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ORIGINAL ARTICLE

Morphometry of the Hypoglossal Canal, Occipital


Condyle, and Foramen Magnum
Emine Dondu Kizilkanat,* Neslihan Boyan,* Roger Soames,w and Ozkan Oguz*

with the spinal roots of the accessory nerve and the


Abstract: The present study was undertaken to determine the vertebral arteries. The occipital condyles (OC) are
detailed morphometry of occipital condyle (OC), hypoglossal anterolateral to the FM and participate in the articulation
canal (HC), and foramen magnum (FM) in Turkish–Caucasian of the skull with the cervical vertebral column.1,2 Current
skulls: measurements were taken from 59 dry skulls of unknown data, obtained from morphometric studies, on the
sex. There was no significant difference (P>0.05) in measure- anatomic and biomechanical properties of the craniover-
ments taken from the right and left sides, consequently the tebral junction, have made surgical intervention in the
overall means and associated standard deviations were calcu- region safer.3,4 The hypoglossal canal (HC) is located on
lated. The length of the HC was 9.9 ± 1.9 mm and the HC the OC and at the anterolateral border of the FM1: it is
intracranial and extracranial diameters were 6.5 ± 1.3 mm and not only important as a part of the occipital bone but also
6.6 ± 1.1 mm, respectively, with the angle of the HC to the in evolutionary terms. Divisions of the HC support the
sagittal plane being 45.6 ± 4.6 degrees. The distances from the basioccipital bone theory, which states that the formation
intracranial and extracranial ends of HC to the jugular foramen of basioccipital bone is by the union of 3 or 4 previously
were 13.3 ± 3.3 mm and 8.4 ± 2.0 mm, respectively, whereas the separate vertebrae. According to this theory, the HC
distances from the HC to the jugular tubercle, opisthion and reflects the union of the intervertebral foramen.5,6 The
basion were 12.2 ± 2.2 mm, 29.2 ± 2.6 mm, and 16.5 ± 1.8 mm, HC is surrounded by cortical bone and transmits the
respectively. The distances from the intracranial end of the HC to hypoglossal nerve, the meningeal branch of the ascending
the posterior, anterior, inferior margins of the OC were pharyngeal artery and a venous plexus which provides
12.3 ± 2.4 mm, 11.2 ± 1.6 mm, and 9.4 ± 1.2 mm, respectively. communication between the basilar venous plexus and the
The anteroposterior length and transverse width of the OC were marginal sinus.7 To avoid damage during surgical
24.5 ± 2.5 mm and 13.1 ± 1.6 mm, and the angle of the OC to the intervention, a knowledge of the embryological develop-
sagittal plane 31.5 ± 5.1 degrees; the mean sagittal intercondylar ment of this region is equally as important as a knowledge
angle was 62.2 degrees. The anterior and posterior intercondylar of the morphometry. Variations in the anatomy of this
distances were 22.6 ± 3.9 mm and 44.2 ± 3.2 mm. The antero- region can best be understood and appreciated from an
posterior and transverse diameters of the FM were 34.8 ± 2.2 mm embryologic viewpoint.6
and 29.6 ± 2.4 mm, giving a mean FM index of 1.2. The presence Conditions such as FM tumors, HC nerve lesions,
or absence of a septum in the HC, protrusion of OC into the FM and vertebral artery lesions are particularly important as
and the presence of condylar foramen were also determined. they present at a risky site. A sound knowledge of the
Detailed morphometric analysis will help in the planning of morphometry of this area can provide important benefits
surgical intervention involving the skull base safer and easier. in determining safe surgical zones during surgical
Key Words: hypoglossal canal, foramen magnum, occipital procedures such as transcondylar, supracondylar, and
condyle, morphometry lateral suboccipital approaches.7,8,9 Thus, a preoperative
morphometric analysis of the FM, OC, and HC will
(Neurosurg Q 2006;16:121–125) enable the surgeon to choose the most appropriate
surgical technique and approach to be employed. The
aim of the present study is to determine and define the
detailed anatomy of the FM, OC, and HC for use in
T he base of the skull is an important area in terms of
both its anatomy and surgery. The foramen magnum
(FM) lies in the center of the skull base and through it
surgical intervention in this region.

