Acta Neurochir (Wien) (2005) 147: 889–895

DOI 10.1007/s00701-005-0555-x

Quantitative Neuroanatomy
A morphometric analysis of the foramen magnum region
as it relates to the transcondylar approach

N. Muthukumar1, R. Swaminathan1 , G. Venkatesh1 , and S. P. Bhanumathy2

1
Department of Neurosurgery, Madurai Medical College, Madurai, India
2
Department of Anatomy, Madurai Medical College, Madurai, India

Received August 9, 2004; accepted April 12, 2005; published online June 9, 2005
# Springer-Verlag 2005

Summary
Background. The transcondylar approach is being increasingly used
to access lesions ventral to the brainstem and cervicomedullary junc-
tion. Understanding the bony anatomy of this region is important for
this approach. The purpose of this study was to conduct a morpho-
metric analysis of the hypoglossal canal (HC), occipital condyle
(OC) and the foramen magnum (FM) as it pertains to the transcon-
dylar approach.
Methods. 50 dry skulls provided 100 hypoglossal canals, 100 occipital
condyles and 50 foramina magna. Twenty one parameters were ana-
lyzed. They were: length of the HC, diameter of the intra- and extra-
cranial ends of the HC, angle of the HC to the sagittal plane, distance
of the HC from the posterior, anterior and inferior margins of the
OC, antero-posterior and transverse diameter of the OC, presence of
condylar foramen, distance of HC from the jugular foramen intra- and
extracranially, distance of HC from basion, opisthion, carotid canal and
jugular tubercle. The anteroposterior and transverse diameters of the FM
were measured and a FM index was calculated by dividing the AP
diameter of the FM by the transverse diameter. The angle of the long
axis of the occipital condyles to the sagittal plane was measured. Pro-
trusion of the occipital condyle into the foramen magnum was noted.
Where applicable, the measurements were made separately for the right
and left side.
Findings. The average length of the hypoglossal canal in this study
was 12.6 mms. The hypoglossal canal makes an angle of 49 to the
sagittal plane. In 30% of the dry skulls studied, the HC was divided
into two by a bony septum. The distance of the intracranial end of
the HC from the posterior margin of the OC was 12.2 mms. The average
anteroposterior length of the occipital condyle was 23.6 mms and the
transverse diameter was 14.72 mms. The occipital condyle made an
angle of 60 to the sagittal plane. In 20% of the skulls studied the
occipital condyle protruded into the foramen magnum. The condylar
foramen was absent on the right side in 4 skulls and on the left side
in 16 skulls. The average anteroposterior length of the foramen
magnum was 33.3 mms and the width was 27.9 mms. When the
foramen magnum index was >1.2, the foramen was found to be ovoid.
Forty six percent of the skulls studied exhibited an ovoid foramen
magnum.
Conclusions. The occipital condyle is frequently being drilled
to expose lesions ventral to the brainstem. From our study, it is
evident that the occipital condyle can be safely drilled for a dis-
tance of 12 mms from the posterior margin before encountering
the hypoglossal canal. In 20% of the skulls the occipital con-
dyle protrudes significantly into the foramen magnum. Wide and
sagittally inclined occipital condyles, medially protruberant occi-
pital condyles along with a foramen magnum index of more than
1.2 will require much more extensive bony resection than other-
wise. With the availability of recent imaging techniques, it is
possible to anticipate the extent of bony resection required in an
individual case by using the above mentioned morphometric
features.
Keywords: Anatomical study; condylar foramen; foramen magnum;
hypoglossal canal; occipital condyle; skull base; transcondylar
approach.
Introduction
Traditionally, lesions located anterior to the craniocer-
vical junction have posed a surgical challenge. Recently,
the transcondylar approach is being increasingly used to
access lesions ventral to the craniocervical junction [2,
3, 9, 15–17, 22]. There have been few anatomical stu-
dies that have dealt with the increase in exposure gained
by this approach [2, 5, 18, 21, 22]. However, to date
there has been no study which has detailed how the
individual’s bony anatomy can influence this approach.
The aim of this study was to conduct a morphometric
analysis of the hypoglossal canal, occipital condyle &
890 N. Muthukumar et al.

foramen magnum as it pertains to the transcondylar Table 1.

