartilages. After dealing with the
lesion, the mucosa and musculature of the tongue and floor of
the mouth are reapproximated, the mandibular osteotomy is
repositioned with wire, and the lip, chin, and submandibular
region are carefully closed.
Transmaxillary approach
Transmaxillary approaches have been advocated for pa-
thology extending to the upper and middle third of the clivus,
which is difficult to reach by the transoral approach (Figs. 6.12
and 6.14-6.16). Four different types of transmaxillary ap-
proaches have been used (2, 3). In one approach, a LeFort I
osteotomy is completed, and the maxilla and hard palate are
down-fractured into the oral cavity. In the second approach,
called the extended maxillectomy, the LeFort osteotomy is
combined with a midline incision of the hard and soft palate
and the halves of the maxilla are swung laterally. In the third
approach, the unilateral lower subtotal maxillotomy, half of
the maxilla, and the hard palate are hinged on the soft palate

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 Foramen Magnum S183

FIGURE 6.14. E–H. Lower maxillotomy route to the clivus and foramen magnum. E, the nasal mucosa has been opened and
the posterior pharyngeal wall reflected to the opposite side. The longus capitis attachments have been separated from the cli-
vus. F, the longus capitis and longus coli have been reflected laterally to expose the anterior arch of the atlas and the dens
and body of the axis. G, the clivus and the dura have been opened to expose the medulla and vertebral arteries. H, the expo-
sure has been extended upward by removing the anterior wall of the sphenoid sinus and sella. The terminal part of the
petrous carotids limits the lateral exposure at the level of the clivus, and the cavernous carotids limit the lateral exposure at
the level of the sphenoid sinus. The intercavernous sinuses interconnect the paired cavernous sinuses.
and folded downward into the floor of the mouth (6). The roots, and extending into the nasal cavity leaving the
medial maxillotomy is a fourth and less extensive approach branches of the internal maxillary artery and the nerves to
permitting exposure of the clivus. It involves removing the the maxilla and palate intact. The mucosa on the nasal
medial part of the anterior maxillary wall and the part of the surface of the maxilla is dissected off, and the nasal septum
maxilla bordering the anterior piriform aperture (Fig. 6.15). is divided just above its attachment to the palate. The freed
This provides an opening through the sinus and adjacent part bone block includes, in one piece, the part of both maxilla and
of the nasal cavity that exposes the clivus above the level of the maxillary teeth situated below the infraorbital foramen
the upper side of the hard palate. The sinus wall and the with their intact blood and nerve supply, which enters in the
anterior piriform aperture can be reconstructed at the end of region of the infratemporal fossa and pterygoid plates. The
the procedure. It can commonly be performed through a fact that the soft palate is left intact reduces the incidence of
degloving incision, although a lateral rhinotomy incision speech and swallowing disorders. The intact maxillary block,
would be used if there is a need to extend the approach to the however, blocks access to the craniovertebral junction, al-
medial orbit (11, 12). though it provides reasonable access to the upper and middle
In the first approach, with a LeFort osteotomy, the upper third of the clivus. In an effort to increase access to the
lip is elevated and a mucosal incision is made along the craniovertebral junction, the LeFort osteotomy has been com-
upper alveolar margin, extending around the molars on bined with a midline incision of the hard and soft palate, thus
both sides (Fig. 6.16). The mucosa is stripped off the ante- allowing the maxillary halves, with their attachment, to be
rior face of the maxilla below the infraorbital foramen. The reflected laterally (3). The disadvantage of the procedure is
saw cuts extend into the maxillary sinuses below the in- the difficulty obtaining good dental occlusion and proper
fraorbital foramen and high enough to avoid the dental functioning of the hard and soft palate.