passes the medulla oblongata and surrounding meninges, MATERIALS AND METHODS
Measurements from 59 adult Turkish skulls of
unknown sex were undertaken in this study. Twenty
From the *Department of Anatomy, Faculty of Medicine, Cukurova parameters (distances and angles) were measured using
University, Balcali-Adana, Turkey; and wJames Cook University, standard calipers and a goniometer: all measurements
School of Veterinary and Biomedical Sciences, Townsville, Australia. were undertaken using the protocols of Muthukumar
Reprints: Prof Dr Ozkan Oguz, Department of Anatomy, Faculty of
Medicine, Cukurova University, 01330 Balcali-Adana, Turkey
et al3 and Naderi et al.4 The distances measured were:
(e-mail: ozoguz@cu.edu.tr). the length, intracranial and extracranial diameters of the
Copyright r 2006 by Lippincott Williams & Wilkins HC; the distances between the intracranial end of the HC

Neurosurg Q  Volume 16, Number 3, September 2006 121


Kizilkanat et al Neurosurg Q  Volume 16, Number 3, September 2006

protrusion of the OC into the FM, and the presence of a


condylar foramen (CF).

RESULTS
The range, mean, and associated standard deviation
of measurements taken from the right and left HC and
OC, together with those of the FM are presented in
Table 1. There was no significant difference (P>0.05) in
the mean values for measurements made bilaterally,
consequently the means and standard deviations of the
bilateral measurements were calculated. The overall
means and standard deviations of the HC dimensions
are as follows: HC length 9.9 ± 1.9 mm, HC intracranial
diameter 6.5 ± 1.3 mm, HC extracranial diameter
FIGURE 1. Illusturation of the HC. A, Distance of the 6.6 ± 1.1 mm, and the angle of the HC to the sagittal
intracranial end of the HC to the anterior margin of the OC. plane was 45.6 ± 4.6 degrees. The overall mean distance
B, Distance of the intracranial end of the HC to the posterior of the intracranial end of the HC to the JF was
margin of OC. C, Anterior intercondylar distance. D, Posterior 13.3 ± 3.3 mm, of the extracranial end of the HC to the
intercondylar distance. JF was 8.4 ± 2.0 mm, of the HC to the JT was
12.2 ± 2.2 mm, of the HC to the opisthion
was 29.2 ± 2.6 mm, and of the HC to the basion was
16.5 ± 1.8 mm. The overall mean distance of the intra-
to the anterior, posterior, and inferior margins of the OC cranial end of the HC to the posterior margin of the
and to the jugular foramen (JF); the distances between the OC was 12.3 ± 2.4 mm, of the intracranial part of the HC
HC and the jugular tubercle (JT), basion and opisthion, to the anterior margin of the OC was 11.2 ± 1.6 mm,
and the anteroposterior and transverse lengths of the OC; and of the intracranial end of the HC to the inferior
and the anterior and posterior intercondylar distances margin of the OC was 9.4 ± 1.2 mm. For the OC the
(Fig. 1); the anteroposterior and transverse widths of the overall means and standard deviations were as follows:
FM; the angles from the sagittal plane of the long axes of anteroposterior length 24.5 ± 2.5 mm and transverse
the HC and OC; and the sagittal intercondylar angle. A width 13.1 ± 1.6 mm. The overall mean angle of
FM index was calculated from the anteroposterior and the OC to the sagittal plane was 31.5 ± 5.1 degrees. The
transverse diameters of the FM. In addition, the presence sagittal intercondylar angle was 62.2 ± 9.1 degrees,
of a septum associated with the HC was noted, as was any the FM anteroposterior and transverse diameters were

