Surgical treatment of ventral tumors of the greater occipital foramen requires rigorous exposure of the surgical approach and intraoperative management of the vertebral artery and nerve roots. It is most commonly seen clinically with meningioma. The presentation mostly starts with discomfort in the neck and gradually develops hoarseness, low tone, dysphagia, choking, chest girdling sensation, and weakness of the extremities. Physical examination reveals: hypopharyngeal reflex or loss of pharyngeal reflex, dysphonia, deviation of the uvula, weakness of the sternocleidomastoid and trapezius muscles, deviation of the tongue extension, hypotonia of one or all four limbs, atrophy of the shoulder girdle muscle and upper limb muscles, and hyposensitivity of the superficial senses below the T2-5 plane. The diagnosis was established by MRI examination. Preoperatively, the tumor was located in the front of the brainstem at the base of the skull, and the tumor disappeared on postoperative review. A “C” incision was made behind the auricle, starting from the posterior aspect of the superior margin of the auricle, extending posteriorly and inferiorly in an arc, then turning anteriorly and ending above the midpoint of the sternocleidomastoid muscle. The skin is incised and the trapezius, cephalic, cervical and scapular muscles are disconnected from the occipital bone and turned anteriorly and inferiorly to reveal the suboccipital triangle formed by the posterior rectus, inferior oblique and superior oblique muscles. In this triangle, the vertebral artery running below can be found. The attachment point of the posterior rectus major muscle is severed from the occipital bone, which is free and turned posteriorly; the attachment point of the inferior oblique muscle is severed from the C1 transverse process, which is free and turned posteriorly; the attachment point of the superior oblique muscle is severed from the occipital bone and turned anteriorly. At this point, the vertebral artery, which had passed through the C1 transverse foramen, was wrapped by the venous plexus and traveled posteriorly about 2 cm into the vertebral artery sulcus, folding inward and crossing the dura mater into the skull. The vertebral artery was pushed out along the vertebral artery sulcus under the periosteum, the C1 hemiposterior arch was freed and occluded, and the occipital foramen was opened by occluding the occipital scales. If the main body of the tumor reaches the level of the pontine brain, part of the mastoid should also be removed to reveal the sigmoid sinus and its anterior part. The dura mater is cut and suspended in “Y”, and the dura mater is retracted anteriorly along with the vertebral artery to fully expose the tumor in the occipital foramen. The arachnoid membrane on the surface of the tumor and nerve is sharply dissected, and the CN and C1 nerve roots are seen often traveling on the outer surface of the tumor. After freeing the nerve with a nerve stripper, the base of the tumor attached to the dura mater was eradicated and the blood supply was disconnected, and the tumor was removed in pieces or whole pieces. The posterior approach to the inferior occipital sigmoid sinus and the posterior cervical approach are commonly used in previous surgeries for lesions in the occipital foramen, which have greater limitations in revealing the ventral side of the occipital foramen. In addition, most of the ipsilateral cervical nerve, Ⅸ, Ⅹ, Ⅺ, Ⅻ cranial nerve and intracranial segment of vertebral A are located on the surface of the tumor and facing the operator. After using the distal lateral approach, the operator can directly view the ventral and contralateral regions of the foramen magnum from the lateral side of the lower brainstem in a tangential line, which can fully expose the lesion and shorten the surgical path by about 2~3Cm, increase the view angle by at least 15~20o, and significantly expand the surgical field than the posterior suboccipital sigmoid sinus approach. The intracranial segment of vertebral A and ipsilateral cervical nerve, Ⅸ, X, D, Ⅻ cranial nerve can be viewed directly, so that the base of the tumor can be removed directly under direct vision, thus disconnecting the blood supply of the tumor and facilitating the surgical resection of the tumor, while avoiding and reducing nerve and vascular injury, and even if there is injury, there are conditions for intraoperative anastomosis or repair. By using the distal lateral approach to resect the tumor, there is no other medical nerve injury except for the sacrifice of the paramedian nerve on the surface of the tumor because it affects the operation, and the patients have good surgical efficacy and their preoperative symptoms are significantly improved or disappeared. The distal lateral approach can expand the operative field and increase the exposure by grinding away the occipital condyle and lateral block. Especially when the tumor is large and grows to the contralateral side, the advantages of this approach can be fully reflected. The length of occipital condyles is about 30+/-4 mm, and for each 1 mm of occipital condyles removal, the view can be enlarged ventrally by about 2.4o, for 1/3 of occipital condyles removal, the view can be enlarged by 15.9o, and for 1/2 of occipital condyles removal, the view can be enlarged by 19.9o. When the anterior-posterior diameter of the tumor is relatively large and the brainstem is obviously pushed backward, the operative field can be manipulated more, and the range of occipital condyles removal can be relatively reduced, and vice versa, the range of