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ANATOMIC REPORT

Morphometric Analysis of the Foramen Magnum:


An Anatomic Study
R. Shane Tubbs, MS, PA-C, PhD OBJECTIVE: To further elucidate the importance of anatomic variations in morphology of
Pediatric Neurosurgery, the foramen magnum and associated clinical implications, we conducted a morphomet-
Children’s Hospital,
Birmingham, Alabama
ric study.
METHODS: Seventy-two dry skulls were used for this study. Digital images were obtained
Christoph J. Griessenauer, MD of the foramen magnum from an inferior view. These images were studied using a computer-
Pediatric Neurosurgery, assisted image analysis system. Next, an image processor was used to calculate pixel dif-
Children’s Hospital,
Birmingham, Alabama ferences between 2 selected points, which allowed accurate translation of pixel differences
into metric measurements.
Marios Loukas, MD, PhD RESULTS: We found that the mean surface area of the foramen magnum was 558 mm2,
Department of Anatomical Sciences, the mean anteroposterior diameter was 3.1 cm, and the mean horizontal diameter was
St. George’s University,
Grenada 2.7 cm. For comparison, surface areas were classified into 3 types based on size. Type I
foramina were identified in 20.8% of the dry skulls (15 skulls) and exhibited a surface area
Mohammadali M. Shoja, MD of less than 500 mm2. Type II (66.6%, 48 skulls) was applied to foramina of an intermediate
Clarian Neuroscience Institute, size with surface areas ranging between 500 to 600 mm2. Type III (12.5%, 9 skulls) was
Indianapolis Neurosurgical Group, and
Department of Neurosurgery,
applied to large foramina with surface areas of more than 600 mm2.
Indiana University, CONCLUSION: These data may be of use as a morphometric database for description of
Indianapolis, Indiana
“normal” variants of foramen magnum morphology.
Aaron A. Cohen-Gadol, MD, MSc KEY WORDS: Craniocervical junction, Foramen magnum
Clarian Neuroscience Institute,
Indianapolis Neurosurgical Group, and Neurosurgery 66:385-388, 2010 DOI: 10.1227/01.NEU.0000363407.78399.BA www.neurosurgery- online.com
Department of Neurosurgery,
Indiana University,

T
Indianapolis, Indiana
he embryologic development of the cran- which develop from intramembranous ossification,
Reprint requests:
R. Shane Tubbs, MS, PA-C, PhD,
iocervical junction is a complex process the cranial base takes the intermediate step of cal-
Pediatric Neurosurgery, involving the notochord as an inducer of cification of a previously arranged cartilaginous
1600 7th Avenue South, ACC 400, neuroectodermal differentiation and the parax- network.
Birmingham, AL, 35233. ial mesoderm, a precursor to bone and skeletal Configuration and size of the foramen mag-
E-mail: rstubbs@uab.edu
muscle in the craniocervical region. For the for- num play an important role in the pathophysiol-
Received, January 15, 2009. mation of the cranial base, a combination of endo- ogy of various disorders of the craniovertebral
Accepted, September 16, 2009. chondral ossification and the growth of regional junction. Thus, a fundamental knowledge of nor-
sutures is necessary. Elongation of the clivus and mal anatomy and basic craniometric measurements
Copyright © 2010 by the the anterior aspect of the foramen magnum results for assessing craniovertebral relations is important
Congress of Neurological Surgeons
from growth of the spheno-occipital synchon- to the clinician who diagnoses this region or the
drosis and sutural growth along the lateral portion surgeon who operates on this anatomy.2 Although
of the base. Descent of the occiput via growth linear measurements of the foramen magnum have
from the petro-occipital and sphenopetrosal junc- been detailed in several anatomic studies, analy-
tions is important in the formation of the bone sis of the area of this structure using state-of-the-
around the foramen magnum, while the primary art imaging technology is lacking in the literature.3
determinants of foramen magnum size and area From a clinical perspective, such results might aid
are the basi-exoccipital and exo-supraoccipital in the diagnosing, classifying, and treatment of
synchondroses and the 3 enchondral parts of the diseases related to anomalies of the foramen mag-
basiocciput, exocciput, and supraocciput.1 In num and serve as a future reference defining an
contrast to the majority of cranial and facial bones, anatomic range.

