Modified Skin Incision and Location of Burr-Hole Surgery via a Retrosigmoid Approach: An Anatomical Study

Abstract

Objective This study aims to reduce the tissue damage during craniotomy with retrosigmoid approach. A modified sickle-shaped skin incision was developed, and a new burr-hole positioning method was proposed.

Methods Five adult cadaveric heads (10 sides) were used in this study. The sickle-shaped skin incision was performed during craniotomy. The nerves, blood vessels, and muscles were observed and measured under a microscope. Additionally, 62 dry adult skull specimens (left sided, n = 35; right sided, n = 27) were used to measure the distance between the most commonly used locating point (asterion [Ast] point) and the posteroinferior point of the transverse sigmoid sinus junction (PSTS) (Ast-PSTS), as well as the distance between the new locating O point and the PSTS (O-PSTS). Then, the reliability of the new locating O point was validated on the same five adult cadaveric heads (10 sides) used for the sickle-shaped skin incision.

Results The sickle-shaped skin incision reduced the damage to the occipital nerves, blood vessels, and muscles during the surgery via a retrosigmoid approach. The dispersion and variability of O-PSTS were smaller than those of Ast-PSTS.

Conclusion The sickle-shaped skin incision of the retrosigmoid approach can reduce the tissue damage and can completely expose the structures in the cerebellopontine angle. The modified O point is a more reliable locating point for a burr-hole surgery than the Ast point.

Keywords

retrosigmoid approach - anatomy - burr-hole surgery - occipital nerve - suboccipital nerve - occipital artery - skull specimen

Ethics Approval

The study was approved by the Institutional Ethics Committee and performed in accordance with the 1964 Declaration of Helsinki and its later amendments or comparable ethical standards.

