CHAPTER 7
The Far-lateral Approach and Its Transcondylar,
Supracondylar, and Paracondylar Extensions
Albert L. Rhoton, Jr., M.D.
Department of Neurological Surgery, University of Florida, Gainesville, Florida
Key words: Cranial base, Cranial nerve, Craniocervical junction, Foramen magnum, Microsurgical anatomy, Occipital bone, Occipital condyle,
Skull base, Surgical approach, Temporal bone, Vertebral artery
T
he basic far-lateral exposure is carried up to but does
not include removal of the posterior part of the occipital
condyle. It includes 1) dissection of the muscles along
the posterolateral aspect of the craniocervical junction to per-
mit an adequate exposure of the C1 transverse process and the
suboccipital triangle; 2) early identification of the vertebral
artery either above the posterior arch of the atlas or in its
ascending course between the transverse processes of the atlas
and axis; and 3) a suboccipital craniectomy or craniotomy
with removal of at least half of the posterior arch of the atlas
(5, 19, 20). It provides access for the following three ap-
proaches: the transcondylar approach directed through the
occipital condyle or the atlanto-occipital joint and adjoining
parts of the condyle; the supracondylar approach directed
through the area above the occipital condyle; and the para-
condylar exposure directed through the area lateral to the
occipital condyle (Fig. 7.1). The transcondylar extension ac-
companied by drilling the condyles allows a more lateral
approach and provides access to the lower clivus and pre-
medullary area. The supracondylar approach provides access
to the region of and medial to the hypoglossal canal and
jugular tubercle. The paracondylar approach, which includes
drilling of the jugular process of the occipital bone in the area
lateral to the occipital condyle, accesses the posterior part of
the jugular foramen, and the posterior aspect of the facial
nerve and mastoid on the lateral side of the jugular foramen.
In the standard posterior and posterolateral approaches, an
understanding of the individual suboccipital muscles is not
essential. However, these muscles provide important land-
marks for the far-lateral approach and its modifications. Im-
portant considerations include the relationship of the occipital
condyle to the foramen magnum, hypoglossal canal, jugular
tubercle, the jugular process of the occipital bone, the mastoid,
and the facial canal (1–3, 6, 7, 10, 12, 15–17).
STAGES OF APPROACH
The approach is divided into three anatomic stages (Fig.
7.2). The first stage, the muscular dissection, includes the skin
incision, reflection of muscles, including those forming the
Neurosurgery, Vol. 47, No. 3, September 2000 Supplement
suboccipital triangle, and examination of the relationship of
the muscles to the occipital and vertebral arteries, the verte-
bral venous plexus, the transverse process of the atlas, and the
upper cervical nerves. The second stage, the extradural dis-
section, examines landmarks for the suboccipital craniectomy,
the extent of occipital condyle removal, and the exposure and
identification of the hypoglossal canal, jugular process, jugu-
lar tubercle, and facial nerve. The final stage, the intradural
exposure, reviews the relationships of the intradural segment
of the vertebral artery and its branches, including the postero-
inferior cerebellar artery (PICA), the lower cranial and upper
cervical nerves, and the dentate ligament.
Muscular stage
For our study of the region, the exposure was done using a
horseshoe scalp flap because it provided a better display of
the muscular layers and their relationships to the neural and
vascular structures (Fig. 7.2A). The incision began in the mid-
line, approximately 5 cm below the external occipital protu-
berance, and was directed upward to just above the external
occipital protuberance, turned laterally just above the supe-
rior nuchal line, reached the mastoid, and turned downward
in front of the posterior border of the sternocleidomastoid
muscle onto the lateral aspect of the neck to approximately 5
cm below the mastoid tip and below where the transverse
process of the atlas can be palpated through the skin. The skin
flap was reflected downward and medially to expose the most
superficial layer of muscles formed by the sternocleidomas-
toid and splenius capitis muscles laterally and the trapezius
and the semispinalis capitis muscles medially. In this descrip-
tion, the muscles are reflected separately but at an operation,
the scalp and muscles superficial to the suboccipital triangle
are reflected from the suboccipital area in a single layer,
leaving a musculofascial cuff attached along the superior
nuchal line for closure.
Muscular dissection
The sternocleidomastoid and trapezius are in the first layer
encountered (Fig. 7.2, B--H). Dividing the sternocleidomastoid
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S196 Rhoton

FIGURE 7.1. Osseous relationships. A, inferior view of the occipital condyles and foramen magnum. The occipital condyles are
ovoid structures located along the lateral margin of the anterior half of the foramen magnum. Their articular surfaces are convex,
face downward and laterally, and articulate with the superior facet of C1. A probe inserted through the hypoglossal canal passes
forward approximately 45 degrees from the midsagittal plane in an anterolateral direction. The hypoglossal canal is located above
the middle third of the occipital condyle and is directed from posterior to anterior and from medial to lateral. The intracranial end
of the hypoglossal canal (small oval ) is located approximately 5 mm above the junction of the posterior and middle third of the
occipital condyle and approximately 8 mm from the posterior edge of the condyle. The extracranial end of the canal is located
approximately 5 mm above the junction of the anterior and middle third of the condyle. The average length of the longest axis of
the condyle is 21 mm. The large arrow shows the direction of the transcondylar approach and the cross-hatched area shows the
portion of the occipital condyle that can be removed without exposing the hypoglossal nerve in the hypoglossal canal. The condy-
lar fossa is frequently the site of a canal, the condylar canal, which transmits the posterior condylar emissary vein that connects the
vertebral venous plexus with the sigmoid sinus just proximal to the jugular bulb. The condylar canal passes above and usually does
not communicate with the hypoglossal canal. The jugular process of the occipital bone extends laterally from the posterior half of
the occipital condyle to form the posterior margin of the jugular foramen. The portion of the jugular process located immediately
behind the jugular foramen serves as the site of attachment for the rectus capitis lateralis muscle. The stylomastoid foramen is situ-
ated lateral to the jugular foramen. The styloid process is located anterior and slightly medial to the stylomastoid foramen. B,
inferolateral view. A probe has been passed through the hypoglossal canal, which passes above occipital condyle. From its intracra-
nial to its extracranial end it is directed forward, lateral, and slightly upward. C, superior view. The occipital condyle projects
downward from the lateral margin of the anterior half of the foramen magnum. The intracranial entrance of the hypoglossal canal
is located above the condyle. The jugular tubercles are located above and anterior to the hypoglossal canals. The jugular process of
the occipital bone extends laterally from the condyles to form the posterior margin of the jugular foramen. The sigmoid sinus
crosses the occipitomastoid suture and turns in a hooklike groove on the upper surface of the jugular process to reach the jugular
foramen. Drilling the occipital condyle increases access to the anterolateral margin of the foramen magnum. Drilling in a supracon-
dylar location below the hypoglossal canal accesses the lateral edge of the clivus. Drilling in the supracondylar location above the
hypoglossal canal accesses the jugular tubercle, which projects upward and often blocks visualization of the junction of the middle
and lower clivus and the region of the pontomedullary junction during the far-lateral approach. Drilling the jugular process in a