approach. Parameter Mean Range

Length of hypoglossal canal 12.6 mms 11–15 mms

Diameter of the intracranial 7.2 mms 4–9 mms
Methods end of the HC
Diameter of the extracranial 7.9 mms 5–9 mms
50 dry skulls were randomly chosen from the archives of our
end of HC
Department of Anatomy. These provided 100 hypoglossal canals,
Angle of the HC to the 49 45–55
100 occipital condyles and 50 foramina magna. Using standard
sagittal plane
calipers and goniometers, twenty one parameters were analyzed.
Distance of the intracranial 12.2 mms 9–16 mms
They were: the length of the hypoglossal canal, diameter of the intra-
end of HC to the posterior
and extracranial ends of the hypoglossal canal, angle of the hypo-
margin of OC
glossal canal to the sagittal plane, distance of the hypoglossal canal
Distance of the intracranial 12.6 mms 11–15 mms
from the posterior, anterior and inferior margins of the occipital
end of HC to the anterior
condyle, distance of the hypoglossal canal from the basion, opisthion,
margin of OC
carotid canal and jugular tubercle, distance of the hypoglossal canal
Distance of the intracranial 11.9 mms 10–14 mms
from the jugular foramen intra- and extracranially, antero-posterior
end of HC to the inferior
and transverse diameters of the occipital condyles, angle of the occi-
margin of OC
pital condyles to the sagittal plane, protrusion of the occipital con-
Distance of the intracranial 10 mms 8–12 mms
dyle into the foramen magnum, presence of condylar foramen,
end of the HC to the jugular
anteroposterior and transverse diameters of the foramen magnum.
foramen
The foramen magnum index was calculated by dividing the antero-
Distance of the extracranial 5 mms 4–6 mms
posterior length of the formen by the transverse diameter. Where
end of HC to the jugular
applicable, the measurements were made separately for the right
foramen
and left side.
Distance between HC and 15.4 mms 14–19 mms
basion
Distance between HC and 27.5 mms 19–35 mms
Results opisthion
Distance between HC and 11.7 mms 8–12 mms
The results of 17 of the 22 parameters studied are- jugular tubercle
Anteroposterior length of 33.3 mms 27–39 mms
summarized in Table 1. The average length of the
the foramen magnum
hypoglossal canal (HC) in this study was 12.6 mms Transverse diameter of the 27.9 mms 23–32 mms
(range 11–15 mms). The HC makes an angle of 49 foramen magnum
to the sagittal plane. The distance of the intracranial Anteroposterior length 23.6 mms 18–34 mms
of OC
end of the HC from the posterior margin of occipital Transverse diameter 14.7 mms 12–17 mms
condyle (OC) was 12.2 mms (range 9–16 mms). In of the OC
30% of the skulls studied the HC was divided by a Angle of the OC to the 60 59–61
sagittal plane
septum. In one of these specimens, on both sides,
there were two septa dividing the canal into three
compartments. Bipartite HCs were found on the left
side alone in 5 skulls, right side alone in 4 and on the transverse diameter was 27.9 mms (range 23–
both sides in 6. The septum that divided the HC 32 mms). The foramen magnum index was calcu-
was often present only near the intracranial end of lated by dividing the AP and transverse diameters.
the HC and rarely did it extend throughout the entire When the FM index was equal to or more than 1.2,
length of the HC. The thickness of the septum was the FM was found to be oval. Forty six percent of
also found to be variable. When the HC was divided the skulls had a FM index of equal to or more
by a septum, often it was divided into two unequal than 1.2 (Fig. 2A, B). The average anteroposterior
halves (Fig. 1A, B). Less commonly, it was divided length of the OC was 23.6 mms (range 18–34 mms)
into equal halves. In one specimen, where the HCs and the transverse diameter was 14.7 mms (range
were found to be tripartite on both sides (Fig. 1C, 12–17 mms). The OC made an angle of 60 to the
D), the two septa were not found side-by-side. On sagittal plane. In 20% of the skulls studied the OC
the other hand, one septum was found near the intra- protruded significantly into the FM (Fig. 3A, B).
cranial end of HC and another one was found near The condylar canal was present in 60% of the
the extracranial end but not in the same plane. The skulls studied. The condylar canal (CC) was absent
average anteroposterior length of the foramen mag- on the right side in 4 skulls and the left side in 16
num (FM) was 33.3 mms (range 27–39 mms) and skulls (Fig. 4A–D).
Analysis of the FM region as it relates to the transcondylar approach 891

Fig. 1. The view from the exterior of the skull; OC occipital condyle; FM foramen magnum; arrow points to the hypoglossal canal. (Panel A):
Shows the hypoglossal canal is divided into two unequal halves by a septum that is present only near the intracranial end of the canal.
(Panel B): Shows the hypoglosssal canal divided into two equal halves by a septum that extends throughout the length of the hypoglossal canal.
(Panel C): Shows the hypoglossal canal divided into three compartments by two septa that are not located side-by-side. (Panel D): Opposite side of
the specimen shown in Panel C; the hypoglossal canal is divided into three compartments by two septa; both the septae are of different thickness

Fig. 2. View from the exterior of the skull; OC occipital condyle; FM foramen magnum. (Panel A): Shows a specimen with an ovoid foramen
magnum. Arrows point to the absence of the condylar foramen on both sides. (Panel B): Shows a specimen with a circular foramen magnum. Arrows
point to the bilaterally large condylar foramina
892 N. Muthukumar et al.

