The Benefits of Progressive Occipital Condylectomy in Enhancing the Far Lateral Approach to the Foramen Magnum

The portion of the occipital condyle that is safe to remove remains controversial in the transcondylar approach. We aimed to correlate the gain in exposure with incremental removal of the occipital condyle to determine if there is a point where further drilling yields diminishing gains. Virtual reality rendering of the skull was generated from 25 subjects with no posterior fossa pathology. A suboccipital far lateral craniotomy was done in virtual reality space, stopping at the posterior edge of the occipital condyle. Angular measurements of surgical corridor were taken at this point and after removal of 25% and 50% of the condyle. Two surgical targets were used: at the anterior midline of the foramen magnum and the vertebrobasilar junction. Progressive removal of the occipital condyle increased exposure to both targets in a linear fashion. For the midline of the foramen magnum, the working angle increased from 12° to 18° for quarter condylectomy and then to 25° for half condylectomy. The corridor to the vertebrobasilar junction was much tighter, and the angle increased from 5.5° to 9° for quarter condylectomy and then to 12° for half condylectomy. The gain in exposure for the low target was greater than for the high target (P < 0.001). Progressive removal of the occipital condyle yielded a linear increase in exposure without an ideal point beyond which the drilling was futile. However, the impact of condylectomy was greater for our low target compared with our high target.