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DOI:
10.4103/0028-3886.253609
“Tailored” far lateral approach
to anterior foramen magnum
meningiomas – The importance of
condylar preservation
Dwarakanath Srinivas, Pragyan Sarma1, Harsh Deora, Manish Beniwal, V Vikas,
KVLN Rao, BA Chandramouli, Sampath Somanna

PMID:
xxxx Abstract:
Introduction: Anterior and anterolaterally situated foramen magnum meningiomas are a technically complex
subgroup of meningiomas. The need for an extensive exposure and bone work and their complex anatomy
make them a difficult and challenging group of tumors to resect. The bone work has ranged from an extensive
condylar resection to condylar preserving exposures. In this paper, we present our experience with condylar
preserving or minimal condylar resection based approaches to these tumors.
Materials and Methods: All patients who underwent surgical resection of anterior and anterolaterally situated
foramen magnum meningiomas were included in the analysis. The study period was more than 10 years from
2005 to 2015 at our institute; a tertiary referral centre in India. The records along with demographic profile,
clinico‑radiological features, surgical strategies, outcomes as well as mortality and morbidity were analysed.
Results: There were a total of 20 patients (9 males and 11 females) who were operated during the study
period. The average age was 36.7 years. In 16 patients, gross‑total or near‑total resection could be achieved,
four patients underwent subtotal resection. Eight patients had fresh morbidity in the form of new motor deficits,
pseudomeningocele formation, worsening of the lower cranial nerve functions or post‑operative adhesions
leading to syrinx formation. The follow‑up ranged from 6 months to 140 months.
Conclusion: Foramen magnum meningiomas are an eminently treatable group of tumors. Condylar preservation
provides a good visualization, while helping to preserve joint stability and in avoiding instrumental stabilization.
Key Words:
Far lateral, foramen magnum, meningioma, skull base, surgery

Key Message:
In the far lateral approach to anteriorly placed foramen magnum meningiomas, following the natural corridor
created by the mass of the tumor between the cervicomedullary neuraxis and the clivus, and a conservative
occipital condylar resection (thus obviating the need for an occipital condylar‑C1 lateral mass stabilization),
Department of helps in achieving a satisfactory excision of these complex lesions with a very low morbidity and mortality.
Neurosurgery,
National Institute
of Mental Health
and Neurosciences,
M eningioma of the foramen magnum (FMM)
are unusual and comprise only 0.3%–3.2%
of the overall incidence of meningiomas.
challenging in view of the very limited space
available between the cervicomedullary junction
and the clivus at the foramen magnum; and, the
Bengaluru, Karnataka, However, they are the most common benign propensity of the tumor to involve the lower
1
Department of intracranial, extra‑axial tumors arising at the brainstem, the spinal cord, the lower cranial
Neurosurgery, Guru craniocervical junction.[1,2] Initially described by nerves and the vertebral artery  (VA). Over
Teg Bahadur Hospital, Hallopeau in 1872 in a post‑mortem of a patient the past decades, various surgical approaches
New Delhi, India with rapidly progressing quadriparesis leading have been described and refined by different
to death within a short span of 5 months, they authors. Since the landmark article by Sen
Address for
correspondence: are often diagnosed late (especially when they and Sekhar,[6] extensive skull base exposures
Dr. Dwarakanath Srinivas, have attained a large size), in view of their slow have been the mainstay in their microsurgical
Department of indolent course.[3-5] The management is often removal. These include extensive condylar
Neurosurgery, National
Institute of Mental Health This is an open access journal, and articles are distributed under the terms
How to cite this article: Srinivas D, Sarma P,
and Neurosciences, of the Creative Commons Attribution‑NonCommercial‑ShareAlike 4.0
Deora H, Beniwal M, Vikas V, Rao KV, et al.
Bengaluru, License, which allows others to remix, tweak, and build upon the work
non‑commercially, as long as appropriate credit is given and the new “Tailored” far lateral approach to anterior foramen
Karnataka, India. magnum meningiomas – The importance of condylar
creations are licensed under the identical terms.
E‑mail: dwarakaneuro@ preservation. Neurology India 2019;67:142-8.
yahoo.com For reprints contact: reprints@medknow.com