TABLE 1. The Results of Measured HC, OC, FM


Minimum Maximum Mean ± SD
Variables (n: 59) Left Right Left Right Left Right
Length of HC (mm) 5.6 6.0 15.2 16.4 10.0 ± 1.9 9.8 ± 1.8
Diameter of the intracranial end of HC (mm) 4.1 4.3 9.6 11.1 6.4 ± 1.1 6.5 ± 1.4
Diameter of the extracranial end of HC (mm) 4.1 4.4 9.6 9.1 6.6 ± 1.1 6.5 ± 1.0
Angle of the HC to the sagittal plane (degrees) 30 36 55 57 45.1 ± 4.5 46.0 ± 4.2
Distance of the intracranial end of HC to the JF (mm) 5.2 7.3 20.4 21.2 13.1 ± 3 13.5 ± 3.2
Distance of the extracranial end of HC to the JF (mm) 5.4 5.4 15.8 16.9 8.2 ± 1.9 8.6 ± 1.9
Distance between HC and JT (mm) 5.1 6.7 17.5 17.5 12.2 ± 2.2 12.2 ± 2
Distance between HC and opisthion (mm) 21.9 24.1 34.2 37.6 29.1 ± 2.4 29 ± 2.6
Distance between HC and basion (mm) 12.1 12.1 19.7 23.7 16.4 ± 1.6 16.6 ± 1.8
Distance of the intracranial end of HC to the posterior margin of OC (mm) 8.4 8.2 17.6 17.4 12.4 ± 2.3 12.2 ± 2.2
Distance of the intracranial end of HC to the anterior margin of OC (mm) 8.2 8.1 16.9 16.9 11.3 ± 1.5 11.0 ± 1.6
Distance of the intracranial end of HC to the inferior margin of OC (mm) 6.5 6.8 11.8 12.2 9.3 ± 1.2 9.4 ± 1.1
Anteroposterior length of OC (mm) 18.2 19.7 31.1 30.7 24.6 ± 2.5 24.4 ± 2.2
Transverse width of the OC (mm) 10.1 10.3 17.2 16.9 13.1 ± 1.6 13 ± 1.5
Angle of the OC to the sagittal plane (degrees) 15 16 44 42 31.3 ± 4.8 31.6 ± 4.9
Sagittal intercondylar angle (degrees) 31 78 62.2 ± 9.1
Anterior intercondylar distance (mm) 15 32 22.6 ± 3.9
Posterior intercondylar distance (mm) 33 50 44.2 ± 3.2
Anteroposterior diameter of the FM (mm) 29.7 39.7 34.8 ± 2.2
Transverse diameter of the FM (mm) 24.4 38.6 29.6 ± 2.4
Index of FM 1 1.3 1.2 ± 0.1
Mean ± SD indicates mean ± standard deviation.

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TABLE 2. Frequencies and Percentages of the Presence of a Septum in the HC, Protrusion of the OC into the FM, and Presence
of a Condylar Foramen
Septum of the HC Protrusion of the OC into FM Presence of CF
L R n % n % n %
32 54.2 39 66.1 15 25.4
+ 15 25.4 2 3.4 10 17
+ 7 11.9 3 5.1 5 8.5
+ + 5 8.5 15 25.4 29 49.1
L indicates left; R, right.

