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The Foramen Magnum

The Foramen Magnum

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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 behindthe foramen magnum; a basal (clival) portion locatedanterior to the foramen magnum; and a condylar part thatconnects the squamosal and clival parts (
Fig. 6.1
). 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.
Occipital bone 
The occipital bone surrounds the foramen magnum (
Fig.6.1
). 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
S155
Neurosurgery,
Vol. 47, No. 3, September 2000 Supplement 
 
FIGURE 6.1. Occipital bone and foramen magnum.
A
, inferior view.
, posteroinferior view.
, anterior-inferior view.
,superior view.
, posterosuperior view.
, 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 itencroached on from laterally by the occipital condyles. The wider posterior part transmits the medulla. The occipital bone isdivided into a squamosal part located above and behind the foramen magnum; a basal (clival) part situated in front of theforamen 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 themastoid portion of the temporal bone at the occipitomastoid suture. The convex external surface of the squamosal part hasseveral prominences. The largest prominence, the external occipital protuberance (inion), is situated at the central part of the
S156
Rhoton
Neurosurgery,
Vol. 47, No. 3, September 2000 Supplement 
 
front of the foramen magnum, a small elevation, the pharyn-geal tubercle, gives attachment to the fibrous raphe of thepharynx.The paired lateral or condylar parts are situated at the sidesof the foramen magnum. The occipital condyles, which artic-ulate with the atlas, protrude from the external surface of thispart. These condyles are located lateral to the anterior half ofthe foramen magnum. They are oval in shape, convex down-ward, face downward and laterally, and have their long axesdirected forward and medially. A tubercle that gives attach-ment to the alar ligament of the odontoid process is situatedon the medial side of each condyle. The hypoglossal canal,which transmits the hypoglossal nerve, is situated above thecondyle, and is directed forward and laterally from the pos-terior cranial fossa. The canal may be partially or completelydivided by a bony septum. Septated hypoglossal canals werefound on one or both sides in 6% of the dry skulls (15).The condylar fossa, a depression located on the externalsurface behind the condyle, is often perforated to form theposterior condylar canal through which an emissary veinconnects the vertebral venous plexus with the sigmoid sinus.One or both condylar foramina may be absent or incompletelyperforated (9). The jugular process, a quadrilateral plate of bone, extends laterally from the posterior half of the condyleto form the posterior border of the jugular foramen. It servesas a bridge between the condylar and squamosal portions ofthe occipital bone. The jugular process articulates laterallywith 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 canaland 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 accessorynerves course. The groove of the sigmoid sinus curves medi-ally and forward around an upwardly directed, hook-shapedprocess, on the superior surface of the jugular process, andends at the jugular foramen. The posterior condylar canalopens into the posterior cranial fossa close to the medial endof the groove for the sigmoid sinus.The jugular foramen is situated lateral and slightly superiorto the anterior half of the condyles. It is bordered posteriorly by the jugular process of the occipital bone, and anteriorly andsuperiorly by the jugular fossa of the petrous portion of thetemporal bone (14). The foramen sits at the posterior end ofthe petroclival suture. The jugular foramen is divided intotwo parts by the intrajugular processes on the opposing edgesof the petrous and occipital bones, which either join directlyor are connected by a fibrous band. The smaller anteromedialpart, the petrous part, transmits the inferior petrosal sinus,and the larger posterolateral part, the sigmoid part, transmitsthe sigmoid sinus. The intrajugular part, situated along theintrajugular processes, transmits the glossopharyngeal, vagus,and accessory nerves. The enlarged part of the internal jugularveinlocatedwithintheforamenisreferredtoasthejugularbulb.The jugular process also serves as the site of attachment of therectus capitis lateralis muscle behind the jugular foramen.
The atlas 
The atlas, the first cervical vertebra, differs from the othercervical vertebrae by being ring shaped and by lacking avertebral body and a spinous process (
Fig. 6.2
). It consists oftwo thick lateral masses situated at the anterolateral parts ofthe ring. The lateral masses are connected in front by a shortanterior arch and behind by a longer curved posterior arch.The position of the usual vertebral body is occupied by theodontoid process of the axis. The anterior arch is convexedforward and has a median anterior tubercle. The posterior
Š
external surface. The superior nuchal line radiates laterally from the protuberance. A vertical ridge, the external occipitalcrest, 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 partis concave and has a prominence, the internal occipital protuberance, near its center. The internal surface is divided into fourunequal 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 isthe vermian fossa. The basilar part of the occipital bone, which is also referred to as the clivus, is a thick quadrangular plateof bone that extends forward and upward to join the sphenoid bone just below the dorsum sellae. The superior surface of theclivus slopes upward from the foramen magnum and is concave from side to side. The clivus is separated on each side fromthe 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, thepharyngeal tubercle, gives attachment to the fibrous raphe of the pharynx. The condylar parts of the occipital bone, on whichthe 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 situatedabove the condyle. The condylar fossa, which may be converted into a foramen for the passage of an emissary vein, islocated behind the condyle. The jugular process of the occipital bone extends laterally from the posterior half of the condyleand 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 anteriorlyby the jugular fossa of the petrous temporal bone. The jugular tubercle lies on the internal surface above the hypoglossalcanal.
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.
Foramen Magnum
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Vol. 47, No. 3, September 2000 Supplement 

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