NEUROSURGERY VOLUME 66 | NUMBER 2 | FEBRUARY 2010 | 385


TUBBS ET AL

MATERIALS AND METHODS


Seventy- two adult dry skulls from 32 female and 40 male skeletons were
examined. These were derived from commercial skeletal sources and were
primarily Caucasian. None of the dry skulls revealed evidence of gross
pathology, previous surgical procedures, or traumatic lesions. On the
basis of bony fusion and degradation, the age of the specimens was approx-
imately 50 to 90 years. All foramina were viewed from an inferior basal
view and recorded with a digital camera (Nikon Coolpix S5; Nikon Corp,
Tokyo, Japan) and studied using a computer-assisted image analysis sys-
tem (Lucia software 5.0, 2000 edition for Windows XP; Laboratory
Imaging, Ltd, Prague, Czech Republic). The digital camera was con-
nected to an image processor (Nvidia GeForce 6800 GT; Nvidia Corp,
Santa Clara, CA) linked to a mainframe computer. Digitized images of
the foramina were stored in the Lucia program (2048 × 1536 pixels).
After applying a standard 1-mm scale to all images, the program was able
to calculate pixel differences between 2 selected points, such as the width
of a foramen, as previously described.4 This allowed easy and accurate
translation of pixel differences into metric measurements. Measurements
included the anteroposterior and horizontal diameters, as well as the sur-
face area of all foramina. Statistical analysis was performed with Statistica
for Windows (StatSoft, Inc, Tulsa, OK) with significance set at P < 0.05.

RESULTS
The subsequent morphologic patterns regarding the dimensions
of the foramina demonstrated wide ranges of variation. To compare
specimens and analyze the various patterns, the results of the sur-
face area measurements were classified into 3 types, designated “I”
through “III.” Type I foramina were identified in 20.8% of the dry
skulls (15 skulls) and exhibited a surface area of less than 500 mm2
(Figure 1). Type II (66.6%, 48 skulls) was applied to foramina of
an intermediate size with surface areas ranging between 500 and 600 FIGURE 1. Superior view of specimen used in the present study. Example of
mm2 (Figure 2). Type III (12.5%, 9 skulls) was applied to large foramen type I.
foramina with surface areas of more than 600 mm2 (Figure 3). The
morphometric analysis of the foramen magnum revealed that the
mean surface area of the foramen magnum was 558 mm2 (range, num and the first 2 sclerotomes form the basiocciput. The third
385–779 mm2). The mean anteroposterior diameter of the foramen sclerotome, as it forms the jugular tubercles, develops the exoc-
magnum was 3.1 cm (range, 2.5–3.7 cm). The mean horizontal cipital centers. A key player in this process is the fourth sclero-
diameter was 2.7 cm (range, 2.4–3.5 cm). There was no signifi- tome, called the proatlas. The proatlas contains 3 parts: the
cant difference between the sexes with regard to surface area and ver- hypocentrum, which forms the anterior tubercle of the clivus; the
tical and horizontal diameters (P > 0.05). centrum, a precursor of the apical ligament and the apex of the
dens; and the neural arch, which is further subdivided into a ven-
DISCUSSION tral-rostral and dorsal-caudal component. The occipital condyles
and the U-shaped anterior margin of the foramen magnum, as
We identified a wide variation in the area of the foramen mag- well as the alar and cruciate ligaments, arise from the ventral-
num. The foramen magnum varies in shape in children and adults. rostral portion of this embryologic part. The dorsal-caudal divi-
In his textbook, Lang4a classified the shapes into 5 groups, with sion forms the superior part of the posterior arch and the lateral
the following composition: 2 semicircles (adults, 41.2%; children, masses of C1. Consequently, anomalies and malformations of the
18.4%); an elongated circle (adults, 22.4%; children, 20.4%); egg- occipital sclerotomes result in irregular geometry of the foramen
shaped (adults, 17.6%; children, 25.5%); rhomboidal (adults, magnum and related structures.5
11.8%; children, 31.6%); and rounded (adults, 7%; children, 4%). The foramen magnum is a fundamental component in the com-
He found that the average anteroposterior diameter of the fora- plex interaction of bony, ligamentous, and muscular structures
men was 3.5 cm and the average horizontal diameter was 3 cm. composing the craniovertebral junction. Shape and size of the
The sclerotomes of the first 4 somites eventually fuse to form foramen are critical parameters for the manifestation of clinical
the occipital bone, and the posterior part of the foramen mag- signs and symptoms in craniocervical pathology. These include

386 | VOLUME 66 | NUMBER 2 | FEBRUARY 2010 www.neurosurgery-online.com


MORPHOLOGY OF FORAMEN MAGNUM

FIGURE 2. Superior view of specimen used in the present study. Example of


FIGURE 3. Superior view of specimen used in the present study. Example of
foramen type II. foramen type III.

