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\def\RunningAuthor{Sharmila Aristotle et al.}
\firstPage{3528}
\articleType{Original article}
\receivedDate{01 May 2020}
\acceptedDate{08 Jun 2020}
\revisedDate{01 Jun 2020}
\journalVolume{2020, 11}
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\title{Anatomical and Radiological study of the posterior cranial base in relationship to occipital condyles and Foramen magnum}
\author{Sharmila~Aristotle\textsuperscript{*}\textsuperscript{1},  
            Balaji~Ramraj\textsuperscript{2},  
            Shantanu~Patil\textsuperscript{3}, 
            Sundarapandian~Subramanian\textsuperscript{1}~\\[5pt]{\textsuperscript{1}Department of Anatomy, SRM Medical College Hospital and Research Center, Chennai, Tamil Nadu, India}~\\{\textsuperscript{2}Department of Community Medicine, SRM Medical College Hospital and Research Center, Chennai, Tamil Nadu, India}~\\{\textsuperscript{3}Department of Translational Medicine and Research, SRM Institute of Science and Technology, Chennai, Tamil Nadu, India}}

\begin{abstract}
Detailed morphometric analysis is required for various surgical approaches in the craniovertebral junction. High mortality and morbidity are anticipated for the surgical procedures when undertaken without in-depth anatomical knowledge. With so much clinical importance in this area, our study will present a thorough understanding in terms of skull and CT values. The main aim of this study is to give the morphometric details of occipital condyles and foramen magnum in cadaveric skulls and CT scans. Seventy dried human skulls and 70 CT images on the three-dimensional volume-rendered reconstruction of the skull base was used for this study. The length and width of the occipital condyle of right and the left side was 22.21 \ensuremath{\pm}5.20 mm; 22.05\ensuremath{\pm}4.83 mm; 12.57 \ensuremath{\pm} 2.50 and 12.68 \ensuremath{\pm} 2.92 mm respectively in cadaver skull. The length and width of occipital condyles in CT scans for right and left side was 21.61 \ensuremath{\pm} 3.09 mm; 21.58 \ensuremath{\pm} 3.50 mm; 13.04 \ensuremath{\pm} 1.58 mm and 13.13 \ensuremath{\pm} 2.54 mm respectively. The Anteroposterior and transverse diameters of the foramen magnum in cadaveric skulls and CT images was 33.17 \ensuremath{\pm} 7.23; 29.22 \ensuremath{\pm} 6.17; 34.15 \ensuremath{\pm} 2.88 and 28.14 \ensuremath{\pm} 2.43 mm respectively. Each surgical approach and the radiological diagnostic procedures have their limitations. Moreover, analysis of cranial base dimensions of occipital condyles and foramen magnum can be considered as a reliable method for sex determination. Hence this study will a useful guide for surgeons, radiologists, anthropologists and forensic experts.
\end{abstract}\def\keywordstitle{Keywords}

\begin{keywords}Craniovertebral junction,\newline cadaveric skull,\newline foramen magnum,\newline morphology,\newline occipital condyles
\end{keywords}
\twocolumn[ \maketitle {\printKwdAbsBox}]
\makeatletter{\raggedright\textsuperscript{*}Corresponding Author\par Name:\ Sharmila~Aristotle~\\ Phone:\ +919790807674~\\  Email:\ drsharmiaris@gmail.com
        \par}\vspace*{-11pt}\hrulefill\par{\fontsize{12}{14}\selectfont ISSN: 0975-7538}\par% 
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\section{Introduction}
The base of the skull is such a complex region with numerous foramina through which several vital structures have access to the closed cranium. Awareness about the various foramina and the anatomical landmarks is essential while planning multiple surgical approaches for reaching the middle and posterior cranial base \unskip~\citep{828053:19795328}. However, the study of the foramina becomes an integral part of the anthropologist for the study of significant change in size and shape during the evolution \unskip~\citep{828053:19795335}.

Tumours of the foramen magnum and other Craniovertebral junction surgeries can be approached both ventrally and dorsally, the safest of both these is the dorsal approach which is highly preferred at the craniovertebral junction. The maximum extent of the condylar resection is unclear, ranging from suboccipital craniotomy to total occipital condyle removal. Hence dimensional anatomy of occipital condyle has a vital role in minimizing the complications of the surgical procedures \unskip~\citep{828053:19795323}.

The dimensions are not only crucial in establishing safe operational techniques but also to evaluate and analyze the age, gender, stature, and ethnicity. Discrimination functional analysis of foramen magnum is of great help in anthropologic and forensic techniques \unskip~\citep{828053:19795340}. This study aims to evaluate the morphometric analysis of occipital condyles and the Foramen magnum in the posterior skull base and its surgical importance.
    