occipital condyles removal should be relatively enlarged. On the contrary, the scope of occipital condyle grinding should be enlarged. The atlanto-occipital joint capsule should be opened before grinding, and the occipital condyles can be hollowed out internally before the cortical part is removed with bone biting forceps. Since grinding the occipital condyles and C1 lateral block destroys the atlanto-occipital joint and affects the stability of the cranio-occipital junction area, it is necessary to consider both grinding to increase the exposure of the tumor and caution so as not to cause stability problems. When grinding the occipital condyle more than 1/2, bone grafting and fixation are required. In this group of cases, the grinding range was within 1 cm and did not exceed 1/2 of the length of the occipital condyle. We believe that the tumor was well exposed to meet the surgical needs, and all patients did not have bone grafting, and the patients recovered well after surgery without stability problems. The management of the vertebral artery during surgery is crucial. The average distance from the transverse foramen to the dura mater is 22+/-3 mm, and the average distance from the vertebral artery through the dura mater to the branch of the posterior inferior cerebellar artery is 17+/-8 mm, and exposure of this segment of the vertebral artery must minimize damage. When exposing and freeing the extracranial segment of the vertebral artery, it is important to first identify the suboccipital triangle composed of the posterior superior rectus, superior oblique, and inferior oblique muscles, under which the vertebral artery travels. When separating the part of the vertebral artery that is located in the sulcus, it should be done posteriorly and forward under the periosteum, and the periosteum and vertebral artery should be pushed together inward and upward. The extracranial segment of the vertebral artery is often encircled by a venous plexus, which often causes troublesome plexus hemorrhage during exposure and can be stopped with gelatin sponge compression and bipolar electrocoagulation. Unless necessary, the vertebral artery can also be separated together with the venous plexus without opening the plexus to reduce surgical bleeding; identification and treatment of the intracranial segment of the vertebral artery is very important. The arachnoid membrane between the tumor and vertebral artery can be sharply separated and the vertebral artery can be freed by following the path of the vertebral artery. When the tumor is large, grows posteriorly and encircles the vertebral artery, its entry into the subdural origin can be inferred from the site where the vertebral artery penetrates into the dura mater from the epidural, and then the base can be eradicated from the cephalic and caudal ends of the origin, respectively, and when the vertebral artery is approached, the tumor can be sharply dissected dorsally by following the general course of the vertebral artery, firstly revealing and freeing the dorsal side of the vertebral artery, and then bypassing the vertebral artery from the cephalic and caudal ends, respectively. The ventral portion of the vertebral artery can be removed by eradicating the tumor ventral to the vertebral artery. When reaching the contralateral side, care must be taken to prevent injury to the contralateral vertebral artery. Care and caution should be exercised during operations involving the vertebral artery, and any rupture should be repaired immediately and properly. Most meningiomas are swollen, compressive growths with clear borders with the surrounding nerve roots, medulla oblongata, and cervical medulla. Even if there are local adhesions due to long-term compression, the tumor can be separated from the neural tissues as long as the operation is performed strictly at the arachnoid interface. In this group of cases, before removing the tumor, the arachnoid membrane on the surface of the tumor was sharply cut, and the nerve roots on the surface of the tumor were free and medially retracted. If the sensory roots of the spinal branch of the paramedian nerve or C1 nerve still obviously affect the operation, they can be considered to be cut off. If the posterior group of cranial nerves is encircled by the tumor or pushed posteriorly at the place where the dura mater is penetrated, the tumor can be removed from the cephalic and caudal ends respectively, and then the tumor on the ventral side of the nerve can be “hollowed out”, so as to protect the nerve. The separation of tumor from brainstem or cervical medulla should be performed under the condition of low intracranial pressure. If the tumor is large, lumbar puncture can be performed before surgery and intraoperative fluid can be released to remove the tumor in pieces or within the tumor. After the “intracranial pressure” of the tumor is reduced, the arachnoid interface between the tumor and brainstem and cervical medulla can be revealed by holding the tumor skin to the outside and sharp incision can be made to free and remove the tumor smoothly and protect the brainstem and cervical medulla intact at the same time. At the end of the surgery, the dura mater should be tightly sutured. If it is difficult to suture, autologous fascia or biofilm can be used to repair the tumor, and bioadhesive can be applied to reduce the leakage of cerebrospinal fluid. Because of the large amount of muscle tissue cut/cut in this approach, if the dura mater is not sutured tightly enough, local fluid accumulation may easily cause infection, which needs to be treated with caution.