motor myelopathy, sensory abnormalities, brainstem and lower to be independent risk factors in those patients in whom cranio-
cranial nerve dysfunctions, and signs and symptoms referable to cervical decompression is necessary.8,12-14
vascular compromise.2 Diseases associated with anomalies of the The configuration of the foramen magnum in patients with
foramen magnum include occipital vertebra, basilar invagination, Chiari I and Chiari II malformations has been found to be larger
condylar hypoplasia, and atlas assimilation.6 Interestingly, one than in the normal population.15 Another analysis based on semi-
report found that the persistence of the spheno-occipital synchon- axial cranial x-rays demonstrated a significantly larger horizontal
drosis, aggravated by the coexistence of basilar invagination, diameter of the foramen magnum in 35 children with verified
resulted in stenosis at the foramen magnum.7 Chiari I malformation, when compared with a control group of
Among developmental and acquired craniocervical junction dis- 174 individuals.16 Furthermore, development of symptoms in
orders, achondroplasia is the most commonly reported. Achondro- this group has been found in patients with shorter anteroposterior
plasia, the most common form of dwarfism, results in abnormal diameters of the foramen magnum.17 A wide foramen magnum
enchondral bone formation at the cranial base, resulting in a nar- has also been appreciated in patients with diastrophic dysplasia.18
row cervical spinal canal and a stenotic foramen magnum.5,8,9 Other diseases associated with stenosis of the craniovertebral junc-
Clinical manifestations of chronic brainstem compression by steno- tion include craniometaphyseal dysplasia, Jeune’s asphyxiating
sis of the foramen magnum and related structures are respiratory thoracic dystrophy, and spherophakia-brachymorphism
complications, lower cranial nerve dysfunctions, upper and lower (Marchesani’s syndrome).19-21 Stenosis of the foramen magnum
extremity paresis, hypo- or hypertonia, hyperreflexia or clonus, has also been reported for Beare-Stevenson syndrome, a craniofa-
and general motor development delay.5,8,10 The horizontal and cial syndrome characterized by hypertrophy of the bony mar-
anteroposterior diameters of the foramen magnum in an adult with gins.22 The decision-making process for the diagnosis and treatment
achondroplasia have been found to be equivalent to those of a new- of such disorders with bony abnormalities resulting in changes of
born and a 2-year-old child, respectively.11 The anteroposterior the anatomy of the foramen magnum demands a good under-
and horizontal diameters of the foramen magnum have been found standing of the normal anatomy of this structure.

NEUROSURGERY VOLUME 66 | NUMBER 2 | FEBRUARY 2010 | 387


TUBBS ET AL

CONCLUSIONS 13. Hunter AG, Bankier A, Rogers JG, Sillence D, Scott CI Jr. Medical complications
of achondroplasia: a multicentre patient review. J Med Genet. 1998;35(9):705-712.
Although dry skulls, like the ones used in our study, may con- 14. Pauli RM, Horton VK, Glinski LP, Reiser CA. Prospective assessment of risks for
cervicomedullary-junction compression in infants with achondroplasia. Am J Hum
strict with time, this anatomic study elucidated geometric char- Genet. 1995;56(3):732-744.
acteristics of the foramen magnum and may serve as a future 15. Aydin S, Hanimoglu H, Tanriverdi T, Yentur E, Kaynar MY. Chiari type I malfor-
standard reference. mations in adults: a morphometric analysis of the posterior cranial fossa. Surg
Neurol. 2005;64(3):237-241.
Disclosure 16. Bliesener JA, Schmidt LR. Normal and pathological growth of the foramen occip-
itale magnum shown in the plain radiography. Pediatr Radiol. 1980;10(2):65-69.
The authors have no personal financial or institutional interest in any of the 17. Menezes AH. Primary craniovertebral anomalies and the hindbrain herniation syn-
drugs, materials, or devices described in this article. drome (Chiari I): data base analysis. Pediatr Neurosurg. 1995;23(5):260-269.
18. Remes V, Tervahartiala P, Poussa M, Peltonen J. Cervical spine in diastrophic dys-
plasia: an MRI analysis. J Pediatr Orthop. 2000;20(1):48-53.
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of the anatomic and neurologic findings. Acta Radiol. 1953;40(2-3):335-354. ubbs et al provide a detailed analysis of the size and area of the fora-
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Cervicomedullary decompression for foramen magnum stenosis in achondropla- who constitute the majority of patients with Chiari malformations, and
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9. Hecht JT, Horton WA, Reid CS, Pyeritz RE, Chakraborty R. Growth of the fora- they represent new data that could be useful in distinguishing congeni-
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1987;164(2):515-519. malformation is long overdue, and the authors have made a contribu-
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1985;20(2):355-360. Manhasset, New York

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