Fig. 3. View from the exterior of the skull; OC occipital condyle; FM foramen magnum. (Panel A): Shows a specimen where the occipital condyles
do not protrude into the foramen magnum. (Panel B): Shows a specimen where the occipital condyles protrude significantly into the foramen
magnum narrowing the transverse diameter of the anterior half of the foramen magnum

Fig. 4. View from the exterior of the skull; OC occipital condyle; FM foramen magnum; arrow points to the condylar foramen. (Panel A): Shows a
specimen without condylar foramen. (Panel B): Shows a specimen with a unilateral condylar foramen. (Panel C): Shows a specimen with bilaterally
small, condylar foramina. (Panel D): Shows a specimen with bilaterally large, condylar foramina
Analysis of the FM region as it relates to the transcondylar approach 893

Discussion retraction. In recent times, several authors have studied

the increase in exposure that is gained by this approach
Surgical management of lesions located ventral to the
and its various modifications [5, 18, 21, 22]. However,
foramen magnum, lower clivus, and ventral aspect of
these studies have not dealt with the influence of the
the upper cervical spine is a daunting neurosurgical task
individual’s bony anatomy in this approach.
that in the past has been associated with unacceptably
Dowd et al. have studied the dimensional anatomy of
high mortality and morbidity rates and incomplete tumor
the far lateral transcondylar approach [5]. They observed
removal [2]. The lesions that are commonly encounter-
that the angle of surgical approach decreased from 88
ed in this region include several intra- and extradural
with suboccipital craniectomy to 47 with the transcon-
tumors, vascular lesions of the vertebral artery, congeni-
dylar approach. They also noted that each millimeter of
tal lesions and rheumatoid disease of the craniocervical
OC removal decreased the angle by 2.4 degrees. In addi-
junction [2].
tion, they found that to visualize the contralateral jugular
Hammon and colleagues in 1972 and Heros in 1986
tubercle, the OC should be removed for a distance of
described a lateral suboccipital approach [7, 8]. How-
17 mms. Spektor et al. quantitatively studied the increase
ever, these authors did not drill the occipital condyle.
in exposure gained by the transcondylar transtubercular
Development of the transcondylar approach and its sev-
approach in a step-wise fashion [18]. They found that
eral modifications has permitted the safe and effective
routine suboccipital craniectomy provided only a very
treatment of many of these formidable lesions [2, 9,
narrow slit-like space, enabling a very limited exposure
15–17]. These approaches have been successful in re-
of the petroclival area. After resecting the OC up to
ducing the depth of surgical field and improving the
the HC, visualization of the petroclival area increased
angle of exposure thereby reducing the amount of brain
only marginally from 21% to 28%. They found that the
retraction necessary [5]. It has been reiterated several
main obstacle hindering visualization of the clivus at
times that the extent of bony removal should be tailored
this stage was the jugular tubercle and resection of the
to each case [3, 13]. For example, when a mass lesion is
jugular tubercle dramatically increased the exposure
located anterior to the brainstem, the distortion and pos-
from 28% to 71%, especially, in the ipsilateral, contra-
terior displacement of the brainstem caused by the pres-
lateral and rostral directions. Total removal of the OC
ence of the mass may provide sufficient working space
did not significantly increase the exposure but provided
and thereby limit the extent of bony resection. However,
greater degree of surgical freedom. They emphasized that
if the lesion (such as an aneurysm) does not distort=
the relatively small jugular tubercle occupied little space
displace the brainstem, then for the same bony config-
but hindered visualization considerably and hence the
uration, more radical bone removal may be necessary.
importance of its removal during this approach. Wanebo
It is commonly accepted that extensive bony removal
and Chicoine quantitatively analyzed the transcondylar
on the way to the clivus, although it improves exposure,
approach to the foramen magnum [21]. They found that
brings about certain disadvantages. These include: 1. pro-
25% condylar resection increased the lateral exposure by
longed operating time, 2. risk of damage to the vertebral
3 mms and the angle of exposure increased by 10.7 ,
artery, jugular vein, jugular bulb and sigmoid sinus with
whereas, 50% condylar resection increased the ex-
the attendant risk of hemorrhage and air embolism, and
posure by 7 mms and the angle of exposure by 15.9
3. possible damage to the cranial nerves. In addition,
degrees.
extensive removal of the OC causes instability, necessi-
tating addition of a stabilization procedure [18].
The development of any new approach might lead to
Hypoglossal canals
its overuse by less experienced surgeons which might
lead to unacceptable morbidity and mortality rates and The HC passes from a posteromedial to anterolateral
thereby vitiating the benefits of the approach. Hence, it direction. In this study, the HC was found at an average
has been pointed out that the surgeon should be judi- distance of 12.2 mms from the posterior margin of the