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 Far-lateral Approach S197

just below and with preservation of its upper attachment for
closure and reflecting it laterally exposes the upper extension
of the splenius capitis. Detaching the trapezius and splenius
capitis muscles, while preserving a cuff of their upper attach-
ments for closure, and reflecting them medially exposes the
longissimus capitis muscle. Reflecting the longissimus capitis
downward exposes the semispinalis capitis and the superior
and inferior oblique muscles as well as the transverse process
of the atlas, which has a prominent apex palpable through the
skin between the mastoid process and mandibular angle. The
semispinalis capitis is reflected medially to expose the suboc-
cipital triangle, which is limited by three muscles; 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. 7.2G).
The triangle deep to these muscles is covered by a layer of
dense fibrofatty tissue. The floor in the depth of the triangle is
formed by the posterior atlanto-occipital membrane and the
posterior arch of the atlas (Fig. 7.2H). The structures in the
triangle are the vertebral artery and the C1 nerve, both of which
lie in a groove on the upper surface of the lateral part of the
posterior arch of the atlas. The suboccipital triangle is opened by
reflecting the rectus capitis posterior major inferiorly and medi-
ally, the superior oblique laterally, and the inferior oblique me-
dially. Opening the triangle exposes the portion of the vertebral
venous plexus that surrounds the vertebral artery as it passes
behind the atlanto-occipital joint and across the upper edge of
the posterior arch of the atlas (Fig. 7.2I). Reflecting the superior
oblique muscle, as described earlier, exposes the rectus capitis
lateralis, a short, flat muscle that is an important landmark in
identifying the jugular foramen (Figs. 7.2, K and L, and 7.3). It
arises from the upper surface of the transverse process of the
atlas and attaches above to the rough, lower surface of the
jugular process of the occipital bone behind the jugular foramen.
The jugular process is a plate of occipital bone extending later-
ally from the posterior half of the occipital condyle. It is indented
in front at the site of the jugular notch, which forms the posterior
edge of the jugular foramen (Fig. 7.1). The rectus capitis lateralis,
because it is attached to the jugular process at the posterior edge
of the jugular foramen, provides a landmark for estimating the
position of the jugular foramen and the facial nerve, which exits
the stylomastoid foramen just lateral to the jugular foramen.
Vascular structures
Reflecting the muscles forming the suboccipital triangle, as
described earlier, exposes the vertebral artery, which is sur-
rounded by a rich venous plexus that must be obliterated and
partially removed if the vertebral artery is to be exposed or
transposed (Fig. 7.2, H and I).
The vertebral artery, above the transverse foramen of the axis,
veers laterally to reach the transverse foramen of the atlas, which
is situated further lateral than the transverse foramen of the
axis. The artery, after ascending through the transverse pro-
cess of the atlas, is located on the medial side of the rectus
capitis lateralis muscle. From here it turns medially behind
the lateral mass of the atlas and the atlanto-occipital joint and
is pressed into the groove on the upper surface of the poste-
rior arch of the atlas, where it courses in the floor of the
suboccipital triangle and is covered behind the triangle by
the semispinalis capitis muscle. The first cervical nerve
courses on the lower surface of the artery between the artery
and the posterior arch of the atlas (Fig. 7.2, K–M). After
passing medially above the lateral part of the posterior arch of
the atlas, the artery enters the vertebral canal by passing
below the lower, arched border of the posterior atlanto-
occipital membrane, which transforms the sulcus in which the
artery courses on the upper edge of the posterior arch of
the atlas into an osseofibrous casing that may ossify, trans-
forming it into a complete or incomplete bony canal sur-
rounding the artery (Fig. 7.2H) (5).
The third segment of the vertebral artery, the segment
located between the C1 transverse process and the dural
entrance, gives rise to muscular branches and the posterior
meningeal arteries. The muscular branches arise as the artery
exits the transverse foramen of C1 and courses around the
lateral mass of the atlas to supply the deep muscles and
anastomose with the occipital and ascending and deep cervi-
cal arteries (Fig. 7.2I). Some of the muscular branches may
need to be divided to mobilize and transpose the vertebral
artery. The posterior meningeal artery arises from the poste-
rior surface of the vertebral artery as it passes behind the
lateral mass or above the posterior arch of the atlas or just
before penetrating the dura in the region of the foramen
magnum, but it may also have an intradural origin from the

Š
paracondylar location accesses the posterior margin of the jugular bulb, which is situated in the sigmoid portion of the jugu-
lar foramen. D, medial aspect of the occipital condyle and supracondylar region. The inner surface of the mastoid portion of
the temporal bone is grooved by the sulcus of the sigmoid sinus. The asterion, the site of the junction of the lambdoid, pari-
etomastoid, and the occipitomastoid sutures, is an important landmark used to define the transition between the transverse
and sigmoid sinuses. The sigmoid sulcus crosses the occipitomastoid suture just behind the jugular foramen. The intracranial
end of the hypoglossal canal is located above the junction of the posterior and middle thirds of the occipital condyle. The
external occipital protuberance is located an average of 2 cm below the apex of the internal occipital protuberance and 1 cm
below the lower margin of the torcular herophili. The parietal notch, located at the junction of the squamosal and parieto-
mastoid sutures, defines the upper limit of the petrous portion of the temporal bone and the floor of the posterior portion of
the middle fossa. The midportion of the parietomastoid suture approximates the anterior edge of the junction of the trans-
verse and sigmoid sinuses. Ac., acoustic; Artic., articular; Car., carotid; Cond., condyle; Fiss., fissure; For., foramen; Hypogl.,
hypoglossal; Int., internal; Jug., jugular; Mast., mastoid; Med., medial; Occip., occipital; Parietomast., parietomastoid; Petro-
cliv., petroclival; Proc., process; Protub., protuberance; Sig., sigmoid; Squam., squamosal; Stylomast., stylomastoid; Tymp.,
tympanic.