34.8 ± 2.2 mm and 29.6 ± 2.4 mm, respectively, and the differences, between races. The findings on the mean
FM index was 1.2 ± 0.1. distance of the intracranial part of HC to the posterior,
There was no septum present in the HC on either anterior, and inferior margins of the OC (12.3, 11.2, and
side in 54.2% of the sample, a septum on the left in 9.4 mm, respectively) differ slightly from the values
25.4%, on the right in 11.0%, and on both sides in 8.5% reported by Muthukumar et al3 (12.2, 12.6, and
(Table 2). In 66.1%, there was no protrusion of the OC 11.9 mm, respectively). Given the above observations, it
into the FM on either side, protrusion on the left side in is suggested that surgical approaches to the HC may be
3.4%, on the right side in 5.1%, and on both sides in undertaken to within 10.8 mm anterior to and 9 mm
25.4% (Table 2). The presence of a CF was observed on inferior to the OC: in contrast Muthukumar et al,3
both sides in 49.1%, on the left side in 17%, on the right suggested a minimum distance of 12 mm to the OC to be a
side in 8.5%, and on neither side in 25.4% (Table 2). safe surgical zone. The difference in lengths and distances
between studies is measured in millimeters; therefore,
during surgical intervention these small variations must
DISCUSSION be borne in mind. Notwithstanding these suggestions the
A detailed knowledge and understanding of the detailed individual anatomy of this region should be
morphometry of the skull base is a prerequisite for assessed using morphometric methods prior surgical
surgical intervention in this region, especially in relation intervention.
to the transcondylar approach and its variations. Many The mean distances between the intracranial and
surgical approaches are associated with a high mortality extracranial ends of the HC and the JF in the present
and morbidity when undertaken without detailed mor- study were greater than the values reported by Muthu-
phologic analysis.9,10 Therefore, for improvements in kumar et al3 (13.3 mm and 10.0 mm from the intracranial
surgical technique and the facilitation of safe surgical end, and 8.4 mm and 5.0 mm from the extracranial end,
approaches to the skull base, a detailed morphometric respectively). The differences probably reflect the greater
analysis of the presenting anatomy must be undertaken length of the HC reported by Muthukumar et al.3
and assessed. The JT lies medially on the inferior part of the
Knowing the precise location of the HC is petrooccipital sulcus overlaying the HC on the medial
important in understanding of the spatial relationships edge of the JF.7 It has been reported that by removing the
of surrounding structures, and in the resection of tumors JT a gap can be created, sufficient for the surgical
lying close to or within the canal itself. In addition, when manipulation of neurinomas, epidermoid cysts, or similar
drilling into the OC it is important for the surgeon to noninvasive lesions,8 without the need to drill into the
anticipate the possible depth and direction of the HC.10 In petrous part of the temporal bone. Consequently, data on
the present study, the mean length of the HC was 9.9 mm, the distance between the JT and the HC are of clinical
the mean intracranial diameter 6.5 mm, and the mean importance. In the present study this distance was
extracranial diameter 6.6 mm. These measurements differ 12.2 mm, similar to the value of 11.7 mm reported by
from those of Muthukumar et al3 (12.6, 7.2, and 7.9 mm, Muthukumar et al.3 The clinical and surgical importance
respectively). The mean length of the HC was reported by of this distance in the drilling of the JT has been
Hadley and Shelton11 (11.2 mm), Berlis et al12 (7.78 mm). emphasized.3,14 The distance between the HC observed
The mean intracranial diameter 4.66 mm and the mean here was 29.2 mm, whereas Muthukumar et al3 found it to
extracranial diameter 5.51 mm was reported by Berge and be slightly less (27.5 mm).
Bergman.13 These differing results probably reflect racial The HC can be partially or completely divided by a
differences in the populations studied. The mean sagittal bony septum: the importance of a complete septum is that
plane angle of the hypoglossal in the present study is 45.6 it separates the canal into 2 parts and has implications for
degrees, a figure similar to the angle of 45 degrees of Wen surgery involving the HC.10,15 Of the skulls examined in
et al7 and 44.9 degrees of Berlis et al,12 but less than the 49 the present study, in 54.2% there was no septum present
degrees of Muthukumar et al.3 Nevertheless, these in the HC, whereas 11.9% had septum on the right only,
findings suggest that there are similarities as well as 25.4% on the left only, and 8.5% had bilateral septum.

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Kizilkanat et al Neurosurg Q  Volume 16, Number 3, September 2006