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Srinivas, et al.: “Tailored” far lateral approach to anterior foramen magnum meningiomas

removal, mobilization of the VA and an occipitocervical
fusion. However, these extensive approaches carry their
own mortality and morbidity. In this article, we describe
our technique of “tailored resection” of these lesions with
the stress on condylar preservation in our series of these
extremely complex tumors. The importance of condylar
preservation  (>50%), and minimal VA handling have been
emphasized, thus obviating the need for extensive skull base
approaches in order to resect these tumors.
Materials and Methods
presented with headache, which was holocranial in nature
that worsened in the morning and was suggestive of raised
intracranial pressure secondary to hydrocephalus [Figure 1].
Pre‑operatively, three patients were in Nurick grade 2, 10 in
Nurick grade 3 and 7 in Nurick grade 4. The detailed patient
characteristics have been outlined in Table 1. Eighteen cases
were operated primarily and two of them underwent surgery
for recurrence. One patient was operated for both residual
and recurrent tumor, to excise the extradural part extending
up to cervical (C)2 level, which was left behind at the time
of first surgery.

This is a retrospective analysis of all anterior and anterolaterally Radiology

situated FMMs operated over a period of 10 years (2005–2015)
at our institute, a tertiary referral center in India. All of them
underwent a modified far lateral approach (FLA) with stress
on condylar preservation. The patient records were scanned
and the demographic profile, clinico‑radiological features,
surgical strategies, and outcome, along with the mortality and
morbidity were analysed. The pathology of the tumors was
reconfirmed via re‑examination of the histological slides. The
follow‑up data was collected from the outpatient department
records. The range and average duration of follow‑up were
noted.
All the patients underwent a pre‑operative computed
tomographic (CT) scan with thin posterior fossa cuts (1 mm)
and also an magnetic resonance imaging (MRI) of the head.
The assessment of high‑resolution, thin‑slice CT sections
of the craniocervical junction was an integral part of our
pre‑operative planning protocol to clearly demarcate the
bone margins and also to accurately measure the surgical

Results

Demographics and clinical presentation

There were a total number of 20 patients (9 male and
11  female patients) with an average age of 36.7  years. The
duration of the symptoms varied from 6 to 22 months.
The presence of pyramidal tract sign was the commonest
presentation (present in all the included patients) followed Figure 1: Compostite image showing T1 weighted post-gadolinium enhanced
by lower cranial nerve involvement (present in 11 patients). sagittal image and correspoding FLAIR image of a patient with an anterior foramen
Three patients had dysesthetic neck pain and two patients magnum meningioma with hydrocephalus

Table 1: Demographics and clinico‑radiological characteristics of the patient cohort