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FIGURE 7.2. A–D. Far-lateral and transcondylar approach. A, a suboccipital scalp flap is commonly selected for the far-
lateral exposure. The medial limb extends downward in the midline so that a wide upper cervical laminectomy can be com-
pleted if needed. The lateral limb extends below the C1 transverse process, which can be palpated between the mastoid tip
and the angle of the jaw to access the vertebral artery as it ascends through the C1 transverse process. In this dissection, the
muscles are reflected separately to show their anatomy; however, at an operation, the muscles superficial to the suboccipital
triangle can be reflected from the suboccipital area in a single layer with the scalp flap, leaving a cuff of suboccipital muscle
and fascia attached along the superior nuchal line to aid in closure. B, the scalp flap has been reflected to expose the sterno-
cleidomastoid and trapezius, the edges of which form the margins of the posterior triangle of the neck. The splenius and
semispinalis capitis are in the floor of the triangle. C, the sternocleidomastoid has been detached from the lateral part of the
superior nuchal line and reflected laterally to expose the splenius capitis, which is attached just below the line. The asterion,
located at the junction of the lambdoid, occipitomastoid, and parietomastoid sutures, most commonly overlies the lower half
of the junction of the transverse and sigmoid sinuses. D, the splenius capitis has been reflected to expose the longissimus
capitis and deep cervical fascia. The occipital artery may pass superficial or deep to the longissimus capitis. A., artery; Atl.,
atlanto; Br., branch; Cap., capitis; CN, cranial nerve; Dent., dentate; Digast., digastric; Dors., dorsal; Gang., ganglion;
Hypogl., hypoglossal; Inf., inferior; Lat., lateralis; Lev., levator; Lig., ligament; Long., longissimus; M., muscle; Maj., major;
Mas., mastoid; Memb., membrane; Men., meningeal; Min., minor; Musc., muscular; Obl., oblique; Occip., occipital; P.I.C.A.,
posteroinferior cerebellar artery; Plex., plexus; Post., posterior; Proc., process; Rec., rectus; Scap., scapula; Semispin., semispi-
nalis; Splen., splenius; Suboccip., suboccipital; Sup., superior; Trans., transverse; Vent., ventral; Vert., vertebral.

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FIGURE 7.2. E–J. Far-lateral and transcondylar approach. E, the fascia has been removed to expose the occipital artery
passing behind the superior oblique and semispinalis. F, the longissimus capitis has been reflected to expose the attach-
ment of the superior and inferior oblique muscles to the C1 transverse process. G, the suboccipital triangle, in the
depths of which the vertebral artery courses behind the atlanto-occipital joint and across the posterior arch of C1, is
situated in the depths of the area between the superior and inferior oblique and the rectus capitis posterior major. H,
the superior oblique muscle has been reflected laterally and the rectus capitis posterior major muscle inferomedially.
The floor of the suboccipital triangle is formed by the posterior atlanto-occipital membrane and the posterior arch of
the atlas. The vertebral artery and the C1 nerve root, which are surrounded by the vertebral venous plexus, course
along the upper surface of the posterior arch of the atlas. I, the muscles forming the margins of the suboccipital triangle
have been reflected to expose the vertebral artery ascending through the C1 transverse process and behind the atlanto-
occipital joint and the surrounding venous plexus. J, the venous plexus around the vertebral artery has been removed.
The vertebral artery gives off muscular branches, passes medially behind the atlanto-occipital joint and above the poste-
rior arch of C1, and turns upward and anterior to penetrate the dura.

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FIGURE 7.2. K–O. Far-lateral and transcondylar approach. K, a suboccipital craniectomy has been completed and the right
half of the posterior arch of C1 has been removed. The posterior root of the transverse foramen of the atlas has been
removed while preserving the portion of the tip of the transverse process of the atlas to which the rectus capitis lateralis,
levator scapulae, and the superior oblique attach. The atlanto-occipital joint and the posterior condylar emissary vein are
exposed. The ventral rami of the C1 and C2 nerve roots pass behind the vertebral artery. The dorsal ramus of C2 gives rise to
the greater occipital nerve, which passes through the semispinalis capitis to reach the posterior scalp. L, the area above the
occipital condyle has been drilled to the depth of the cortical bone surrounding the hypoglossal canal. The change from can-
cellous to cortical bone indicates that the hypoglossal canal has been reached. M, the hypoglossal canal has been opened to
expose the venous plexus, which surrounds the hypoglossal nerve in the canal and connects the basilar venous plexus with the
marginal sinus, which encircles the foramen magnum. The dorsal ramus of the C1 nerve root, also termed the suboccipital

