The suboccipital midline approach to foramen magnum meningiomas

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Anterior and anterolateral meningiomas of the foramen magnum (FM) can be resected either through extensive skull base approaches or through the classical suboccipital midline approach with limited bone removal.


This paper describes the suboccipital midline approach focusing on some peculiar technical features that serve to achieve the necessary space for safe resection of these challenging tumors.


In our experience, by adopting appropriate strategies to gain space (some of them natural, others acquired) the suboccipital midline approach can achieve the safe resection of anterior and anterolateral FM meningiomas in the majority of cases.

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Conflict of interest


Author information

Correspondence to Alessandro Della Puppa.

Additional information

Key points

1. The suboccipital midline approach is feasible in a large part of cases of anterior and anterolateral FM meningiomas displacing the brainstem. However, confidence of the surgeon with the approach, intra-operative monitoring availability, single case characteristics must be carefully evaluated case by case.

2. Craniocervical stability is maintained.

3. A C-shaped dural opening gains lateral space and avoids the occipital sinus. Intradural VA visualization is promptly achieved.

4. Intraoperative monitoring is mandatory.

5. The tumor creates all the working space needed. In this sense, the larger the tumor the easier the resection.

6. The “clove” tumor resection technique is deployed.

7. Microscope angulation plays a crucial role in optimizing available working space.

8. Good visualization of the tumor, vertebral arteries, cranial nerves, brainstem and clival dura is obtained.

9. There is low risk of postoperative cerebrospinal fistulae, cerebellum spatula contusions, and vertebral artery injury.

10. The tumor cleavage plane is the most important factor determining the surgical outcome. Involvement of these structures is independent of tumor exposure.

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Della Puppa, A., Rustemi, O. & Scienza, R. The suboccipital midline approach to foramen magnum meningiomas. Acta Neurochir 157, 869–873 (2015).

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  • Foramen magnum meningiomas
  • Posterior-fossa meningiomas
  • Clival meningiomas
  • Cranio-cervical junction surgery