Patient Age/ Clinical features and duration Cranial nerves involved Tumor size (AP × width Vertebral artery ‑ tumor interface
sex × cranio‑caudal) cm engulfed/not engulfed
1 13/F HCP, hemiparesis None 3.1×3.2×3.9 NOT ENGULFED
2 45/F Quadriparesis, urge incontinence None 4.1×4.3×4.5 ENGULFED
3 38/M HCP, LCN palsy, ataxia IX, X 4.3×4.1×3.3 ENGULFED
4 13/M Quadriparesis, LCN involved IX, X, XII 2.0×1.8×1.3 ENGULFED
5 13/M Quadriparesis IX, X, XII 1.8×1.3×1.2 NOT ENGULFED
6 49/M Quadriparesis, urinary hesitancy None 4.3×4.4×3.2 ENGULFED
7 24/F Neck pain, quadriparesis None 4.4×3.2×2.8 ENGULFED
8 45/F Neck pain, quadriparesis None 3.1×5.2×4.3 ENGULFED
9 50/M Quadriparesis None 2×2.8×1.8 NOT ENGULFED
10 50/F Quadriparesis, breathing difficulty None 2.1×2.5×3.2 NOT ENGULFED
11 33/M Quadriparesis None 3.1×3.5×2.8 ENGULFED
12 40/F Quadriparesis None 2.1×1.8×1.4 NOT ENGULFED
13 43/M Recurrent tumor after 12 years LCN palsy, quadriparesis 1.8×2.3×2.1 NOT ENGULFED
14 44/M Quadriparesis, LCN palsy IX, X, XI, XII 4.1×4.3×3.4 ENGULFED
15 23/F Quadriparesis, recurrence of tumor IX, X, XII 3.2×2.8×3.6 NOT ENGULFED
16 35/F Hemiparesis X, XII 2.1×2 × 2.8 ENGULFED
17 53/F Quadriparesis IX, X, XII 2.8×3.0×2.9 ENGULFED
18 46/F Neck pain, quadriparesis XII 2.8×3.2×1.8 ENGULFED
19 32/M Quadriparesis XII 3.1×3.2×3.6 NOT ENGULFED
20 45/F Quadriparesis XII 2.5×4.6×3.8 NOT ENGULFED
M=Male; F=Female; HCP=Hydrocephalus; LCN=Lower cranial nerve; AP=Anteroposterior

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Srinivas, et al.: “Tailored” far lateral approach to anterior foramen magnum meningiomas
corridor. An MRI image is often deceptive in assessing
these parameters. A CT scan was also useful in evaluating
the cases associated with an intratumoral calcification
or a bony hyperostosis, or in those with osteolysis of the
surrounding bone. It was also used for the planning of
bony resection required for tumor removal. Additional
findings noted on the CT head scan of the head included
hyperostosis of the bone in 15 patients. The tumor extended
inferiorly into the cervical cord with extension up to the
lower border of C2 in two cases. One patient had both a
significant intra‑ and extradural component and hence
was operated in two settings. On MRI, the FMMs appeared
as well‑delineated dural‑based extra‑axial lesions, which
were isointense or mildly hypointense on T1‑weighted and
T2‑weighted MR images with homogenous‑to‑heterogenous
contrast enhancement with a ‘dural tail’ sign often being
present. Information about the vertebrobasilar system and
of the presence of vessels adjacent to the tumor were also
obtained from the MRI [Figure 2a-d]. Digital subtraction
angiogram of the head was performed only in 9 out of the
20  cases  (45%). Angiography was done in only the cases
where MRI did not provide useful inputs about the VA;
and, whether or not the artery was encased by the lesion.
Alternatively, a CT angiography was done in rest of the
cases and provided a similar information. None of our
patients underwent a preoperative embolization of the
tumor feeders.
Surgical procedure
The patients were placed in the lateral position on the head
holder and their head was fixed with pins. We do not flex
the head laterally or rotate the head. We use prophylactic
antibiotics and mannitol at induction of anesthesia. Mannitol
was given only at induction as a single dose in order to reduce
the intracranial pressure and prevent inadvertent dural tears
during the performance of the craniotomy. Administration of
mannitol prevented dural bulging and its coming in contact with
the drill due to the prevalence of chronically raised intracranial
presssure. A lazy‑S or a C‑shaped incision was given extending
a b
c d
Figure 2: (a-c) T1‑weighted post contrast sagittal, axial and coronal magnetic
resonance images showing a contrast enhancing dural‑based lesion on the anterior
lip of foramen magnum with dural tail. (d) DSA showing tumor blush due to feeders
from the vertebrobasilar system
144 Neurology India | Volume 67 | Issue 1 | January‑February 2019
up to the C5 level in the midline [Figure 3a]. The muscles were
cut in layers and the C1 and C2 posterior elements were exposed
along with the suboccipital region. A cuff of muscle was left
at the nuchal line for better approximation. The exposure also
included the lateral mass of C1 along with the atlanto‑occipital
joint. A suboccipital craniotomy was performed extending
from the level of the inferior nuchal line down to the foramen
magnum. A sub‑periosteal dissection was performed at the C1
and C2 level followed by a laminectomy. While the C1 lamina
was always excised, C2 lamina was removed depending on
the extent of tumor. The V3 segment of the VA, including the
horizontal extradural segment was exposed and dissected
carefully. We followed the VA up to the transverse foramen
of C1 but did not unroof it. The VA was identified over the
superior surface of C1 and traced and skeletonized up to
its point of entry into the dura [Figure 3b and c]. There was
usually a brisk and troublesome bleeding from the vertebral
venous plexus, which, however, could easily be controlled
by surgicel or by fibrin glue. We drilled a part of the occipital
condyle, depending only upon the tumor morphology. The
only indication that necessitated an upfront condylar drilling
was the inadequate visualization of the whole lesion. Neither
complete skeletonizing of the VA nor its mobilization was
indicated in any of our cases. Thus, we “tailored” the condylar
drilling depending on the extent of the tumor. Care was taken
never to drill more than one‑third of the occipital condyle.
The dura was opened in a curvilinear shape. The denticulate
ligaments were cut and the C1 root was sacrificed if it
obstructed the view to the tumor. The tumor was identified and
the rootlets of the lower cranial nerves were carefully dissected
away from the surface of the tumor [Figure 3d]. The tumor
was coagulated, decompressed (using an ultrasonic aspirator
or micro‑  scissors, depending upon the tumor consistency)
and was dissected away from the surrounding structures. It
was important to remember that the VA was closely related
and extreme caution was necessary while working upon the
a b
c d
Figure 3: (a) Intraoperative photograph showing the positioning of the patient and
a lazy‑S or a C‑incision being given extending up to the C5 level in the midline.
(b and c) The VA is identified over the superior surface of C1 and traced and
skeletonized up to its point of entry into the dura. (d) The tumor is identified and the
rootlets of the lower cranial nerves are carefully dissected away from the surface of
the tumor
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Srinivas, et al.: “Tailored” far lateral approach to anterior foramen magnum meningiomas