cious in choosing an approach to cranial base lesions to occipital condyle. This means that the OC can be safely
avoid unnecessary surgery. As techniques in skull base drilled for a distance of 12 mms in most individuals
surgery become more advanced, guidelines regarding without encountering the HC and its contents. In this
when to use these approaches must be developed. The study, the HC was divided by a septum in 30% of the
primary objective of most of these approaches is to max- specimens. It is important to identify this by preopera-
imize bony removal in an attempt to minimize brain tive imaging. While drilling the OC, one first encounters
894
the cortical bone of OC followed by cancellous bone and
finally the cortical bone surrounding the HC is encoun-
tered. Once the cortical bone around the HC is drilled
away, the hypoglossal nerve is skeletonized. However,
failure to identify a bipartite or rarely, a tripartite HC can
lead to avoidable damage to the hypoglossal nerve. In
this study, the distance between the HC and the jugular
tubercle was found to be 11.7 mms. This distance is im-
portant because several authors have stressed the impor-
tance of drilling the jugular tubercle as an important
adjunct that increases the exposure with this approach
[3, 9, 18].
Occipital condyle
In previous studies of the quantitative anatomy of this
region for the transcondylar approach, the degree of pro-
trusion of the OC into the foramen magnum was not
studied. However, in our study, the OCs were found to
protrude significantly into the FM in 20% of the speci-
mens. This presents an unfavourable configuration for
the transcondylar approach. Eventhough, the protruding
OC is not a contra-indication for this approach, this will
entail more extensive bony removal than a situation in
which the OCs do not protrude into the FM.
Foramen magnum
In previous studies, the dimensions of the foramen
magnum were measured. However, in our study in addi-
tion to the dimensions, we have also determined the
shape of the foramen magnum by providing a simple FM
index. By this index we have found that in 46% of the
specimens, when the FM index was equal to or more
than 1.2, the foramen magnum was oval. A similar sized
lesion located anterior to the brainstem will require more
extensive bone removal in a person with an ovoid FM
than in a person with a circular FM.
Condylar foramen
The condylar foramen is present in the condylar fossa
posterior to the OC. It transmits the posterior condylar
vein which is an important emissary vein of the cranium.
This vein connects the vertebral venous plexus with the
sigmoid-jugular complex.
In our study, the condylar foramen was found in 60%
of the specimens studied. They were more frequently
found on the right side than on the left side. The expla-
nation offered for the increased incidence of condylar
N. Muthukumar et al.
canal on the right side is that the straighter the venous
connection to the heart, the greater is the chance of
finding an emissary foramen on that side [14]. The con-
dylar foramen is one of the largest emissary foramina of
the skull and the posterior condylar vein which traverses
it forms an important alternative source of venous drain-
age when the venous flow into the sigmoid sinus-jugular
complex is impeded [1, 6, 11, 12].
In patients with achondroplasia and complex cranio-
synostoses, venous imaging has confirmed the presence
of obstruction at the level of skull base, especially,
jugular foramina [1, 4, 10, 12, 19, 20]. In these sit-
uations, the emissary veins, especially, the posterior
condylar veins become important venous drainage
channels. Failure to appreciate this fact can lead to fatal
complications if these venous channels are obliterated
during surgery [20]. It is now possible to visualize
the condylar foramen by preoperatiave imaging [6].
Ginsberg has shown that this structure can be reliable
identified unilaterally in 50% of the cases and bilater-
ally in 31% of the cases. These figures are consistent
with the incidence of condylar foramen reported in
our study.
Conclusions
Morphometry of the foramen magnum region is
essential for using the transcondylar approaches or its
variants. Our study has shown that in 46% of the cases,
the foramen magnum can be ovoid, in 20% of the
cases, the occipital condyles can protrude significantly
into the foramen magnum and in 30% of the cases, the
hypoglossal canals can be septate, and the incidence
of the condylar canals is noted and their significance.
We believe thoughtful use of preoperative imaging
studies can be helpful in studying the above mentioned
features in an individual patient and thus can help the
surgeon in choosing the correct approach and the extent
of bony resection. Thus, in a patient with a round fora-
men magnum, without significant protrusion of the oc-
cipital condyles into the FM, less bony resection will be
required than in a patient with an ovoid foramen mag-
num, medially protruberant and sagittaly inclined oc-
cipital condyles, eventhough both patients harbour
similar lesions.
Acknowledgements
We thank the staff of the Department of Anatomy, Madurai Medical
College, Madurai for their help and co-operation in the conduct of this
study.
Analysis of the FM region as it relates to the transcondylar approach 895

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