Publication History

Received: 22 October 2020

Accepted: 12 November 2021

Article published online:
16 January 2022

• References

• 1 Quiñones-Hinojosa A, Chang EF, Lawton MT. The extended retrosigmoid approach: an alternative to radical cranial base approaches for posterior fossa lesions. Neurosurgery 2006;58(4, suppl 2):ONS-208–ONS-214, discussion ONS-214
• 2 Samii M, Metwali H, Samii A, Gerganov V. Retrosigmoid intradural inframeatal approach: indications and technique. Neurosurgery 2013;73(1, Suppl Operative):ons53–ons59, discussion ons60
• 3 Samii M, Gerganov V, Samii A. Improved preservation of hearing and facial nerve function in vestibular schwannoma surgery via the retrosigmoid approach in a series of 200 patients. J Neurosurg 2006; 105 (04) 527-535
• 4 Gerganov VM, Hore N, Herold C. et al. Bilateral malignant melanoma metastases to the internal auditory canal/cerebellopontine angle: surgical management and preservation of function. J Neurosurg 2008; 108 (04) 803-807
• 5 Chen S, Zhang X, Lin F, Xu S, Li X, Ma X. A standard operating procedure of clean and fast craniotomy without application of Raney clips. J Craniofac Surg 2018; 29 (04) e353-e354
• 6 Alvernia JE, Fraser K, Lanzino G. The occipital artery: a microanatomical study. Neurosurgery 2006;58(1, Suppl):ONS114–ONS122, discussion ONS114–ONS122
• 7 Chibbaro S, Cebula H, Scibilia A. et al. Retrosigmoid approach: investigating the role of a C-shaped skin incision and muscle flaps in improving functional outcome and reducing postoperative pain. World Neurosurg 2018; 111: e340-e347
• 8 Chen F, Wen J, Li P. et al. Crutchlike incision along the mastoid groove and above the occipital artery protects the lesser occipital nerve and occipital artery in microvascular decompression surgery. World Neurosurg 2018; 120: e755-e761
• 9 Silverman DA, Hughes GB, Kinney SE, Lee JH. Technical modifications of suboccipital craniectomy for prevention of postoperative headache. Skull Base 2004; 14 (02) 77-84
• 10 Fujimaki T, Son JH, Takanashi S. et al. Preservation of the lesser occipital nerve during microvascular decompression for hemifacial spasm. Technical note. J Neurosurg 2007; 107 (06) 1235-1237
• 11 Tomasello F, Germanò A, Lavano A. et al. A novel technical refinement of microvascular decompression: pain relief and complication rate in a consecutive series of patients with trigeminal neuralgia. Oper Neurosurg (Hagerstown) 2020; 19 (03) 226-233
• 12 Tubbs RS, Fries FN, Kulwin C, Mortazavi MM, Loukas M, Cohen-Gadol AA. Modified skin incision for avoiding the lesser occipital nerve and occipital artery during retrosigmoid craniotomy: potential applications for enhancing operative working distance and angles while minimizing the risk of postoperative neuralgias and intraoperative hemorrhage. J Clin Neurosci 2016; 32: 83-87
• 13 Israel JS, Kempton SJ, Afifi AM. Prospective analysis of the greater occipital nerve location in patients undergoing occipital nerve decompression. Ann Plast Surg 2018; 81 (01) 71-74
• 14 Won HJ, Ji HJ, Song JK, Kim YD, Won HS. Topographical study of the trapezius muscle, greater occipital nerve, and occipital artery for facilitating blockade of the greater occipital nerve. PLoS One 2018; 13 (08) e0202448
• 15 Hirata S, Kobayashi M, Wakiya K, Fujimaki T. Preservation of the lesser occipital nerve prevents occipital sensory disturbance after microvascular decompression: long-term results. World Neurosurg 2020; 136: e126-e131
• 16 Tayebi Meybodi A, Gandhi S, Lawton MT, Preul MC. Anterior greater auricular point: novel anatomic landmark to facilitate harvesting of the greater auricular nerve. World Neurosurg 2018; 119: e64-e70
• 17 Khavanin N, Carl HM, Yang R, Dorafshar AH. Surgical “safe zone”: rapid anatomical identification of the lesser occipital nerve. J Reconstr Microsurg 2019; 35 (05) 341-345
• 18 Sharma VS, Stephens RE, Wright BW, Surek CC. What is the lobular branch of the great auricular nerve? Anatomical description and significance in rhytidectomy. Plast Reconstr Surg 2017; 139 (02) 371e-378e
• 19 Tayebi Meybodi A, Lawton MT, Moreira LB. et al. Retromastoid-transmuscular identification and harvest of the occipital artery during retrosigmoid craniotomy. J Neurosurg 2019; •••: 1-8
• 20 Benet A, Tabani H, Ding X. et al. The transperiosteal “inside-out” occipital artery harvesting technique. J Neurosurg 2018; 130 (01) 207-212
• 21 Babacan S, Yildiz-Yilmaz M, Kafa IM, Coşkun I. The surface and intracranial location of asterion. J Craniofac Surg 2019; 30 (08) e753-e755
• 22 Li RC, Liu JF, Li K. et al. Localization of anterosuperior point of transverse-sigmoid sinus junction using a reference coordinate system on lateral skull surface. Chin Med J (Engl) 2016; 129 (15) 1845-1849
• 23 Bozkurt B, Kalani MYS, Yağmurlu K. et al. Low retrosigmoid infratonsillar approach to lateral medullary lesions. World Neurosurg 2018; 111: 311-316
• 24 Tubbs RS, Loukas M, Shoja MM, Bellew MP, Cohen-Gadol AA. Surface landmarks for the junction between the transverse and sigmoid sinuses: application of the “strategic” burr hole for suboccipital craniotomy. Neurosurgery 2009;65(6, Suppl):37–41, discussion 41
• 25 Ribas GC, Rhoton Jr AL, Cruz OR, Peace D. Suboccipital burr holes and craniectomies. Neurosurg Focus 2005; 19 (02) E1
• 26 da Silva Jr EB, Leal AG, Milano JB, da Silva Jr LF, Clemente RS, Ramina R. Image-guided surgical planning using anatomical landmarks in the retrosigmoid approach. Acta Neurochir (Wien) 2010; 152 (05) 905-910