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S184 Rhoton

FIGURE 6.15. Medial

maxillotomy approach to the
clivus and foramen magnum. A, a
lateral rhinotomy incision has
been extended along the medial
orbital rim. The medial canthal
ligament has been exposed. B, the
medial canthal ligament has been
divided to expose the medial
aspect of the orbit. The ligament
can be preserved and the medial
orbital wall left intact if orbital
exposure is not needed. The
anterior pyriform aperture is
exposed. C, the osteotomies are
as outlined to open the nasal
cavity and medial maxilla. The
medial one opens the nasal cavity
and the lateral bone removal
exposes the maxillary sinus. The
medial maxillotomy aids in expos-
ing the clivus. D, the exposure has been directed to the posterior nasopharyngeal wall behind which the clivus sits. The anterior
wall of the sphenoid sinus has been removed, exposing the sphenoid septum. The posterior part of the nasal septum has been re-
moved to expose the clivus below the sphenoid sinus. Removal of the medial part of the posterior wall of the maxillary sinus ex-
poses the maxillary artery in the pterygopalatine fossa. E, enlarged view of the pterygopalatine fossa exposed by removing the me-
dial part of the posterior wall of the maxillary sinus. The maxillary nerve and artery enter the pterygopalatine fossa. The maxillary
artery is the major source of bleeding during surgery in this area. The maxillary artery enters the pterygopalatine fossa by passing
through the pterygomaxillary fissure. The maxillary nerve enters the fossa by passing through the foramen rotundum and gives off
communicating rami to the pterygopalatine ganglion. F, the pharyngeal mucosa has been opened, the longus capitis reflected later-
ally, and the clivus and dura opened to expose the basilar artery ascending in front of the pons. The pituitary gland is at the upper
margin of the exposure. A., artery; A.I.C.A., anteroinferior cerebellar artery; Ant., anterior; Bas., basilar; Cap., capitis; CN, cranial
nerve; Eust., eustachian; Gang., ganglion; Gl., gland; Gr., greater; Lig., ligament; Long., longus; M., muscle; Max., maxillary; Med.,
medial; N., nerve; Nasolac., nasolacrimal; Post., posterior; Pterygopal., pterygopalatine; Sphen., sphenoid; Vert., vertebral.

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 Foramen Magnum S185

FIGURE 6.16. Transmaxillary approaches. Three variants of the transmaxillary approaches are shown. All three can be com-
pleted through an intraoral incision with degloving. Another type of incision extending onto the face, such as a Weber-
Fergusson incision, might be considered. A, the upper lip is elevated and the mucosa is incised along the upper alveolar mar-
gin around the molars. The mucosa is elevated from the anterior face of the maxilla below the infraorbital foramen, but high
enough to avoid the dental roots. The mucosa is elevated from the nasal surface of the maxilla, and the nasal septum is
divided above its attachment to the palate. B, the saw cuts (solid line) extend into the maxillary sinus on both sides. The free
block of maxilla is moved downward (arrow) to give access to the clivus. C, the intraoral retractor has been placed. Displac-
ing the maxilla downward gives wide access to the clivus. D, a modified technique, called the extended maxillectomy,
includes the LeForte I osteotomy with a midline incision of the hard and soft palate (solid lines). E, this allows the halves of
the maxilla, which are attached to the muscles and vessels in the infratemporal fossa, to be reflected laterally, providing
wider exposure to the clivus and upper cervical spine. F, retractors have been placed to expose the clivus and upper cervical
area. The approach can be extended upward into the sphenoid and ethmoid sinuses and downward to C2 or C3. G–I. Unilat-
eral maxillotomy. G, in this approach, half of the maxilla is mobilized by a bone cut, which extends back to the infratemporal
fossa in the area just below the infraorbital foramen, and the maxilla is divided in the midline. A mucosal incision is made
along the low surface of the hard palate parallel to the midline on the side opposite the saw cut through the hard palate, and
the anterior face of the maxilla is degloved on one side. The soft palate is left intact. H, the unilateral block of maxilla, which
is still attached to the structures in the infratemporal fossa along the pterygoid plates and to the soft palate, which is not
interrupted, is folded downward into the floor of the mouth. I, the anterior part of the nasal septum is left undisturbed, but
the posterior part is removed along with some of the turbinates and wall of the sinuses to provide a wide exposure of the cli-
vus. This exposure can be enlarged to include the walls of the sphenoid and ethmoid sinuses. (From, Rhoton AL Jr: Anatomi-
cal basis of surgical approaches to the region of the foramen magnum, in Dickman CA, Spetzler RF, Sonntag VKH (eds): Sur-
gery of the Craniovertebral Junction. New York, Thieme Medical Publishers, Inc., 1998, pp 13–57 [24].)
In the lower subtotal maxillotomy approach, the part of half palate. This opens a route through the nasal and oral cavities to the
of the maxilla, located below the orbital floor and infraorbital clivus, foramen magnum, and upper cervical area.
canal, is folded into the floor of the mouth on a hinge of In each of the approaches, the posterior part of the nasal
vascularized tissue, including the internal maxillary artery septum and turbinates may be removed to expose the poste-
and leaving the soft palate intact (Fig. 6.14) (2, 11). The hard rior pharyngeal wall and provide access to the clivus and
palate is divided in the midline, care being taken to preserve the soft upper cervical vertebrae. These approaches also provide ac-