lower and anterior surface of the tumor. Once the tumor had
been excised, hemostasis was attained and the dura closed in
a watertight manner.
Results
We were able to achieve Simpson Grade II excision in 16 cases
[Figure 4a and b]. Grade III excision was performed in two
cases, and only partial decompression could be achieved in
two cases. The details of the patients operated as a part of this
study are given in Table 2. Encasement of the dominant VA
in three cases, a high vascularity in one case and an ill‑defined
arachnoidal plane in two cases, were the reasons for incomplete
excision of the lesion. Re‑exploration was done in two cases,
among whom one had been operated at another center.
cranial nerve paresis worsened in three cases; among these
patients, two recovered, whereas the third patient required a
tracheostomy. The follow‑up duration varied from 6 months
to 140  months  (average follow  ‑up duration: 61  months).
Significant morbidity included worsening of hemiparesis in
one case, a pseudomeningocele formation in three cases, and
post‑operative dural adhesions leading to syrinx formation
in one case. The Nurick grade improved in 13 patients,
deteriorated in 1 patient, and remained same in 6 patients.
Post‑operative MRI was obtained 6 months after surgery and
at a one‑year interval subsequently. Only two patients had a
residual tumor for which stereotactic radiosurgery (SRT) was
administered. Both these patients had Grade II meningiomas.
Discussion