The percentages of skulls having a septum on the right for extradural lesions in front of the FM.7,9,14,15,17
side only and of bilateral septa are similar to those The anteroposterior (34.8 mm) and transverse (29.6 mm)
reported by Bastianini et al5 and Hauser et al,6 however, diameters of the FM reported in this study are
both reported a higher percentage of skulls with no septa similar to those reported by Muthukumar et al3
(66.2% to 77.8%5 depending on race and sex and 66.2%6) (33.3 mm and 27.9 mm), Naderi et al4 (anteroposterior
and a lower percentage with a septum on the left side only distance 34.7 mm), Wanebo and Chicoine9 (36.0 mm and
(9.6% to 14.3%5 depending on race and sex and 17.7%6). 31.0 mm), Berge and Bergman13 (33.8 mm and 28.3 mm),
The entry positions of the hypoglossal nerve de Olivera et al15 (34.5 mm and 29.4 mm). When the FM
fascicles into the canal, their course within the canal index is greater than 1.2 the FM is oval in shape3: in the
and that where within the distal part of the canal they present study the mean FM index was 1.2. The shape of
approach each other to become a single fiber is a practical FM is important in determining the amount of bone to be
importance for the surgeon. A venous plexus and the removed, as too much may encroach on the OC and HC.
meningeal branch of the ascending pharyngeal artery are The transcondylar approach is suitable for patients with a
also contents of the canal and their position also needs to small FM as the gap between foramen and brain stem is
be known. Venous bleeding may occur when trying to small.9 Knowledge of the FM index is, therefore,
avoid compressing the hypoglossal nerve: this is often important in determining which surgical technique to use.
difficult as the venous plexus is usually the initially In the present study, 66.1% of the skulls showed no
structure encountered when entering the canal. The close protrusion of the OC into the FM, 5.1% showed
association of the HC with other hemostatic structures protrusion on the right side only, 3.4% on the left side
material is potentially hazardous.10 It is, therefore, clear only, and 25.4% had bilateral protrusions. Muthukumar
that knowledge of the possible positions of the HC when et al3 reported that 20% of skulls examined had
drilling into the occipital bone is extremely important significant protrusions into the FM. Because of the need
during surgical intervention. to remove a greater amount of bone when the OC
When OC resection and/or a lateral approach to the protrudes into the FM the transcondylar approach is not
FM is required, an intimate knowledge of the dimensions appropriate in such individuals.3 A condylar fossa may be
of the condyle is a necessary for a safe resection to present running anteromedially from the posterolateral
be undertaken.3,4,9 In the present study, the mean side of the OC: it may transmit an emissary in which case
anteroposterior length of the OC was 24.5 mm, a value it communicates with the sigmoid sinus it transmits
larger than those reported by Muthukumar et al3 complete through which passes an emissary vein, which in
(23.6 mm), Naderi et al4 (23.4 mm), and Wanebo and turn communicates with the sigmoid sinus. There may be
Chicoine9 (23.0 mm), whereas the mean transverse width one or more such CF on each side or merely blind ending
was 13.1 mm was less than that reported by Muthukumar condylar fossae.3,13,15,18 In the present study, 25.4% of
et al3 (14.7 mm). The mean sagittal plane angle of the OC the skulls had showed no CF, 8.5% had one on the right
in the present study was 31.5 degrees, with the sagittal side only, 17% on the left side only, and 49.1% showed
intercondylar angle (62.2 degrees) being similar to that CF bilaterally. Muthukumar et al3 observed CF in 60%
observed by Naderi et al4 (59.3 degrees). In the present of skulls examined, Berge and Bergman13 in 72%, and de
study, the anterior and posterior intercondylar distances Oliveira et al15 in 80% on the left and 72% on the right.
were 22.6 mm and 44.2 mm, respectively: Naderi et al4 In this study, a morphometric analysis of the FM,
reported distances of 21 mm and 41.6 mm, respectively. OC, and HC in skulls of Turkish origin has been
The lengths, widths, and the sagittal angles of the undertaken. Comparison with other studies shown both
OC, together with the intercondylar distances are similarities and differences in the measurements taken
important when determining the quantity of bone to were observed, highlighting the need to be aware of racial
removed during resection16: less bone will need to be differences in some measurements. The data presented
removed in individuals with a wide intercondylar gap here will provide additional information on the complex
and more bone with a smaller intercondylar gap. There- morphology of this region of the base of the skull, which
fore, if condylar resection is to be undertaken the location will help in reducing the mortality and morbidity during
of the HC and the sagittal OC angle must both be taken surgical intervention.
into consideration.
Lesions involving the FM pose special problems due
to its deep location and the many associated structures:
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