A Multilayered Technique for the Repair of a Suboccipital Retrosigmoid Craniotomy

Background The retrosigmoid suboccipital craniotomy is a commonly used surgical corridor to the cerebellopontine angle. Despite its frequent utilization among neurosurgeons, there remains no standardized repair technique for this craniotomy. The risks of this approach include postoperative cerebrospinal fluid (CSF) leak, persistent suboccipital headaches, and wound infections. We report our institutional experience performing a multilayered anatomic repair of the retrosigmoid suboccipital craniotomy.

Methods A retrospective chart review was performed in 25 consecutive patients who underwent retrosigmoid suboccipital craniotomy, to evaluate for incidence of postoperative headache, CSF leak, or wound infection. All patients underwent a retrosigmoid approach in the lateral “park bench” position, using a linear incision within the hair-bearing scalp. A 14- to 18-mm craniectomy was performed using a high-speed drill, with bone dust saved in antibiotic saline for subsequent repair ([Fig. 1A]). Any exposed mastoid air cells were obliterated with bone wax during the approach and again prior to final repair. The dura was opened in a C-shape and reflected laterally toward the transverse sinus. After completing the intradural portion of the operation, the dura was primarily repaired using interrupted 4–0 braided nylon suture ([Fig. 1B]). A collagen onlay was then placed on the top of the dural repair ([Fig. 1C]), followed by Surgicel (Ethicon) ([Fig. 1D]), then autologous bone chips/dust from the craniectomy ([Fig. 1E], [F]), followed by a second outer layer of Surgicel (Ethicon) to secure the bone in place ([Fig. 1G]). A titanium burr hole plate was then placed over the entire defect ([Fig. 1H]). Muscle layers were reapproximated individually using 3–0 Vicryl sutures. The deep fascia and dermis were reapproximated using 3–0 Vicryl sutures, and a simple running 4–0 nylon suture was used to close the skin. The wound was dressed with bacitracin ointment, a nonadhesive gauze covering, and tape. Dressings were left in place for 48 hours, and then patients were instructed to shower daily and apply no ointments to the incision.

Fig. 1 Panels (A–H) depict a step-by-step demonstration of the cranioplasty technique describe in this abstract.

Results A consecutive series of 25 patients with a mean follow-up time of 16 months was included in this study. Of the 25 patients retrospectively reviewed, 2 patients (8%) reported persistent suboccipital headaches. None of the patients in this series developed CSF leak or wound infections. Outcomes were similar to those reported in previous clinical series.

Conclusion A multilayered anatomic repair after retrosigmoid suboccipital craniotomy results in favorable clinical results and may reduce the risks associated with this operation.