The Foramen Magnum
Albert L. Rhoton, Jr., M.D.
Department of Neurological Surgery, University of Florida, Gainesville, Florida
Cranial nerves, Craniovertebral junction, Foramen magnum, Microsurgery, Vertebral artery
he foramen magnum is located in the occipital bone,which has three parts: a squamosal part located behindthe foramen magnum; a basal (clival) portion locatedanterior to the foramen magnum; and a condylar part thatconnects the squamosal and clival parts (
). The suboc-cipital approaches are directed through the squamosal partand the anterior approaches through the clival part. The con-dylar part, which includes the occipital condyle, posteriormargin of the jugular foramen, and hypoglossal canal, isexposed in the far-lateral approach and its transcondylar,retrocondylar, and supracondylar modifications described inthe chapter on the far lateral approach. Structures involved inforamen magnum lesions include the lower cranial and upperspinal nerves, the caudal brainstem and rostral spinal cord,the vertebral artery and its branches, the veins and duralsinuses at the craniovertebral junction, and the ligaments andmuscles uniting the atlas, axis, and occipital bone (5, 26). Theforamen magnum is most commonly approached from pos-teriorly through the suboccipital and upper cervical region orfrom anteriorly through the nasal and oral cavities, the phar-ynx, or maxilla.
THE FORAMEN MAGNUMOsseous relationships
The osseous structures that must be considered in planningan approach to the region of the foramen magnum are theoccipital bone, the atlas, and the axis.
The occipital bone surrounds the foramen magnum (
). The foraminal opening is oval shaped and is widerposteriorly than anteriorly. The wider posterior part transmitsthe medulla, and the narrower anterior part sits above theodontoid 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, andpaired condylar parts located lateral to the foramen magnum.The squamous part is an internally concave plate locatedabove and behind the foramen magnum. Its upper marginsarticulate with the parietal bones at the lambdoid sutures andits lower margins articulate with the mastoid portion of thetemporal bones at the occipitomastoid sutures. The convexexternal surface has several prominences on which the mus-cles of the neck attach. The largest prominence, the externaloccipital protuberance or inion, is situated at the central partof the external surface. The inion is located an average of 1 cm below the apex of the internal occipital protuberance and theinferior margin of the confluence of the sagittal and transversesinuses. Two parallel ridges radiate laterally from the protu- berance: the highest nuchal line is the upper and thinnerridge, and the superior nuchal line is the lower and moreprominent one. The area below the nuchal lines is rough andirregular and serves as the site of attachment of numerousmuscles. A vertical ridge, the external occipital crest, descendsfrom the external occipital protuberance to the midpoint ofthe posterior margin of the foramen magnum. The inferiornuchal lines run laterally from the midpoint of the crest.The internal surface of the squamous part is concave andhas a prominence, the internal occipital protuberance, near itscenter. The internal surface is divided into four unequal fos-sae by the sulcus of the superior sagittal sinus that extendsupward from the protuberance, the internal occipital crest, aprominent ridge that descends from the protuberance, and thepaired sulci for the transverse sinuses that extend laterallyfrom the protuberance. The sulcus for the right transversesinus is usually larger than the one on the left. The upper twofossae are adapted to the poles of the occipital lobes. Theinferior two fossae conform to the contours of the cerebellarhemispheres. The internal occipital crest bifurcates above theforamen magnum to form paired lower limbs, which extendalong each side of the posterior margin of the foramen. Adepression between the lower limbs, the vermian fossa, isoccupied by the inferior part of the vermis. The falx cerebelliis attached along the internal occipital crest.The basilar part of the occipital bone, which is also referredto as the clivus, is a thick quadrangular plate of bone thatextends forward and upward, at an angle of about 45° fromthe foramen magnum. It joins the sphenoid bone at the sphe-noccipital synchondrosis just below the dorsum sellae (7). Thesuperior surface of the clivus is concave from side to side andis separated on each side from the petrous part of the tempo-ral bone by the petroclival fissure. This fissure has the inferiorpetrosal sinus on its upper surface and ends posteriorly at the jugular foramen. On the inferior surface of the basilar part, in
Vol. 47, No. 3, September 2000 Supplement