2026 Poster Presentations
P119: EVOLUTION OF THE FAR-LATERAL APPROACH: REFINING ACCESS TO THE ANTERIOR FORAMEN MAGNUM AND CRANIOVERTEBRAL JUNCTION
Kivanc Yangi, MD; Kashif Qureshi, MS; Egemen Gok; Robert F Spetzler, MD; Mark C Preul, MD; Barrow Neurological Institute
Introduction: The anterior foramen magnum and craniovertebral junction have long posed significant challenges in neurosurgery, obscured by dense bone and critical neurovascular structures. Lesions in this region, such as meningiomas and aneurysms, historically carried high rates of morbidity and mortality due to the inherent difficulties of surgical exposure. Traditional midline posterior, transoral, and transcervical approaches often required substantial cerebellar and brainstem retraction, with risks of neurological injury and postoperative infection. These limitations prompted the development of a lateral approach that provided more direct visualization with reduced manipulation and morbidity. We reviewed the historical evolution of the far-lateral approach (FLA) and its refinement into contemporary variants.
Methods: All available articles, books, and atlases authored by key figures in the historical development of the FLA were systematically reviewed. References from these works were examined to identify and access primary sources. In addition, archived interviews with these figures, supplementary materials, and the existing body of literature on the FLA were comprehensively analyzed, allowing for retrospective tracing of its evolution.
Results: The conceptual basis of the FLA was established in 1972 by Hammon and Kempe, who described a more lateral trajectory for addressing posterior circulation vascular lesions. In 1978, Seeger recognized the jugular tubercle and medial occipital condyle as the key osseous obstacles. Soon after, Koos advocated for a stability-preserving strategy that emphasized jugular tubercle drilling while avoiding condylar resection. Heros (1986) standardized a lateral suboccipital craniotomy, which included removal of the lateral rim of the foramen magnum and selective C1 exposure to obtain an inferolateral view. George (1988) further advanced the approach by incorporating vertebral artery mobilization. In following years, Sen, Sekhar, Bertalanffy, and Seeger refined the surgical corridor, giving rise to variants such as the extreme-lateral and dorsolateral suboccipital transcondylar approaches. Meanwhile, Spetzler, Crockard, George, and Lang expanded its clinical applications and helped popularize its use. Matsushima (1996) emphasized condyle- and atlanto-occipital joint–sparing methods and introduced the transcondylar fossa approach. The next year, Rhoton and de Oliveira classified the FLA into transcondylar, supracondylar, and paracondylar subtypes. Subsequent decades have seen further modifications, including the minimally invasive supracondylar transtubercular (MIST) and the extreme lateral infrajugular transcondylar transtubercular (ELITE) approaches, among others.
Conclusions: The development of the FLA over a relatively recent time period offers a unique opportunity to examine the evolution of a neurosurgical approach. Since its initial description in 1972 as a lateralized posterior fossa exposure for vertebrobasilar aneurysms, the FLA has undergone substantial evolution. Foundational refinements established the principles of selective bone removal and systematic corridor development, while subsequent modifications extended its utility to complex ventral craniovertebral junction pathologies. More recently, the focus has shifted toward condyle-sparing, stability-preserving, and minimally invasive strategies, exemplified by juxtacondylar and retrocondylar variants as well as modern adaptations such as ELITE and MIST. Through these advances, a once-nearly inaccessible region has become a surgically approachable domain. Ongoing refinement of the FLA underscores the fundamental neurosurgical balance between achieving adequate exposure and preserving function, serving as a continuing platform for innovation in skull base surgery.