\section{Materials and Methods}
The study was carried out after getting Institutional Ethical committee clearance. Reference no:1162/IEC/2017. Adult cadaveric skulls 70 and 70 CT scans of patients who underwent an examination of the skull region for various reasons were used for these studies. Measurements were taken for both sides. All the cadaveric skulls were collected from the department of anatomy and the department of Forensic medicine. CT scan studies were obtained from the Department of Radiology SRM Medical college hospital and research centre Chennai. All the skulls selected were of south Indian origin, and the damaged skulls in the base were excluded for this study. CT skull images studied were of high resolution 0.6 mm slice thickness. Patients with a history of trauma, surgery, pathological lesions with poor image quality were excluded from this study.


\begin{table*}[!htbp]
\caption{\boldmath {Measurements of parameters for cadaveric skull and CT scan} }
\label{tw-212c2238ab08}
\centering 
\begin{threeparttable}

\def\arraystretch{1.1}
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\centering 
\begin{tabulary}{\linewidth}{p{\dimexpr.242\linewidth-2\tabcolsep}p{\dimexpr.26\linewidth-2\tabcolsep}p{\dimexpr.2761\linewidth-2\tabcolsep}p{\dimexpr.2219\linewidth-2\tabcolsep}}
\tbltoprule \rowcolor{kwdboxcolor}Parameter & Skull(n70) \mbox{}\protect\newline Mean and SD in mm & CT(n70) \mbox{}\protect\newline Mean and SD in mm &  P-value\\
\tblmidrule 
OC-length-R &
  22.21 \ensuremath{\pm} 5.20 &
  21.61 \ensuremath{\pm} 3.09 &
  0.409\\
OC-length-L &
  22.05 \ensuremath{\pm} 4.83 &
  21.58 \ensuremath{\pm} 3.50 &
  0.515\\
OC-width-R &
  12.57 \ensuremath{\pm} 2.50 &
  13.04 \ensuremath{\pm} 1.58 &
  0.186\\
OC-width-L &
  12.68 \ensuremath{\pm} 2.92 &
  13.13 \ensuremath{\pm} 2.54 &
  0.335\\
FM-AP &
  33.17 \ensuremath{\pm} 7.23 &
  34.15 \ensuremath{\pm} 2.88 &
  0.295\\
FM-T &
  29.22 \ensuremath{\pm} 6.17 &
  28.14 \ensuremath{\pm} 2.43 &
  0.175\\
\tblbottomrule 
\end{tabulary}\par 
\begin{tablenotes}\footnotesize 
    
\item{OC-occipitalcondyles; FM-Foramen Magnum; AP-anteroposterior; }
    
\item{T-transverse diameter;R-Right;L-left}
\end{tablenotes}
\end{threeparttable}

\end{table*}

\begin{table*}[!htbp]
\caption{\boldmath {Comparison of cadaveric skull and CT scan for right and left side} }
\label{tw-4912c2673034}
\centering 
\begin{threeparttable}

\def\arraystretch{1.1}
\ignorespaces 
\centering 
\begin{tabulary}{\linewidth}{p{\dimexpr.12850000000000001\linewidth-2\tabcolsep}p{\dimexpr.1595\linewidth-2\tabcolsep}p{\dimexpr.16869999999999997\linewidth-2\tabcolsep}p{\dimexpr.0827\linewidth-2\tabcolsep}p{\dimexpr.16749999999999996\linewidth-2\tabcolsep}p{\dimexpr.1812\linewidth-2\tabcolsep}p{\dimexpr.11190000000000001\linewidth-2\tabcolsep}}
\tbltoprule \rowcolor{kwdboxcolor} & \multicolumn{3}{p{\dimexpr(.4108999999999999\linewidth-2\tabcolsep)}}{Skull (mm)} & \multicolumn{3}{p{\dimexpr(.4606\linewidth-2\tabcolsep)}}{CT(mm)}\\
\rowcolor{kwdboxcolor}Parameters & Right (mm) & Left  & P & Right & Left & P\\
\tblmidrule 
OC-L &
  22.21 \ensuremath{\pm} 5.20 &
  22.05 \ensuremath{\pm} 4.83 &
  0.852 &
  21.61 \ensuremath{\pm} 3.09 &
  21.58 \ensuremath{\pm} 3.50 &
  0.963\\
OC-W &
  12.57 \ensuremath{\pm} 2.50 &
  12.68 \ensuremath{\pm} 2.92 &
  0.816 &
  13.04 \ensuremath{\pm} 1.58 &
  13.13 \ensuremath{\pm} 2.54 &
  0.811\\
\tblbottomrule 
\end{tabulary}\par 
\begin{tablenotes}\footnotesize 
    