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S186 Rhoton
FIGURE 6.17. Transsphenoidal approach. A, Upper left, this
approach, directed beneath the upper lip, along the nasal
septum, and through the sphenoid sinus, may be used to
expose the upper third of the clivus. The resectable area
(oblique lines) includes the floor and anterior wall of the sella,
the vomer, and the upper third of the clivus. This approach is
suitable for biopsying some tumors that extend upward from
the foramen magnum. Lower right, a cup forceps biopsies a
clival tumor. B, view through nasal speculum. The anterior
nasal spine is preserved and the anterior part of the septal carti-
lage remains attached to the septal mucosa on one side. The
nasal speculum is inserted between the left side of the nasal
septum and its mucosa. The nasal septum and the mucosa on
the right side of the septum are pushed to the right by the
speculum, and the mucosa on the left side of the septum is
pushed to the left. The keel on the vomer is exposed. C, magni-
fied view. The vomer has been removed to open the sphenoid
sinus. The sellar floor is above the midline septum. In approach-
ing the clivus, the floor of the sella is removed, and the opening
in the bone is extended downward on the clivus (interrupted
lines) to the inferior margin of the sphenoid sinus.
cess to the sphenoid and ethmoid sinuses and the sella, and
the medial part of the floor of the anterior fossa. The posterior
part of the mucosa on both sides of the nasal septum may be
prepared to provide flaps that can be folded into the clival
defect for closure. In addition, planning will allow for a tempo-
ralis muscle graft to be folded into the clival defect for closure.
The incidence of swallowing and speech difficulties is signifi-
cantly greater with those approaches in which the soft palate is
Neurosurgery, Vol. 47, No. 3, September 2000 Supplement
divided than when it is left intact. In each approach, plates and
screws are positioned before making the bone cuts to achieve
satisfactory dental occlusion after the procedure. The unilateral
lower maxillotomy provides a more rapid recovery of oropalatal
function because only half of the maxilla is disturbed, and the
soft palate remains intact. That approach to the clivus is slightly
oblique, but can provide as wide an exposure as is achieved with
the approaches involving a bilateral maxillotomy.
Transsphenoidal approach
The transsphenoidal approach along the nasal septum may
be used to expose the upper third of the clivus (Figs. 6.9-6.11
and 6.17) (10). The vomer is resected to enter the sphenoid
sinus and expose the floor of the sella turcica and the ventral
surface of the clivus. The anterior nasal spine and the anterior
part of the septal cartilage are preserved. In approaching the
clivus, the floor of the sella turcica may be removed and the
bony opening extended downward on the clivus to the infe-
rior margin of the sphenoid sinus. Lesions extending to the
upper third of the clivus may be biopsied or partially re-
moved through this approach. The sellar and clival openings
are closed with fat or muscle and nasal septal cartilage. The
advantage of this approach is the low complication rate, and
the disadvantage is the small operative field limited to the
superior third of the clivus.
Transcervical approach
The transcervical approach, as performed by Stevenson et
al., is directed through the fascial planes of the neck to the
region of the foramen magnum (Fig. 6.18) (31). It avoids
opening the oropharyngeal mucosa, but is selected infre-
quently because of the depth of the exposure and because it is
not a direct midline exposure. A tracheostomy, which allows
the jaws to be closed tightly, facilitates the exposure. The
T-shaped skin incision includes a submandibular incision
from the mastoid tip to the symphysis menti and an inferior
extension carried from the midpoint of the submandibular
incision across the sternocleidomastoid muscle. The fascial
plane between the pharynx and the prevertebral muscles is
reached through an exposure directed along the anterior bor-
der of the sternocleidomastoid muscle and between the ca-
rotid sheath laterally and the esophagus and trachea medially.
The prevertebral fascia and muscles are retracted laterally to
expose the ventral aspect of the clivus, atlas, and axis. Struc-
tures that may be divided from below to above to increase the
exposure include the ascending pharyngeal and superior thy-
roid arteries, external laryngeal nerve, ansa hypoglossi, internal
laryngeal nerve, lingual artery, hypoglossal nerve, stylohyoid
muscle, anterior belly of the digastric muscle, stylohyoid liga-
ment, glossopharyngeal nerve, and the stylopharyngeus and
styloglossus muscles. The anterior arch of the atlas and the
odontoid process, and a 2 cm width of clivus extending from the
foramen magnum to the sphenooccipital synchondrosis may be
removed. Deviation laterally may damage the internal jugular
vein, internal carotid artery, eustachian tube, and the ninth
through the twelfth cranial nerves.
 Foramen Magnum S187