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 Far-lateral Approach S201

vertebral artery, in which case it pierces the arachnoid over
the cisterna magna to reach the dura (Fig. 7.2L) (20).
The occipital artery is also exposed as the superficial and
deep muscles in the region are reflected (Fig. 7.2, C--G). It
originates from the posterior wall of the external carotid ar-
tery at the level of the angle of the mandible, ascends parallel
and medial to the external carotid artery and lateral to the
internal jugular vein to reach the area posteromedial to the
styloid process. At that point, it changes its course to posterior
and lateral, passing first between the rectus capitis lateralis
and the posterior belly of the digastric and then between the
superior oblique and the posterior belly of the digastric where
it courses in the occipital groove medial to the mastoid notch,
in which the posterior belly of the digastric muscle arises.
After exiting the area between the superior oblique muscle
and the posterior belly of the digastric, it courses medially,
being related to the longissimus capitis and semispinalis ca-
pitis. If the occipital groove is present, the occipital artery will
course deep to the longissimus capitis muscle, but if the
groove is absent, the artery will course superficial to the
longissimus capitis muscle (Fig. 7.2E). It courses medially
behind the semispinalis capitis just below the superior nuchal
line in the upper part of the posterior triangle to pass between
the upper attachment of trapezius and the semispinalis capi-
tis, where it pierces the attachment of the trapezius muscle to
the superior nuchal line and ascends in the superficial fascia
of the posterior scalp.
Osseous structures
The transverse process of the atlas, an important landmark
in these approaches, projects further lateral than the trans-
verse processes on the adjacent cervical vertebrae and has an
apex that can be felt through the skin in the area between the
mastoid process and angle of the mandible (Fig. 7.2A). Several
muscles important in completing the exposure attach to the
transverse process of the atlas (Fig. 7.2G). The rectus capitis
lateralis arises from the anterior portion, and the superior
oblique arises from the posterior portion of the upper surface
of the transverse process. The inferior oblique muscle inserts
on the lateral tip of the transverse process. The levator scap-
ulae, splenius cervicis, and the scalenus medius attach to the
inferior and lateral surface of the transverse process. The
levator scapulae is also attached by tendinous slips to the
posterior tubercles of the transverse processes of C2 to C4 (Fig.
7.2, F and G).
Neural structures
The neural structures encountered during the muscle dis-
section arise predominantly from the C1 and C2, and to a
lesser extent from the C3 spinal nerves that are formed by the
united dorsal and ventral roots and are described in the
chapter on the foramen magnum (Fig. 7.2, J–M).
Extradural stage
The extradural stage begins with a suboccipital craniec-
tomy or craniotomy, identification of the occipital condyle,
and removal of at least half of the posterior arch of the atlas
and possibly the posterior root of the transverse foramen, if
mobilization of the vertebral artery is needed (Fig. 7.2K). Two
osseous landmarks important in planning the suboccipital
craniotomy are the asterion located along the lower half of the
groove on the inner table of the cranium near the point where
the transverse sinus empties into the sigmoid sinus, and the
inion (external occipital protuberance) 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 trans-
verse sinuses. In completing the removal of the posterior arch
of the atlas, the tip of the transverse process is preserved along
with the attachment of the superior oblique, which is reflected
laterally while preserving the attachment of the rectus capitis
lateralis.
At this stage, the segment of the vertebral artery extending
from the transverse foramen of C2 to its entrance to the dura
is exposed. Removal of the posterior root of the transverse
foramen will permit the artery to be displaced downward and
medially away from the atlanto-occipital joint to expose the
occipital condyle (Fig. 7.2, L--N). The occipital condyles
project downward along the lateral edges of the anterior half
of the foramen magnum (Figs. 7.1 and 7.3). The articular
surfaces, which are ovoid with the long axis in the AP direc-
tion, are located on the lower-lateral margin of the condyles.
They face downward and laterally to articulate with the su-
perior facets of the atlas, which face upward and medially.
The intracranial end of the hypoglossal canal is located
approximately 5 mm above the junction of the posterior and
middle third of the occipital condyle and appropriately 5 mm
below the jugular tubercle (Fig. 7.1). The canal is directed
forward and laterally at a 45-degree angle with the sagittal
plane. The extracranial end of the hypoglossal canal is located
immediately above the junction of the anterior and middle
third of the occipital condyle and medial to the jugular fora-
men. The average length of the longest axis of the condyle is

Š
nerve, passes backward between the posterior arch of the atlas and the vertebral artery, supplies the muscles bordering the
suboccipital triangle, and sends fibers to the rectus capitis posterior minor and the semispinalis capitis muscles. N, an upper
cervical laminectomy has been completed and the dura opened. The dural incision completely encircles the vertebral artery,
leaving a narrow dural cuff on the artery so that the artery can be mobilized. The drilling in the supracondylar area exposes
the hypoglossal nerve in the hypoglossal canal, and can be extended extradurally to the level of the jugular tubercle to
increase access to the front of the brainstem. O, enlarged view of the site of dural penetration by the vertebral artery in
another specimen. The rostral end of the dentate ligament ascends behind the vertebral artery with the accessory nerve and
attaches to the dura along the lateral margin of the foramen magnum.

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FIGURE 7.3. Relationships in the transcondylar,

supracondylar, and paracondylar exposures. A, right
side. The segment of the vertebral artery coursing
behind the superior articular process of C1 has been
removed. The posterior condylar emissary vein
passes through the posterior condylar canal and joins
the sigmoid sinus. The rectus capitis lateralis
attaches below to the transverse process of C1 and
above to the jugular process of the occipital bone
that forms the posterior edge of the jugular foramen.
The internal jugular vein descends on the anterior
side of the rectus capitis lateralis and the C1
transverse process. B, the cancellous bone within the
occipital condyle has been drilled away while
preserving the cortical and articular surfaces to
expose the hypoglossal nerve in the hypoglossal
canal. The posterior condylar vein passes above the
occipital condyle and hypoglossal canal to empty
into the sigmoid sinus. The transition between the
sigmoid sinus and jugular bulb is located lateral to
the occipital condyle in front of the jugular process
of the occipital bone. The posterior third of the
occipital condyle can be removed without entering
the hypoglossal canal. The extracranial end of the hypoglossal canal is located medial to the jugular foramen. C, the portion
of the rectus capitis lateralis that attaches to the jugular process of the occipital bone has been removed to expose the
internal jugular vein, and the jugular process of the occipital bone has been removed to expose the jugular bulb. The facial
nerve is exposed laterally at the stylomastoid foramen. Several meningeal branches of the occipital artery ascend to pass
through the jugular foramen. An emissary vein passes from the jugular bulb to the vertebral venous plexus. A., artery; Atl.,
atlanto; Cap., capitis; CN, cranial nerve; Cond., condyle; Dent., dentate; Emiss., emissary; Int., internal; Jug., jugular; Lat.,
lateralis; Lig., ligament; M., muscle; Men., meningeal; Occip., occipital; P.I.C.A., posteroinferior cerebellar artery; Post.,
posterior; Proc., process; Rec., rectus; Sig., sigmoid; V., vein; Vert., vertebral.