In one case, there was VA injury, which was controlled
with packing. However, the symptoms related to lower
a b
Figure 4: (a) T1‑weighted contrast enhanced magnetic resonance images at
follow‑up showing a Grade II excision of the meningioma. (b) CT axial bone section
shows the extent of bony removal needed for exposure and removal of the lesion
FMM pose a significant challenge for the operating surgeon
in view the difficulties that arise in accessing these lesions,
their close proximity to the lower brain stem, and the frequent
involvement of the lower cranial nerves and the VA. These
lesions have a slow growth rate and the patients often have a
propensity to remain asymptomatic for a long duration. The
insidious growth of the tumor has been partly contributed by
the wide subarachnoid space present at this level. Thus, usually
these tumors are detected at an advanced stage.[3-5] Frazier
and Spiller,[7] way back in 1922, for the first time attempted
surgical excision of FMM, and 7 years later, Elsberg and Strauss
performed the first successful excision of this benign entity.[8]
However, the surgery of anterior and anterolaterally placed
lesions operated by the posterior approach continues to be
hazardous due to the very high complication rates.[9,10] the
incipient occipito‑cervical instability, the prolonged duration
of surgery, the high incidence of operative site pain. The
possibility of injuring the VA and the XII nerve have also

Table  2: Perioperative findings and outcomes

Patient Tumor VA transposition/ Extent of Histopathology Complications of surgery Follow‑up Nurick grade
character condylar drilling resection (months) Pre op Post op
1 Soft/firm/hard Yes/no Grade II Transitional meningioma None 6 2 2
2 Soft Yes Grade III Chordoid meningioma XII nerve worsening 6 3 2
3 Hard Yes Grade II Psammomatous meningioma Hemiparesis worsened 12 3 4
4 Firm No Grade II Atypical meningioma Pseudomeningocele 12 3 2
5 Hard Yes Grade IV Psammomatous meningioma None 48 4 2
6 Hard No Grade III Psammomatous meningioma None 0 4 4
7 Hard Yes Grade II Psammomatous meningioma None 30 4 3
8 Hard Yes Grade II Clear cell meningioma None 40 4 2
9 Firm Yes Grade II Transitional meningioma None 140 3 2
10 Firm No Grade II Transitional meningioma IX, X ‑ transient worsening 30 3 2
11 Firm No Grade II Meningothelial meningioma None 62 4 3
12 Firm Yes Grade II Psammomatous meningioma Pseudomeningocele 72 3 3
13 Firm No Grade II Fibrous meningioma Pseudomeningocele 84 4 4
14 Soft Yes Grade IV Psammomatous meningioma IX, X, XI, XII worsened 24 3 2
15 Hard Yes Grade II Psammomatous meningioma Syrinx underwent 60 4 3
adhesiolysis with duraplasty
16 Hard No Grade III Transitional meningioma None 42 3 2
17 Soft Yes Grade II Transitional meningioma None 28 3 2
18 Hard Yes Grade II Transtitional meningioma None 12 3 2
19 Firm Yes Grade II Transitional meningioma None 14 2 2
20 Hard Yes Grade II Transitional meningioma None 22 2 2
VA=Vertebral artery

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Srinivas, et al.: “Tailored” far lateral approach to anterior foramen magnum meningiomas

posed significant challenges during surgery of these benign
lesions by the posterior approach. Mortality has been recorded
due to respiratory failure, VA injury, brainstem infarction and
pneumonia due to aspiration. An en‑plaque growth of the
tumor, a hard tumor consistency and the presence of strong
adhesions of the tumor capsule to adjacent neurovascular
structures are potential risk factors leading to lower cranial
nerve deficits and subsequent morbidity.[11]
extent of condylar removal. Açikbaş, et al.,[17] studied the effect
of condylectomy during the FLA and concluded that bony
removal of the postero‑medial part of the condyle beyond
the hypoglossal canal significantly increased the angle of
exposure and decreased the working distance. There are
several proponents of the modified FLA without the removal
of occipital condyle; prominent among them are studies by
Koos and Spetzler[15] and Samii, et al.[18]