FIGURE 6.18. A, transcervical approach. A tracheostomy allows the jaws to be closed tightly. The T-shaped skin
incision (interrupted lines) includes a submandibular incision extending from the mastoid tip to the symphysis
menti and an inferior extension carried downward across the sternocleidomastoid muscle. B, the resectable area
(oblique lines) includes the clivus, anterior arch of the axis, and the body of the odontoid process of the axis. C,
the exposure is directed along the anterior border of the sternocleidomastoid and between the external and
internal carotid arteries and internal jugular vein laterally, and the esophagus, hypopharynx, and trachea medially.
Structures that may be divided to increase the exposure include the ascending pharyngeal and superior thyroid
arteries, the external laryngeal nerve, ansa hypoglossi, internal laryngeal nerve, lingual artery, hypoglossal nerve,
stylohyoid muscle, anterior belly of the digastric, stylohyoid ligament, glossopharyngeal nerve, and the stylopharyn-
geus and styloglossus. The accessory nerve passes behind the sternocleidomastoid. D, the prevertebral fascia and lon-
gus capitis and longus colli are separated in the midline from the clivus to C3 and are retracted laterally using sub-
periosteal dissection to expose the ventral aspect of the clivus, atlas, and axis. E and F, the anterior arch of the atlas
and the odontoid process, and a 2.5-mm width of clivus extending from the foramen magnum to the spheno-occipital
synchondrosis may be removed. The basilar, vertebral, and anterior spinal arteries are exposed in the dural opening.
After dealing with the pathology, the dura is closed, muscle and fat are placed in the clival window, and the preverte-
bral and fascia are sutured in the midline. (From, Rhoton AL Jr: Anatomical basis of surgical approaches to the
region of the foramen magnum, in Dickman CA, Spetzler RF, Sonntag VKH (eds): Surgery of the Craniovertebral Junc-
tion. New York, Thieme Medical Publishers, Inc., 1998, pp 13–57 [24].) A., artery; Ant., anterior; Bas., basilar; Car.,
carotid; Ext., external; Inf., inferior; Int., internal; Jug., jugular; M., muscle; Sp., spinal; Sup., superior; V., vein; Vert.,
vertebral.

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S188 Rhoton

FIGURE 6.19. A–F. Relationships in the transbasal and extended frontal approaches. A, a bicoronal scalp flap has been reflected forward.
The pericranium is commonly reflected as a separate layer for later use in closing the floor of the anterior cranial fossa. B, bone flap and
osteotomy. The transcranial-transbasal approach uses only a bifrontal craniotomy bordering the floor of the anterior cranial fossae with-
out the osteotomy. A large bifrontal craniotomy and a fronto-orbitozygomatic osteotomy have been completed. The osteotomized seg-
ment may extend through the nasal bone and lateral orbital rim, but for most clival lesions a more limited bone flap and osteotomy (dot-
ted lines) will usually suffice and can be tailored as needed to deal with involvement of the nasal cavity, paranasal sinuses, or orbit. C, the
periorbita has been separated from the walls of the orbit in preparation for the osteotomies. Division of the medial canthal ligament is not
necessary for most lesions, but may be required for lesions extending into the lower nasal cavity or orbit. The ligaments should be
re-approximated at the end of the procedure. D, the right medial canthal ligament has been divided and the orbital contents retracted
laterally to expose the nasolacrimal duct and the anterior ethmoidal branch of the ophthalmic artery at the anterior ethmoidal foramen.
E, the osteotomies have been completed and the frontal dura elevated. The dura remains attached at the cribriform plate. The upper part
of both orbits are exposed. F, an osteotomy around the cribriform plate leaves it attached to the dura and olfactory bulbs, a maneuver