21 mm (range, 18–24 mm) and the average distance between
the posterior edge of the occipital condyle and the posterior
border of the intracranial end of the hypoglossal canal is 8.4
mm (range, 6–10 mm) (20). The hypoglossal canal is sur-
rounded by cortical bone. The contents of the hypoglossal
canal are the hypoglossal nerve, a meningeal branch of the
ascending pharyngeal artery, and the venous plexus of the
hypoglossal canal, which communicates the basilar venous
plexus with the marginal sinus that encircles the foramen
magnum (Figs. 7.2M, 7.3B, and 7.4, C and D). Posterior to the
occipital condyle, a depression, the condylar fossa, may be
pierced by the condylar canal, which transmits the posterior
condylar emissary vein, a communication between the verte-
bral venous plexus and the sigmoid sinus (Fig. 7.3). The canal

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is directed slightly upward as it proceeds anteriorly to join the
sigmoid sinus at the hook-like turn immediately proximal to
where the sinus empties into the jugular bulb. The condylar
canal does not communicate with the hypoglossal canal.
The jugular process of the occipital bone serves as a bridge
between the condylar and squamosal parts of the occipital
bone and forms the posterior margin of the jugular foramen
(Fig. 7.1). It extends laterally from the posterior half of the
condyle. The jugular process also serves as the site of attach-
ment of the rectus capitis lateralis muscle behind the jugular
foramen. The stylomastoid foramen, which transmits the fa-
cial nerve, is situated lateral to the jugular foramen at the
anterior end of the mastoid notch (Figs. 7.3C and 7.4C). The
styloid process is located anterior to the stylomastoid foramen
and anterolateral to the jugular foramen.
After removing the superficial layer of cortical bone cover-
ing the occipital condyle, soft cancellous bone will be encoun-
tered. Further drilling of the cancellous bone in and above the
posterior third of the condyle exposes the second layer of
hard, cortical bone that surrounds the hypoglossal canal (Figs.
7.2N and 7.3–7.6). Subsequent drilling of this cortical bone
exposes the venous plexus of the hypoglossal canal. The lat-
eral aspect of the intracranial end of the hypoglossal canal is
reached with removal of approximately the posterior third of
the occipital condyle (8.4 mm of 21 mm) (Fig. 7.1) (20). Further
drilling of the occipital condyle can be done after reaching the
lateral aspect of the intracranial end of the hypoglossal canal,
as the canal is directed anteriorly and laterally, permitting the
lateral part of the posterior two-thirds of the condyle to be
removed without entering the hypoglossal canal. The distance
between the upper surface of the hypoglossal nerve and the
roof of the hypoglossal canal averages 4.4 mm. Extensive
drilling around the canal may allow the nerve to be trans-
posed from its normal course (Fig. 7.6).
After exposing the hypoglossal canal above the occipital
condyle, the bone of the jugular tubercle situated above the
hypoglossal canal can be removed extradurally to gain addi-
tional exposure (1–3, 9, 10, 13). The jugular tubercle is a
rounded prominence located at the junction of the basilar and
condylar parts of the occipital bone (Figs. 7.1, 7.4, C and D,
and 7.5, A–C). It is situated above the hypoglossal canal and
medial to the lower half of the intracranial end of the jugular
foramen. The average distance from the posterior edge of the
jugular tubercle (the site of the groove in which the lower
cranial nerves course) to the upper border of the hypoglossal
canal is 4.5 mm (20). The glossopharyngeal, vagus, and acces-
sory nerves cross the posterior portion of the jugular tubercle
in passing from the brainstem to the jugular foramen, some-
times coursing in a shallow groove on the surface of the
tubercle (Figs. 7.4 and 7.5).
The prominence of the jugular tubercle blocks access to the
basal cisterns and clivus anterior to the lower cranial nerves.
As the jugular tubercle is removed extradurally the cranial
nerves, which course along the back margin of the tubercle
and are intradural, will not be visualized. As the drilling
proceeds, bone will be removed from below the cisternal
segment of the accessory and the vagus nerves that course
above the tubercle just inside the dura. Caution is required in
Neurosurgery, Vol. 47, No. 3, September 2000 Supplement
Far-lateral Approach S203
removing the jugular tubercle to avoid damaging the lower
cranial nerves, either by direct trauma, by stretching the dura,
or by the heat generated by the drilling (Fig. 7.5, A–C). The
lateral margin of the jugular tubercle is situated just medial to
and below the medial edge of the jugular bulb. If a more
lateral exposure is needed, or the jugular foramen is to be
opened from posteriorly, the jugular process of the occipital
bone, which extends laterally from the occipital condyle, can
be removed after detaching the rectus capitis lateralis muscle
from its lower surface (Figs. 7.3 and 7.4). Removing the jugular
process, which forms the posterior margin of the jugular fo-
ramen, will expose the transition between the sigmoid sinus,
jugular bulb, and internal jugular vein. Care is required to
avoid damaging the vertebral artery, because it passes up-
ward through the transverse process of the atlas and turns
medially in the area directly below the jugular process. For an
even more lateral exposure, the posterior belly of the digastric
muscle can be separated from the mastoid notch to expose the
facial nerve just distal to the stylomastoid foramen (Figs. 7.3C,
7.4, B and C, and 7.6). A partial mastoidectomy can be per-
formed to expose the mastoid segment of the facial nerve in
the facial canal at this stage.
Intradural stage
The dural incision begins behind the sigmoid sinus and
extends behind the vertebral artery into the upper cervical
area. The upper extent of the dural opening depends on how
much of the cerebellopontine angle is to be exposed. Possible
sources of bleeding during the dural opening are the marginal
sinus that encircles the foramen magnum and the posterior
meningeal artery, which usually originates from the vertebral
artery extradurally, but may infrequently originate intra-
durally, in which case it crosses the lateral medullary cistern
and pierces the arachnoid to reach the dura. Opening the dura
exposes the intradural segment of the vertebral artery. As the
artery pierces the dura, it is encased in a fibrous tunnel that
binds the posterior spinal artery, dentate ligament, first cer-
vical nerve, and the spinal accessory nerve to the vertebral
artery (Figs. 7.2, N and O, 7.3) (14). Care should be taken to
preserve the posterior spinal artery during the dural opening
and mobilization of the vertebral artery because it may be
incorporated into the dural cuff around the vertebral artery.
At the craniocervical junction, the dentate ligament is lo-
cated between the vertebral artery and ventral roots of C1
anteriorly and the branches of the posterior spinal artery and
spinal accessory nerve posteriorly, and is often incorporated
into the dural cuff around the vertebral artery (Figs. 7.2O, 7.3,
and 7.5). 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 and behind the accessory
nerve, although the dentate ligament is located anterior to the
accessory nerve at lower levels. Section of the upper two
triangular processes will increase access anterior to the spinal
cord. The first cervical nerve courses along the posteroinferior
surface of the vertebral 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
S204 Rhoton