Surgery of anterior and anterolaterally placed FMM was
revolutionized in 1988 by George, et al.[12] He described the
FLA for these tumors, which was similar to that proposed
by Heros[13] for vertebral and vertebrobasilar lesions. This
paved the way for the FLA and its variants to become an
important arsenal for the operating surgeon approaching the
lesions involving the lower clivus or the foramen magnum.
Thus, these complex lesions could be resected with minimum
complications. Several modifications of this approach have
been described in literature till now.[14] The backbone of
the FLA is resection of the occipital condyle. The other
documented variations of this approach are the excision of the
superior facet of C1, removal of the jugular tubercle, a more
convenient exposure of jugular foramen, a mastoidectomy
and dissection of the hypoglossal canal with preservation
of its contents.[15,16] However, there was no consensus on the
In 1990, Sen and Sekhar in their study emphasized the need
for a total condylectomy, which was revalidated in 1991 by
further endorsement of partial or complete condylectomy.[6]
It was followed by many different studies which affirmed
and agreed with Sekhar.[19-21] In 1996, Yasargil,[22] in his study,
was able to achieve complete excision of FMM by the lateral
suboccipital approach with very low complication rates. But
Salas et al.,[23] was not able to achieve similar results by the
transcondylar approaches. Nanda, in his cadaveric study,
suggested that resection of the occipital condyle should be
tailored to the individual cases and should not be considered
technically imperative for all the cases in whom surgical
resection is being performed. They also showed that the
degree of improved exposure between one‑third removal
of the ipsilateral occipital condyle and removal of half the
condyle was only 4 degrees.[11] In recommendations published

Table  3: Review of literature of series focusing on the extent of condylar resection, as well as the morbidity and
mortality in these series
Author Year Number of cases Condylar resection (%) Extent of resection Morbidity (%) Mortality (%)
Glisbach 1987 5 ‑ 1/3 20 0
Guidetti 1988 17 ‑ ‑ 12 11
Sen and Sekhar 1990 5 100 1/3‑1/2 60 20
Crockard 1991 3 0 0 100 66
Kratimenos 1993 8 ‑ 1/3 0 25
Babu 1994 9 100 1/3‑1/2 56 11.1
Akalan 1994 8 0 0 0 0
Bertalanffy 1996 19 100 1/3 0 0
Samii 1996 38 17.5 1/3 5 6
George 1997 40 100 Partial 0 7.5
Pirotte 1998 6 100 ½‑1/3 17 17
Sharma 1999 10 0 0 ‑ 15
Salas 1999 24 100 1/3 ‑ 0
Arnautovic 2000 18 100 ½‑1/3 11.1 16.6
Roberti 2001 21 ‑ ‑ 21.5 9.5
Goel 2001 17 11.80 1/3‑1/4 6 0
Nanda 2002 6 0 0 0 0
Marin 2003 7 29 1/3‑1/2 5 14
Parlato 2003 7 ‑ <1/2 ‑ 0
Boulton 2003 10 0 0 10 0
Pamir 2004 22 95 1/3 4.5 0
Margalit 2005 18 50 Partial ‑ 0
Bassiouni 2006 25 0 0 8 4
Wu Z 2009 114 6 1/3 36.5 0
Kandenwein 2009 16 0 0 0 0
Talacchi 2012 64 100 1/3 68.7 0
Colli 2014 13 30.7 1/3 31 0
Li D 2017 185 12.4 Partial 42.7 2.6
Campero 2017 12 66.7 1/3 50 0
Present series 2018 20 55 Tailored (<1/3) 40 0