Neurosurgery, Vol. 47, No. 3, September 2000 Supplement

 Foramen Magnum S189

FIGURE 6.19. G–L. Relationships in the transbasal and extended frontal approaches. G, the sphenoid sinus has been opened to expose
the septa within the sinus. The sphenopalatine arteries cross the anterior face of the sphenoid. H, the septa within the sphenoid sinus, the
sellar floor, and the lateral sinus wall have been removed to expose the cavernous carotid arteries, pituitary gland, and optic canals. I, the
clivus has been opened to expose the dura facing the brainstem. The basilar sinus, which interconnects the posterior parts of the cavern-
ous sinus, is situated between the layers of dura on the upper clivus. J, the clivus has been opened to expose the tortuous vertebral arter-
ies, which join to form the basilar artery at the left lateral margin of the clival opening. Both AICA origins are exposed. A vein splits the
right abducens nerve into two bundles adjacent to the brainstem. K, the frontal dura has been opened and the frontal lobes elevated to
expose the olfactory and optic nerves, the internal carotid, and the anterior and middle cerebral arteries. L, enlarged view. The subfrontal
and clival openings are separated by the sella and pituitary gland. The lateral limit of the clival exposure is defined by the internal carotid
arteries and optic nerves. The lamina terminalis is exposed above the optic chiasm.
Š
that has been attempted to preserve olfaction, but is infrequently successful. The anterior face of the sphenoid sinus and both sphenoid
ostia are exposed between the orbits. A., artery; A.C.A., anterior cerebellar artery; A.I.C.A., anteroinferior cerebellar artery; Ant., anterior;
Bas., basilar; Car., carotid; CN, cranial nerve; Ethm., ethmoidal; Gl., gland; Lam., lamina; Lig., ligament; M.C.A., middle cerebral artery;
Med., medial; Nasolac., nasolacrimal; Pit., pituitary; Sphen., sphenoid; Sphenopal., sphenopalatine; Sup., superior; Term., terminalis; Turb.,
turbinates; Vert., vertebral.

Neurosurgery, Vol. 47, No. 3, September 2000 Supplement

S190 Rhoton

FIGURE 6.20. A, the transcranial-

transbasal approach may be used
to approach tumors of the
anterior edge of the foramen
magnum if the tumor also
involves and requires resection of
part of the ethmoid and sphenoid
bones (oblique lines). B, insert.
The souttar scalp incision is
situated behind the hairline, and
the bifrontal craniotomy
(interrupted lines) is placed
strictly supraorbital without
regard for the frontal sinuses
(oblique lines). Lower right. The
subfrontal dura is separated from
the orbital roofs and the
extradural dissection is carried to
the lesser wings of the sphenoid
bone, the tuberculum sellae, and
the base of the anterior clinoid
processes. The clivus is reached
after resecting the posterior part
of the floor of the anterior cranial
fossa, the upper part of the walls
of the ethmoid and sphenoid
sinuses, and the floor of the sella.
Proceeding downward, the clivus is removed to open the anterior margin of the foramen magnum. Separation of the pharyngeal
mucosa from the front of the spine exposes the anterior arch of the atlas, and even the front of the C2 and C3 vertebral bodies.
The nasal and pharyngeal mucosa should not be opened. Dural defects are closed with a leak-proof dural graft after dealing with
the lesion. C, the orbital roof and the remainder of the cranial base are reconstructed using bone grafts. If the clivus has been
removed, the graft above the ethmosphenoidal space is fitted into the edge of a vertical graft extending from the anterior margin of
the foramen magnum or the anterior arch of the atlas to the floor of the sella. (From, Rhoton AL Jr: Anatomical basis of surgical
approaches to the region of the foramen magnum, in Dickman CA, Spetzler RF, Sonntag VKH (eds): Surgery of the Craniovertebral
Junction. New York, Thieme Medical Publishers, Inc., 1998, pp 13–57 [24].)