FIGURE 7.4. Relationships in the transcondylar, supracondylar, and paracondylar exposures. A, a left suboccipital craniectomy has been
completed and the dura opened. The nerves entering the jugular foramen have been exposed. Bone has been removed above the occipi-
tal condyle to expose the hypoglossal nerve entering the hypoglossal canal. A bridging vein passes from the lateral aspect of the medulla
to the jugular bulb. B, the rectus capitis lateralis has been detached from the cranial base and the jugular process of the occipital bone,
which forms the posterior margin of the jugular foramen, has been removed to expose the jugular bulb. The posterior belly of the digas-
tric muscle has been reflected forward and a mastoidectomy completed to expose the mastoid segment of the facial nerve. C, the jugular
bulb and adjoining segment of the internal jugular vein have been removed to expose the glossopharyngeal, vagus, and accessory nerves
passing through the jugular foramen and descending behind the internal carotid artery. The cortical bone lining the hypoglossal canal has
been removed to expose the hypoglossal nerve and the venous plexus in the canal. The hypoglossal nerve joins the nerves exiting the jug-
ular foramen to descend in the carotid sheath. A mastoidectomy has been completed to expose the bony capsule of the semicircular
canals and the mastoid segment of the facial nerve. D, enlarged view of the nerves passing through the hypoglossal canal and jugular
foramen in the supracondylar and paracondylar areas. A., artery; Bridg., bridging; Car., carotid; CN, cranial nerve; Cond., condyle; For.,
foramen; Gl., gland; Hypogl., hypoglossal; Int., internal; Jug., jugular; Lat., lateral, lateralis; Occip., occipital; P.I.C.A., posteroinferior cere-
bellar artery; Post., posterior; Seg., segment; Sig., sigmoid; Stylomast., stylomastoid; Vert., vertebral.

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

 Far-lateral Approach S205

FIGURE 7.5. Posterior view of the left cerebellopontine angle. A, the glossopharyngeal, vagus, accessory, and hypoglossal
nerves arise from the medulla. The hypoglossal canal has been exposed by drilling the cancellous bone above the occipital
condyle. The posterior root of the transverse process of C1 has been removed. The accessory nerve crosses the jugular tuber-
cle, the latter acting as a trochlea around which the accessory nerve courses to reach the jugular foramen. B, enlarged view.
The area above the occipital condyle has been drilled to further expose the cortical bone around the hypoglossal canal. The
atlanto-occipital joint has been preserved. C, the cortical bone lining the hypoglossal canal has been opened to expose the
hypoglossal nerve and the hypoglossal venous plexus in the canal. D, anterior view. The anterior surface of the posterior
fossa and the anterior wall of the hypoglossal canal have been removed to expose the hypoglossal nerve in its canal. The
rootlets of the hypoglossal nerve originate ventral to the inferior olive and join before exiting the hypoglossal canal. The glos-
sopharyngeal, vagus, and accessory nerves penetrate the dura on the medial side of the jugular bulb. The hypoglossal nerve
exits the hypoglossal canal on the medial side of the jugular foramen. A., artery; A.I.C.A., anteroinferior cerebellar artery;
Atl., atlanto; Bas., basilar; CN, cranial nerve; Cond., condyle; Dent., dentate; For., foramen; Hypogl., hypoglossal; Jug., jugu-
lar; Lig., ligament; Occip., occipital; P.I.C.A., posteroinferior cerebellar artery; Vert., vertebral.

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

S206 Rhoton

FIGURE 7.6. A, axial section extending through the occipital condyle and internal jugular vein below the right jugular fora-
men. The internal jugular vein descends just in front of the rectus capitis lateralis and behind the carotid artery. The occipital
condyle is located on the medial side of the jugular foramen, and the styloid process, facial nerve, and parotid gland are on the
lateral side. The nerves passing through the jugular foramen and hypoglossal canal collect together on the medial side of the inter-
nal jugular vein in an area just below the jugular foramen. B, the parotid gland has been removed. The facial nerve exits the stylo-
mastoid foramen on the lateral side of the internal jugular vein. The styloid process is located along the anterolateral margin of the
internal jugular vein. The central third of the occipital condyle has been removed to expose the hypoglossal nerve as it passes
through the hypoglossal canal and joins the nerves exiting the jugular foramen on the medial side of the internal jugular vein. The
rectus capitis lateralis and some of the jugular process of the occipital bone have been removed to expose the terminal part of the
sigmoid sinus. C–D. Transposition of the hypoglossal nerve. C, the vertebral artery has been displaced medially. The occipital con-
dyle, jugular tubercle, and the bone around and in front of the hypoglossal canal have been removed to expose the edge of the
lower clivus. The dura ostium of the hypoglossal nerve has been opened so that the nerve can be mobilized. D, enlarged view of
the mobilized hypoglossal nerve. A., artery; Atl., atlanto; Cap., capitis; Car., carotid; CN, cranial nerve; Cond., condyle; For., fora-
men; Gl., gland; Hypogl., hypoglossal; Int., internal; Jug., jugular; Lat., lateralis; M., muscle; Occip., occipital; P.I.C.A., posteroinfe-
rior cerebellar artery; Proc., process; Rec., rectus; Sig., sigmoid; Stylomast., stylomastoid; V., vein; Vert., vertebral.

