ANATOMIC REPORT

Morphometric Analysis of the Foramen Magnum:

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

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

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

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


FIGURE 2. Superior view of specimen used in the present study. Example of
foramen type II.
motor myelopathy, sensory abnormalities, brainstem and lower
cranial nerve dysfunctions, and signs and symptoms referable to
vascular compromise.2 Diseases associated with anomalies of the
foramen magnum include occipital vertebra, basilar invagination,
condylar hypoplasia, and atlas assimilation.6 Interestingly, one
report found that the persistence of the spheno-occipital synchon-
drosis, aggravated by the coexistence of basilar invagination,
resulted in stenosis at the foramen magnum.7
Among developmental and acquired craniocervical junction dis-
orders, achondroplasia is the most commonly reported. Achondro-
plasia, the most common form of dwarfism, results in abnormal
enchondral bone formation at the cranial base, resulting in a nar-
row cervical spinal canal and a stenotic foramen magnum.5,8,9
Clinical manifestations of chronic brainstem compression by steno-
sis of the foramen magnum and related structures are respiratory
complications, lower cranial nerve dysfunctions, upper and lower
extremity paresis, hypo- or hypertonia, hyperreflexia or clonus,
and general motor development delay.5,8,10 The horizontal and
anteroposterior diameters of the foramen magnum in an adult with
achondroplasia have been found to be equivalent to those of a new-
born and a 2-year-old child, respectively.11 The anteroposterior
and horizontal diameters of the foramen magnum have been found
NEUROSURGERY
MORPHOLOGY OF FORAMEN MAGNUM
FIGURE 3. Superior view of specimen used in the present study. Example of
foramen type III.
to be independent risk factors in those patients in whom cranio-
cervical decompression is necessary.8,12-14
The configuration of the foramen magnum in patients with
Chiari I and Chiari II malformations has been found to be larger
than in the normal population.15 Another analysis based on semi-
axial cranial x-rays demonstrated a significantly larger horizontal
diameter of the foramen magnum in 35 children with verified
Chiari I malformation, when compared with a control group of
174 individuals.16 Furthermore, development of symptoms in
this group has been found in patients with shorter anteroposterior
diameters of the foramen magnum.17 A wide foramen magnum
has also been appreciated in patients with diastrophic dysplasia.18
Other diseases associated with stenosis of the craniovertebral junc-
tion include craniometaphyseal dysplasia, Jeune’s asphyxiating
thoracic dystrophy, and spherophakia-brachymorphism
(Marchesani’s syndrome).19-21 Stenosis of the foramen magnum
has also been reported for Beare-Stevenson syndrome, a craniofa-
cial syndrome characterized by hypertrophy of the bony mar-
gins.22 The decision-making process for the diagnosis and treatment
of such disorders with bony abnormalities resulting in changes of
the anatomy of the foramen magnum demands a good under-
standing of the normal anatomy of this structure.
VOLUME 66 | NUMBER 2 | FEBRUARY 2010 | 387
TUBBS ET AL

CONCLUSIONS
Although dry skulls, like the ones used in our study, may con-
strict with time, this anatomic study elucidated geometric char-
acteristics of the foramen magnum and may serve as a future
standard reference.
Disclosure
The authors have no personal financial or institutional interest in any of the
drugs, materials, or devices described in this article.
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COMMENT

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T
ubbs et al provide a detailed analysis of the size and area of the fora-
men magnum in 72 cadaveric skulls obtained from 32 females and
40 males estimated to be between the ages of 50 and 90 years. Although
the reported findings are difficult to extrapolate to younger individuals,
who constitute the majority of patients with Chiari malformations, and
do not consider the shape and configuration of the foramen magnum,
they represent new data that could be useful in distinguishing congeni-
tal and acquired anomalies of the craniovertebral junction. The rigorous
application of morphometric science to the diagnosis and treatment of Chiari
malformation is long overdue, and the authors have made a contribu-
tion of new baseline data.
Misao Nishikawa
Thomas H. Milhorat
Manhasset, New York

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