Transcranial-transbasal approach anterior margin of the foramen magnum. Separation of the

The subfrontal-transbasal approach may be used to ap-
proach tumors of the anterior side of the foramen magnum if
the tumor also involves and requires resection of part of the
ethmoid and sphenoid bones, and the clivus (Figs. 6.19 and
6.20). The transbasal approach, as performed by Derome (6), is
made through a bicoronal scalp incision placed behind the
hairline and a bifrontal free bone flap situated strictly su-
praorbital without regard for the frontal sinuses. The subfron-
tal dura mater is separated from the orbital roofs, the olfactory
nerves are divided at the cribriform plates, and the extradural
dissection is carried posteriorly to the lesser wings of the
sphenoid bone, the tuberculum sellae, and the base of the
anterior clinoid processes. Attempts have been made to leave
the olfactory bulbs attached to the cribriform plate, but this
has usually not prevented the loss of the sense of smell seen
commonly after these procedures. The clivus is reached after
resecting the posterior part of the floor of the anterior cranial
fossa, the upper part of the walls of the ethmoid and sphenoid
sinuses, and the floor of the sella turcica. Proceeding down-
ward from the sellar floor, the clivus is removed to open the
pharyngeal mucosa from the front of the spine permits expo-
sure of the anterior arch of the atlas, and even the C2 and C3
vertebral bodies. The nasal and pharyngeal mucosa are not
opened in the transcranial transbasal approach, but are com-
monly exposed in those procedures that include a supraor-
bital osteotomy in addition to a bifrontal flap. Dural defects
are closed with a leak-proof dural substitute, more than twice
the size of the defect, which is sutured to the dura mater at the
most remote margins of the exposure. The orbital roofs and
the remainder of the cranial base are reconstructed using
autogenous bone grafts. If the clivus has been removed, the
graft above the ethmosphenoidal space is fitted into the edge
of a vertical graft extending from the anterior margin of the
foramen magnum or the anterior arch of the atlas to the floor
of the sella. The advantages of the transbasal approach are
that a tighter closure of the dura mater is possible than can be
achieved through the transoral approaches, the subcranial
mucosal planes can be preserved, and it can be combined with
another intradural approach without the high risk of infection
associated with the transoral approaches. The transbasal ap-

Neurosurgery, Vol. 47, No. 3, September 2000 Supplement

 Foramen Magnum S191

FIGURE 6.21. Extended frontal

approach. A, the upper left insert
shows the scalp flap and the order
of the removal of the cranial
bones (1, 2, 3). The third step, the
orbitofrontoethmoidal osteotomy,
includes both supraorbital ridges,
the anterior part of the roof of the
orbits, the frontal sinus,
cribriform plate, and part of the
ethmoid air cells in one block. B,
sagittal view. The oblique lines
along the skull base show the
possible extent of the bone
removal. The foramen magnum is
reached after removing the
posterior part of the floor of the
anterior fossa, the ethmoid air
cells, walls of the sphenoid sinus,
and the clivus. C, the periorbita is
exposed along both orbital roofs.
The bone removal has been
extended into the ethmoid air
cells and the sphenoid sinus. The
exposure can be extended along
the clivus down to the foramen
magnum. D, use of pericranial
flap for reconstruction. A fat graft is placed in the ethmoid and sphenoid sinuses before reflecting the pericranial flap over
them. In addition, a fat graft may also be applied to the inner side of the pericranial flap. (From, Rhoton AL Jr: Anatomical
basis of surgical approaches to the region of the foramen magnum, in Dickman CA, Spetzler RF, Sonntag VKH (eds): Surgery
of the Craniovertebral Junction. New York, Thieme Medical Publishers, Inc., 1998, pp 13–57 [24].)