to the dentate ligament. The rootlets forming the spinal por-
tion of the accessory nerve, which arise from the cervical
portion of the spinal cord midway between the dorsal and
ventral rootlets as far caudally as C5, unite to form a trunk
that ascends through the foramen magnum between the den-
tate ligament and the dorsal roots and enters the posterior
fossa behind the vertebral artery (5).
The intradural segment of the vertebral artery, after emerg-
ing from the fibrous dural tunnel, ascends in front of the
rootlets of the hypoglossal nerve to reach the front of the me-
dulla oblongata where it unites near the junction of pons and
medulla with its mate to form the basilar artery (Fig. 7.2,
N and O). Before reaching the lower border of pons, the
vertebral artery gives off the PICA, which courses backward
around the lateral surface of the medulla and between the
rootlets of glossopharyngeal, vagus, and accessory nerves.
The anterior, lateral, and tonsillomedullary PICA segments
and the intradural segment of the glossopharyngeal, vagus, and
accessory nerves, which may be exposed in this approach, are
described in greater detail in this issue in the chapters on the
cerebellar arteries and cerebellopontine angle (Figs. 7.2, N and
O, and 7.3-7.5) (11).

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


DISCUSSION
The basic far-lateral approach without drilling of the occip-
ital condyle may be all that is required to reach some lesions
located along the anterolateral margin of the foramen mag-
num. However, it also provides a route through which the
transcondylar, supracondylar, and paracondylar approaches
and several modifications of these approaches can be com-
pleted. The transcondylar exposures can be categorized into
several variants. An atlanto-occipital transarticular approach,
in which the adjacent posterior parts of the occipital condyle
and the superior articular facet of C1 are removed to facilitate
completion of a circular dural incision, permitting the verte-
bral artery with the surrounding cuff of dura to be mobilized.
A more extensive removal of the articular surfaces and con-
dyles can be done to gain access to extradural lesions situated
along the anterior and lateral margins of the foramen mag-
num. Another variant, the occipital transcondylar variant, is
directed above the atlanto-occipital joint through the occipital
condyle and below the hypoglossal canal to access the lower
clivus and the area in front of the medulla. The supracondylar
approach directed above the occipital condyle can also be
varied, depending on the pathology to be exposed. The su-
pracondylar exposure can be directed above the occipital
condyle to the hypoglossal canal or both above and below the
hypoglossal canal to the lateral side of the clivus. In the transtu-
bercular variant of the supracondylar approach, the prominence
of the jugular tubercle that blocks access to the area in front of the
glossopharyngeal, vagus, and accessory nerves is removed ex-
tradurally to increase visualization of the area in front of the
brainstem and to expose the origin of a PICA that arises from
the distal part of the vertebral artery near the midline. The
paracondylar approach also has several variants. In the trans-
jugular variant, the exposure is directed lateral to the condyle
through the jugular process of the occipital bone to the pos-
terior surface of the jugular bulb. The approach can also be
extended lateral to the jugular foramen into the posterior
aspect of the mastoid to access the mastoid segment of the
facial nerve and the stylomastoid foramen.
Many suboccipital operations are completed without re-
quiring that each individual muscle be identified. However,
identification of selective muscles is an essential part of com-
pleting the transcondylar, supracondylar, and paracondylar
approaches. Muscles that are especially significant in identi-
fying the neural, vascular, and osseous structures involved in
these exposures are the three muscles forming the suboccip-
ital triangle and the levator scapulae, rectus capitis lateralis,
and the posterior belly of the digastric. Identification of the
individual muscles is also helpful in exposing and preserving
the occipital artery if it is needed for a bypass procedure and
in preserving the peripheral branches of the upper cervical
nerves. The levator scapulae muscle provides an excellent
landmark for localizing the vertebral artery as it ascends
between the transverse foramina of the atlas and axis where
the artery is located medial to the upper attachments of the
muscle. The main risk in this area is related to a tortuous
vertebral artery that loops posteriorly as it ascends between
the transverse processes of the axis and atlas, making it vul-
Neurosurgery, Vol. 47, No. 3, September 2000 Supplement
Far-lateral Approach S207
nerable to injury when one expects the artery to be passing
straight upward from the lower to the upper transverse fora-
men. The artery is also susceptible to damage as it passes
behind the superior articular facet of the atlas. The artery
normally hugs the posterior surface of the superior articular
facet of the atlas, extending upward only to the level of the
atlanto-occipital joint. However, if the artery elongates and
becomes tortuous it can loop upward behind the occipital
condyle, even resting against the occipital bone behind the con-
dyle. It also can loop backward and bulge posteriorly between
the lips of the suboccipital triangle, which it can damage if one
expects it to be found in the depth of the suboccipital triangle.
In obliterating and coagulating the venous plexus around
the vertebral artery, there is the risk that some of the branches
of the vertebral artery, which arise in an extradural location or
even a hypoplastic vertebral artery, might be occluded or
divided. The posterior spinal artery, and uncommonly the
PICA, may arise extradurally in the region of the portion of
the vertebral venous plexus, which may need to be partially
excised or obliterated to gain access to the vertebral artery.
The far-lateral approach, in which the exposure is carried
up to, but does not include, the posterior margin of the
occipital condyle, may be selected for lesions located along the
lateral or anterolateral aspect of the foramen magnum. It is
frequently necessary to remove a small portion of both the
occipital condyle and the superior articular facet of the atlas if
there is a need to complete a circumferential dural incision
around the site where the artery penetrates the dura, so that
the artery can be displaced for access to lesions located ventral
to the artery and in front of the cervicomedullary junction. For
lesions requiring a greater anterior and superior exposure, the
posterior third of the occipital condyle can be removed with-
out entering the hypoglossal canal. It is possible to drill the
