Lateral Thinking: A Historical Analysis of the Evolution of the Far Lateral Approach and Associated Bony Resection...

The anterior foramen magnum and craniovertebral junction region is surgically demanding because of its complex osseous and neurovascular architecture. Traditional midline posterior and transoral approaches are associated with significant morbidity, prompting the search for safer lateral corridors. The origins of the far lateral approach (FLA) date to 1972, when William Hammon and Ludwig Kempe described a lateral trajectory for accessing posterior circulation vascular lesions. In 1978, Wolfgang Seeger identified the jugular tubercle and medial occipital condyle as key anatomical constraints. Wolfgang Koos subsequently introduced a stability-preserving technique, emphasizing jugular tubercle drilling while avoiding condylar resection. In 1986, Roberto C. Heros standardized a reproducible lateral suboccipital approach combining lateral-caudal craniotomy, lateral foramen magnum rim removal, and selective C1 exposure to achieve an inferolateral view. In 1988, Bernard George postulated vertebral artery mobilization. The term "far lateral approach" was coined and systematized by Robert F. Spetzler in 1990, with further clinical adoption and refinement driven by Alan Crockard and Bernard George. Chandranath Sen, Laligam N. Sekhar, Helmut Bertalanffy, and Wolfgang Seeger also contributed technical refinements. Variations, including the extreme lateral and dorsolateral suboccipital transcondylar approaches, soon followed. In 1996, Toshio Matsushima emphasized condyle and atlanto-occipital joint-sparing techniques and defined the transcondylar fossa approach. Soon after, Albert Rhoton subcategorized the FLA as transcondylar, supracondylar, or paracondylar. Following decades of refinement, the FLA is now widely adopted, with ongoing modifications to optimize exposure while preserving neurological and biomechanical integrity. This study traces the historical evolution of the FLA into its modern variants.