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Srinivas, et al.: “Tailored” far lateral approach to anterior foramen magnum meningiomas
to date, it is advised that the occipitocervical joint (OCJ)  should
be stabilized when  >70% of the occipital condyle has been
removed.[24] However,   Vishteh et al., analyzed the effect of
occipital condyle removal on joint mobility and found that
greater than 50% removal causes major instability. They
recommended an occipito‑cervical fusion for this extent of
condylar resection.[25] Till date, this study continues to provide
the only scientific evidence for the assessment of instability
at the CVJ. A review of the various series of FMMs focusing
on the extent of condylar resection shows a decreasing trend
towards the the extent of condylar resections being done, thus
further cementing our belief in a less aggressive resection
strategy [Table 3].
Despite these various studies published in literature, there is
no consensus till now regarding the extent of condylar drilling
required for safe excision of these tumors. Although complete
removal of the occipital condyle improves visualization and
helps in the dissection of the tumor‑nervous tissue interface,
the same may also be achieved by cutting of the denticulate
ligament and mobilization of the cord. Also, more extensive
bone removal is usually not necessary because displacement of
the brainstem by the lesion provides an enhanced visualization.
In our technique, we do not remove the occipital condyle
completely. Instead the condyle is exposed and depending on
the visualization, the occipital condyle is drilled (the “tailored”
resection technique). In all these cases, we have not found
the necessity to remove more than one‑third of the occipital
condyle or mobilize the VA from the C1 foramen. Employing
this technique, we found that the operative exposure was
adequate, stability of the occipito-cervical joint was not
compromised, and chances of hypoglossal nerve injury and
VA were minimized. This strategy is a safe alternative to
the FLA or the extreme lateral exposure for the anterior and
anteriolaterally placed FMM. During our surgery, to improve
the exposure, we sometimes sacrificed the C1 root, whenever
it obstructed visualization of the tumor‑neuraxial interface.
To reach the tumor, we follow the naturally existing trajectory
between the lower cranial nerve rootlets and the C2 nerve.
The most important and challenging step was to avoid the
injury to the VA. There are reports in the literature of partial
drilling of the occipital condyle and the jugular tubercle for
clipping of VA and vertebrobasilar aneurysms, without medial
mobilization of the intradural VA.[13] Our technique was to
identify the VA from the superior surface of the C1 and then
skeletonize it up to its point of entry into the dura. The dura
was opened in a C‑shaped manner. We neither drilled the
entire occipital condyle upfront  (thus avoiding instability)
nor did we mobilize the VA medially. The tumor could be
identified and provided the natural path through which
removal could be performed. A watertight dural closure
has been considered as mandatory to avoid the troublesome
incidence of pseudomeningocele.
Conclusion
FMMs though rare are an eminently treatable group of tumors
which require a great degree of skill by the operating skull base
neurosurgeon. The modified FLA with condylar preservation
provides a good visualization, while helping to preserve
joint stability and to avoid an instrumented stabilization of
Neurology India | Volume 67 | Issue 1 | January‑February 2019 147
the occipito‑atlantal joints. With the introduction of recent
advances in microsurgical techniques and the application of
novel principles of surgery, the outcome of surgery has been
excellent with an overall very low rate of morbidity and the
occurrence of negligible mortality.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
References
1. Arnautović KI, Al‑Mefty O, Husain M. Ventral foramen magnum
meningiomas. J Neurosurg Spine 2000;92(1 Suppl):71‑80.
2. Gilsbach JM. Extreme lateral approach to intradural lesions of the
cervical spine and foramen magnum. Neurosurgery 1991;28:779.
3. Bassiouni H, Ntoukas V, Asgari S, Sandalcioglu EI, Stolke D,
Seifert V. Foramen magnum meningiomas: Clinical outcome
after microsurgical resection via a posterolateral suboccipital
retrocondylar approach. Neurosurgery 2006;59:1177‑87.
4. George B, Lot G, Boissonnet H. Meningioma of the foramen
magnum: A series of 40 cases. Surg Neurol 1997;47:371‑9.
5. Hallopeau H. Note sur deux faits de tumeur de mesocephale.
Gaz Med (Paris) 1874;3:2.
6. Sen CN, Sekhar LN. An extreme lateral approach to intradural
lesions of the cervical spine and foramen magnum. Neurosurgery
1990;27:197‑204.
7. Frazier C, Spiller W. An analysis of fourteen consecutive cases of
spinal cord tumor. Arch Neurol Psychiatr (Chicago) 1922;8:455‑501.
8. Elsberg CA, Strauss I. Tumors of the spinal cord which project
into the posterior cranial fossa. Report of a case in which a growth
was removed from the ventral and lateral aspects of the medulla
oblongata and upper cervical cord. Arch Neurol Psychiatry
1929;21:261‑73.
9. Stein BM, Leeds NE, Taveras JM, Pool JL. Meningiomas of the
foramen magnum. J Neurosurg 1963;20:740‑51.
10. Meyer FB, Ebersold MJ, Reese DF. Benign tumors of the foramen
magnum. J Neurosurg 1984;61:136‑42.
11. Nanda A, Vincent DA, Vannemreddy PS, Baskaya MK, Chanda A.
Far‑lateral approach to intradural lesions of the foramen
magnum without resection of the occipital condyle. J Neurosurg
2002;96:302‑9.
12. George B, Dematons C, Cophignon J. Lateral approach to the anterior
portion of the foramen magnum. Application to surgical removal of
14 benign tumors: Technical note. Surg Neurol 1988;29:484‑90.
13. Heros RC. Lateral suboccipital approach for vertebral and
vertebrobasilar artery lesions. J Neurosurg 1986;64:559‑62.
14. Spektor S, Anderson GJ, MCMenomey SO, Horgan MA,
Kellogg JX, Delashaw JB. Quantitative description of the far‑lateral
transcondylar transtubercular approach to the foramen magnum and
clivus. J Neurosurg 2000;92:824‑31.
15. Koos WT, Spetzler RF. Color Atlas of Microneurosurgery.
New York: Thieme; 1985, pp 125‑34.
16. Wen HT, Rhoton AL Jr, Katsuta T, de Oliveira E. Microsurgical
anatomy of the transcondylar, supracondylar, and paracondylar
extensions of the far‑lateral approach. J Neurosurg 1997;87:555‑85.
17. Açikbaş SC, Tuncer R, Demirez I, Rahat O, Kazan S, Sindel M,
et al. The effect of condylectomy on extreme lateral transcondylar
approach to the anterior foramen magnum. Acta Neurochir (Wien)
1997;139:546‑50.
[Downloaded free from http://www.neurologyindia.com on Friday, May 3, 2019, IP: 223.186.9.95]