\item{OC-occipitalcondyles; L-Length; W-width}
\end{tablenotes}
\end{threeparttable}

\end{table*}

\bgroup
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\centering \makeatletter\IfFileExists{images/ec9436ea-5fe9-479f-b350-3a8c5635068c-upicture1.png}{\includegraphics{images/ec9436ea-5fe9-479f-b350-3a8c5635068c-upicture1.png}}{}
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\caption{\boldmath {Cadaveric skull showing measurements of occipital condyles and foramen magnum in Digimizer}}
\label{f-177cef289bf4}
\end{figure}
\egroup

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\caption{\boldmath {Three-dimensional volume-rendered reconstruction of the skull base using thin-slice computed tomography (CT)}}
\label{f-d3f2e93a120b}
\end{figure}
\egroup
Morphometric measurements of the occipital condyles were recorded for its length, width, Foramen magnum dimensions were measured for its anteroposterior diameter and transverse diameter.   For skulls, measurements were taken using the digital image analysis program known as Digimizer Software version 4 .3.0. The pictures captured were calibrated before measuring the parameters under the same position with a regular grid sheet. Figure~\ref{f-177cef289bf4}. CT skull images obtained were of 0.6-mm-thin sections. The raw data collected were reformatted in the axial, coronal, and sagittal plane, and then three-dimensional images were created using the Radiant software version5.5.0. Figure~\ref{f-d3f2e93a120b}.

Statistical analysis:Data analysis was done using SPSS software version 20.0 Student's t-test was performed to analyze between the right and left condylar parameters and comparison between the CT and the Skull values was also done. Significance was considered if p{\textless}0.05. 
    
\section{Results and Discussion}
The outcome of our study is summarized in the following tables (Table~\ref{tw-212c2238ab08} and Table~\ref{tw-4912c2673034}).

The right and left side measurements were tested for significance, and no significant differences were noted. Similarly, there is no significant difference between the skull and CT measurements (p{\textgreater}0.05).

The Trans condylar approach is a complex skull base approach that is used to reach the craniocervical junction (CVJ), the foramen magnum and the brainstem. CVJ is in close relationship with vital structures, and therefore, surgeries involved in this area include potential complications \unskip~\citep{828053:19795329}.   Detailed knowledge of condylar and foramen magnum dimensions helps the surgeon in making important decisions for deciding the type of approach and the extent of condylar drilling to be carried out to minimize the injury of neural structures. The condylar width plays an important factor in assessing the screw placement in occipital condylectomy.

In our study, the sagittal length of cadaver skull right and left side was 22.21 \ensuremath{\pm} 5.20, and 22.05 \ensuremath{\pm} 4.83 mm which coincides with the values of \unskip~\cite{828053:19795320}  and \unskip~\cite{828053:19795336}  with results of 22.90\ensuremath{\pm}3.11; 22.60\ensuremath{\pm}2.72 and 23.44 \ensuremath{\pm}2.60; 23.49 \ensuremath{\pm}2.71mm. Notably, this value was even higher than the length of 19.43\ensuremath{\pm}3.27mm, 19.28\ensuremath{\pm}3.57 mm as reported by \unskip~\cite{828053:19795332}.

In our study, the width of right occipital condyles for the cadaveric skull was 12.57 \ensuremath{\pm} 2.50 and left occipital condyles were 12.68 \ensuremath{\pm} 2.92 mm. These values correspond to the study of  \unskip~\cite{828053:19795320}  of 12.98\ensuremath{\pm}1.62mm and 12.97\ensuremath{\pm}1.46 mm and \unskip~\cite{828053:19795337}  of 12.39 mm and 12.37 mm, respectively.  Whereas \unskip~\cite{828053:19795321}  observed the width of occipital condyles as 11.77\ensuremath{\pm}1.52 mm and 11.85-\ensuremath{\pm}1.63 mm, which is slightly lower than our study. Besides,it coincides with \unskip~\cite{828053:19795338}  of 12.2\ensuremath{\pm}1.25 and 12.2 \ensuremath{\pm}1.33 mm. However,our values highly contradicted with \unskip~\cite{828053:19795332}  with much lower values of 9.21\ensuremath{\pm}1.97 and 9.40\ensuremath{\pm}1.87mm right and left side respectively with a higher value observed in \unskip~\cite{828053:19795329}  study of 13.72\ensuremath{\pm}1.56 and 13.96\ensuremath{\pm}1.82 mm.

