Figure 7: Stepwise microscopic approach to craniovertebral junction by far-lateral approach. (a) Skin and subcutaneous tissue reflected exposing muscles attached to mastoid process and occipital bone. Sternocleidomastoid is seen moving forward and splenius capitis moving backward. (b) Superficial and deep muscles removed exposing transverse process of C1, C2 ganglion and vertebral artery. (c) Suboccipital craniectomy is done with the removal of foramen magnum and posterior elements of C1 and C2 vertebra. Occipitocervical joint and C1 C2 joints are exposed. Vertebral artery can be seen passing vertically than turning horizontally to enter intradurally. (d) Dura is opened in front of sigmoid sinus, cerebellum, and cervical spine. Supracondylar bone is drilled with jugular tubercle. Mastoidectomy has been done preserving the tip, and vertical mastoid segment of facial nerve is visible with the origin of chorda tympani nerve. Hypoglossal nerve is seen traveling along hypoglossal canal. Course of vertebral artery is visible from C3 vertebra onward. (e) Close-up view of dissection showing atlantoaxial joint in relation to C2 ganglion. Vertebral artery can be seen traveling across the arch of C1 to enter intracranially. (f) Cerebellum is retracted exposing intracranial path of lower cranial nerves. C2 gang, C2 ganglion; Dig ms, digastric muscle; Lo CN, lower cranial nerves; OC1 Jt, occipitocervical joint; Oc art, occipital artery; SCM, sternocleidomastoid; Sp cap, splenius capitis; VA, vertebral artery