proach may be combined with a transbasal-transsphenoidal
route to gain access to the sella turcica. In the transbasal
approach the clivus and sphenoid bone can be resected more
extensively than by the transsphenoidal approach, but the
subsellar area is hidden by the bulging dura in the transbasal
approach. Both approaches may be combined to permit re-
moval of all of the clivus below the level of the dorsum sellae.
Anosmia is the only certain side effect. The most frequent
complications are cerebrospinal fluid leaks, meningitis, and
pseudomeningoceles.
Extended frontal approach
The extended frontal approach is similar to the transcranial-
transbasal approach, except that it includes an orbitofrontoeth-
moidal osteotomy (Figs. 6.19 and 6.21) (28). It may also be used
to approach tumors of the anterior side of the foramen magnum,
especially if the tumor requires resection of part of the ethmoid
and sphenoid bones as well as the clivus. The approach uses a
souttar scalp incision, bifrontal bone flaps, and an orbitofronto-
ethmoidal osteotomy in which the supraorbital ridges, and part
of the orbital roofs and possibly the upper nasion, the roof of the
ethmoid sinuses, and the cribriform plate are removed in a single
block. The resection of the lesion may involve an extradural or
combined intradural-extradural approach. The clivus and fora-
men magnum are reached after resecting the posterior part of the
floor of the anterior cranial fossa, the upper walls of the ethmoid
and sphenoid sinuses, and the floor of the sella. If needed, the
supraorbital osteotomy can even be tailored in size and site to
include the lateral orbital rims.
Selection of operative approach
Anterior extradural lesions of the clivus or upper cervical
vertebrae are best reached by one of the anterior approaches.
The transoral approach is selected for most anterior extra-
dural lesions involving the foramen magnum because it pro-
vides a midline exposure and is the most direct route to the
pathology. For more extensive lesions, a transmaxillary ap-
proach may be considered. Before selecting an anterior
approach that would require that the dura mater be opened
through the oropharynx, one should consider choosing a pos-
terior approach since the incidence of cerebrospinal fluid
leak, meningitis, and pseudomeningocele is high if the
dura mater is opened through the oropharynx. The transcer-
vical approach has the advantage of reaching the foramen
magnum through the deep fascial planes of the neck rather
than through the oropharynx; however, the depth of the ex-
posure, the length of the time required to complete the dis-
section, and the fact that the foramen magnum is not ap-

Neurosurgery, Vol. 47, No. 3, September 2000 Supplement

S192 Rhoton
proached from the midline have prevented it from gaining
common usage. The transcranial-transbasal and extended
frontal approaches offer another anterior route for reaching
the foramen magnum, however these approaches should not
be considered for approaching a tumor strictly localized in the
region of the foramen magnum, but might be used for an
extensive lesion involving the ethmoid and sphenoid sinuses
as well as the clivus and foramen magnum. The transsphe-
noidal approach provides an easy route for biopsying lesions
in the region of the foramen magnum if they extend to the
upper third of the clivus, but it does not provide adequate
exposure for removing larger lesions of the region. The trans-
sphenoidal approach may be combined with another ap-
proach in removing lesions involving the clivus and foramen
magnum.
The posterior approaches are preferred for most intradural
lesions. The vertical midline incision, and a bilateral suboccipital
craniectomy and upper cervical laminectomy is used for lesions
situated in the upper spinal canal and posterior or posterolateral
in the area above the foramen magnum. The hockey-stick inci-
sion and a unilateral suboccipital craniectomy and upper cervi-
cal laminectomy is selected if the lesion extends anterolateral or
anterior to the brainstem toward the jugular foramen or cerebel-
lopontine angle. The far-lateral modification of the lateral sub-
occipital approach, described in the next chapter on the far
lateral approach, gives a more direct approach to lesions ventral
to the brainstem and along the anterior rim of the foramen
magnum, while reducing the need for retraction of neural struc-
tures (32, 33). The foramen magnum can also be reached through
the approaches directed through the temporal bone, the subject
of the chapter on the temporal bone; however, for reaching the
foramen magnum and clivus, these approaches may require
repositioning of the carotid artery or facial nerve, and possibly
resection of the auditory and vestibular labyrinth.
Reprint requests: Albert L. Rhoton, Jr., M.D., Department of Neuro-
logical Surgery, University of Florida Brain Institute, P.O. Box 100265,
100 South Newell Drive, Building 59, L2-100, Gainesville, FL
32610-0265.
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Drawings by Leonardo da Vinci of the human cranium and spinal canal. Measurement lines indicate an interest in the
study of anatomic proportions. Courtesy, Dr. Edwin Todd, Pasadena, California. (Also see pages S6 and S286.)

Neurosurgery, Vol. 47, No. 3, September 2000 Supplement