Srinivas, et al.: “Tailored” far lateral approach to anterior foramen magnum meningiomas

18. Samii M, Klekamp J, Carvalho G. Surgical results for meningiomas
of the craniocervical junction. Neurosurgery 1996;39:1086‑95.
19. Bertalanffy H, Seeger W. The dorsolateral, suboccipital,
transcondylar approach to the lower clivus and anterior portion of
the craniocervical junction. Neurosurgery 1991;29:815‑21.
20. Dowd GC, Zeiller S, Awasthi D. Far lateral transcondylar approach:
Dimensional anatomy. Neurosurgery 1999;45:95‑100.
21. Spetzler RF, Grahm TW. The far‑lateral approach to the inferior
clivus and the upper cervical region: Technical note. Barrow Neurol
Inst Q 1990;6:35‑8.
22. Yasargil MG. Microneurosurgery of CNS Tumors. Vol. 4 New York:
Thieme Verlag; 1996, pp 134‑65.
23. Salas E, Sekhar LN, Ziyal IM, Wright DC. Variations of the
extremelateral craniocervical approach: Anatomical study and
clinical analysis of 69 patients. J Neurosurg 1999;90:206‑19.
24. Bejjani GK, Sekhar LN, Riedel CJ. Occipitocervical fusion
following the extreme lateral transcondylar approach. Surg Neurol
2000;54:109‑16.
25. Vishteh AG, Crawford NR, Melton MS, Spetzler RF, Sonntag VK,
Dickman CA. Stability of the craniovertebral junction after unilateral
occipital condyle resection: A biomechanical study. J Neurosurg
1999;90 (1 Suppl):91‑8.

148 Neurology India | Volume 67 | Issue 1 | January‑February 2019