C-Shaped Incision for Lateral Suboccipital Approach: Anatomical Study and Clinical Correlation

Objectives: The standard incision for lateral suboccipital approaches has been the classic “reverse hockey stick.” Although that incision provides ample exposure, concern has been raised that excessive muscle dissection and skin elevation might lead to accumulation of cerebrospinal fluid (CSF) under the flap with increased risk of CSF leak. Using the C-shape incision for lateral suboccipital approaches can minimize the amount of muscle dissection and still provide optimal exposure and surgical outcomes. Describing the real advantages and safety of this technique and generalizing the use of it can provide the general neurosurgeon with a more familiar incision and less morbid approach for lesions in this area.

Methods: Cadaveric dissections were performed and described in detail to assess the exposure of the lateral suboccipital area. An extensive retrospective analysis of all the patients operated on in our service using this approach was done. The results of the clinical and operative outcomes are evaluated.

Results: Seven consecutive patients who had undergone this procedure were selected. They all underwent clipping of posterior inferior cerebellar artery (PICA) aneurysms. Six (85%) patients presented with ruptured aneurysms and subarachnoid hemorrhage (SAH). All of them had a suboccipital craniectomy with C1 laminectomy done. The duramater was closed in a watertight fashion in all but one case (85%). No CSF leak or pseudomeningocele was reported. Two patients (30%) had postoperative dysphagia and required percutaneous endoscopic gastrostomy (PEG) tubes. One patient (15%) had chronic respiratory failure and required a tracheostomy. One patient (15%) developed hydrocephalus and required a ventriculoperitoneal shunt.

Conclusions: The C-shaped incision provides the same exposure and access to this difficult anatomical region. Knowing the anatomy and dissection technique can provide the general neurosurgeon with an easier and safer route to address lesions in this area. The results are very satisfactory and were prove to be a good option to achieve lower incidence of CSF leak and pseudomeningocele.