cancellous bone of the occipital condyle to expose the lateral
clivus and hypoglossal canal while preserving some of the
cortical bone of the condyle and the articular surface so that
the joint is not disrupted (Figs. 7.3 and 7.5). The cortical
surface around the hypoglossal canal can be preserved if there
is no need to expose the nerve within the canal.
Another key aspect of this approach is the condyle drilling,
which requires an understanding of the relationship of the
hypoglossal canal to the occipital condyle (Figs. 7.3–7.6). The
maximum extent of the upper portion of occipital condyle that
could be drilled without exposing the hypoglossal canal is the
posterior third of its long axis. The occipital condyle some-
times can be covered by a hypertrophic superior articular
facet of C1 that protrudes into the foramen magnum, making
it easy to overlook the upper medial portion of the occipital
condyle. In exposing lesions located along the anterior portion
of the cervical cord, the inferior portion of the occipital con-
dyle and the superior facet of C1 can be removed after re-
tracting the vertebral artery inferior and medially. In drilling
the upper posterior portion of the condyle, the posterior con-
dylar vein may be a source of bleeding, which could be
mistaken for bleeding from the venous plexus in the hypo-
glossal canal. After exposing the hypoglossal canal, the jugu-
lar tubercle, which is located just above and anterior to the
canal, is identified. The drilling can be extended to a supra-
S208 Rhoton
condylar location above the hypoglossal canal for removal of
all or part of the jugular tubercle, so that the dura covering the
tubercle can be pushed forward to gain access to the front of
the medulla and the pontomedullary junction. Removal of the
jugular tubercle may yield better visualization of the intra-
dural segment of vertebral artery and the origin of the PICA,
especially if the PICA originates from the upper part of the
vertebral artery. The supracondylar approach, in which the
jugular tubercle is removed and the hypoglossal canal is
exposed or opened, provides a route for reaching extradural
lesions located in the lower lateral part of the clivus in front of
the hypoglossal canal. The extradural removal of the jugular
tubercle should be performed with caution because of the risk
of injuring the glossopharyngeal, vagus, and the accessory
nerves that hug and often course in a shallow groove at the
site where they cross the tubercle.
The paracondylar exposure, which accesses the posterior
margin of the jugular foramen and the jugular bulb, can be
completed without drilling the occipital condyle (8, 20). An
excellent landmark for identifying the jugular process is the
rectus capitis lateralis, which extends upward from the trans-
verse process of the atlas to attach to the jugular process just
behind the jugular bulb. The muscle is located medial to the
site where the occipital artery enters the retromastoid area by
passing between the rectus capitis lateralis and posterior belly
of the digastric. The jugular foramen and jugular bulb is
accessed by drilling the jugular process at the posterior mar-
gin of the foramen. Drilling lateral to the jugular bulb from
this posterior exposure risks damaging the facial nerve in the
facial canal at and just above the stylomastoid foramen. The
posterior belly of the digastric muscle, which attaches along
the digastric groove just posterior to the stylomastoid fora-
men, provides a useful landmark for identifying the facial
nerve. A limited or more extensive mastoidectomy may be
completed, depending on the length of the mastoid segment
of the facial nerve to be exposed and the extent to which the
bone on the lateral aspect of the jugular bulb must be re-
moved. A wider exposure of the jugular foramen is obtained
by a retrolabyrinthine transtemporal approach, in which a
more extensive mastoidectomy is completed and the mastoid
and the tympanic segments of the facial nerve are exposed so
that the facial nerve can be transposed forward to provide
access to both the lateral and the posterior margin of the
jugular foramen.
Several controversies concern the positioning of the patient
and the type of skin incision (20). The modified park bench
position that we use offers the main advantage of avoiding air
embolism (2, 3, 10, 14). The sitting position recommended by
others is associated with a less distended venous plexus, but
the rich net of veins around the cervical muscles, vertebral
artery, and bone in the region offers the risk of air embolism
(4, 13). A straight scalp incision has been recommended as
being easier to open and close (10, 13). However, the thick
cervical muscular mass and need for extensive retraction cre-
ate a deep surgical field and the lateral position of the incision
makes it difficult to complete a wide removal of the posterior
C1 arch and C2 lamina, which is especially important if the
lesion extends through the foramen magnum. We prefer an
Neurosurgery, Vol. 47, No. 3, September 2000 Supplement
inverted horseshoe incision, with the medial limb extended so
that a wide C1 to C2 laminectomy can be completed, and a
lateral limb extended below the C1 transverse process so that
the muscles attaching to the transverse processes are visual-
ized (2, 5, 17, 18, 20). A musculofascial cuff is left attached
along the superior nuchal line for closure. The flap on the
upper part of the occipital squama can be reflected as a single
layer, however it is helpful to identify the muscles forming the
suboccipital triangle as an aid to exposing the vertebral artery.
Anatomically, muscle dissection layer by layer offers the best
preservation of the muscular landmarks. However, reflection
of the superficial muscles individually carries a greater risk of
flap dehiscence. Elevating the muscles attached to the upper
part of the occipital squama with the scalp minimizes this
problem and allows identification of important deep muscu-
lar landmarks, such as the suboccipital triangle and levator
scapulae for localizing the vertebral artery and the rectus
capitis lateralis for localizing the posterior portion of the
jugular bulb.
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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Cranium showing various anatomical structures. Vesalius was so confident that his work would be studied and
plagiarized that he obtained the sponsorship and copyright protection of the Emperor, the King of France, and the
Grand Council of Venice, the three great powers of his day. From, Andreas Vesalius, De Humani Corporis Fabrica.
Basel, Ex officina Ioannis Oporini, 1543. Courtesy, Rare Book Room, Norris Medical Library, Keck School of Medicine,
Los Angeles, California. (Also see pages S27, S68, and S285.)

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