The mean condylar length for right and left side on CT scans in our study was 21.61 \ensuremath{\pm} 3.09 and 21.58 \ensuremath{\pm} 3.50mm, which was slightly lower when compared to values reported by \unskip~\cite{828053:19795324}  and \unskip~\cite{828053:19795322}  of 18.7 1.7,18.6 \ensuremath{\pm}1.7,18.6 and 19.9\ensuremath{\pm}2.4,19.4\ensuremath{\pm}2.7mm. Highly coincides with the study of \unskip~\cite{828053:19795326}  with 21.41\ensuremath{\pm}2.05,21.50 \ensuremath{\pm}2.19 mm and \unskip~\cite{828053:19795329}  of 22.61\ensuremath{\pm}2.3,22.36\ensuremath{\pm}2.3 mm. There are not many variations observed in the width of occipital condyles in our study, and by the authors mentioned above. The main focus for extensive investigation of the morphometry of occipital condyles was for the placement of occipital condylar screws \unskip~\citep{828053:19795342}.

The anteroposterior and transverse diameter of the foramen magnum for the cadaveric skull in our study was noted as 33.17 \ensuremath{\pm} 7.23 and 29.22 \ensuremath{\pm} 6. 1mm. All the metric variables assessed in the present study for foramen magnum were found to have similar values with the previous studies as reported by \unskip~\cite{828053:19795341} of  33.3and 27.9 mm and \unskip~\cite{828053:19795327}  of 33.9 and 28.7 mm. However, the transverse diameter was noted to be smaller in our study to that of \unskip~\cite{828053:19795343}  which described values of 33.57 and 27.49 mm. \unskip~\cite{828053:19795331}  observed the anteroposterior diameter as35.3 and transverse diameter as 29.49 mm, which is very closeto our values.Nevertheless, \unskip~\cite{828053:19795325}  reported more extensive areas of the foramen magnum in the transverse diameter of 32 mm significantly when compared to our study. 

Similarly, the CT scan results of our study for anteroposterior and transverse diameters were 34.15 \ensuremath{\pm} 2.88 mm and 28.14 \ensuremath{\pm} 2.43mm, respectively. Notably, these values were even higher than the mean anteroposterior and transverse diameters as observed by \unskip~\cite{828053:19795340}  and \unskip~\cite{828053:19795326}  as 31.64\ensuremath{\pm}2.8 and 26.13\ensuremath{\pm}2.6mm. And 38.5\ensuremath{\pm}3.22,31.57\ensuremath{\pm}2.62mm, respectively. Similar values were found with \unskip~\cite{828053:19795333}  of 33.9 \ensuremath{\pm}2.61, 28.05\ensuremath{\pm}2.22 mm and \unskip~\cite{828053:19795334}  of 33.1\ensuremath{\pm}2.61, 28.05\ensuremath{\pm}2.22 mm.

The difference in morphometric measurements of different studies could contribute to the different angulations of the occipital condyles relative to the sagittal plane. The larger the sagittal intercondylar angles, the more considerable intercondylar distances were noted \unskip~\citep{828053:19795330}. Moreover, the difference could also be associated with the varying prevalence of Occipital condyle overriding into the foramen magnum. The presence of wider intercondylar distances is advantageous in accessing ventral craniovertebral junction lesions,which demands less extensive bony resection for both suboccipital and occipital condylectomy. 
    
\section{Conclusion}
Analysis of the various parameters from this study concludes that there is no significant difference between the cadaveric skulls and CT skull measurements. Besides, the data obtained from anatomical and radiological studies did not differ statistically in the sides also.Understanding the knowledge of anatomy simplifies the understanding of underlying pathological lesions. Moreover, the dimensions of the foramen magnum and occipital condyle canbe usedfor performingtranscondylar approaches for reaching the middle and posterior cranial base surgeries. Hence, this study concludes that preoperative morphometric assessment is mandatory forknowingthe feasibility of occipital condyle in screw fixation.To add up these dimensions will also throw light for the sex determination, thus contributing to new research in the field of anthropology and forensic sciences.
    
\section{Acknowledgement}
The author thanks the SRM institute of science and technology for providing adequate support for the study. Besides, the faculties of Radiology who guided a lot in this study.

\textbf{Source of Funding Support}

Nil

\textbf{Conflict of Interest}

None declared.


    

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