C-shaped Incision for Far-Lateral Suboccipital Approach: Anatomical Study and Clinical Correlation.

Background The standard incision for far-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. We hypothesize that the C-shaped incision can minimize the amount of muscle dissection and provide optimal exposure and surgical outcomes. Objective To describe the anatomical dissection for the C-shaped incision and clinical application of the C-shaped incision for the far-lateral approach. Methods A retrospective analysis of all the patients operated on at our center using this approach for the treatment of aneurysm of the posterior inferior cerebellar artery (PICA) from 2005 to 2011. Results of clinical and operative outcome are evaluated. Surgical techniques are described in detail. Cadaveric dissections using the C-shaped incision were performed to assess the exposure of the far-lateral suboccipital area. Results Eleven consecutive patients who had undergone this procedure were selected. All patients underwent clipping of PICA aneurysms. Nine patients (82%) presented with ruptured aneurysms and subarachnoid hemorrhage. All of them underwent suboccipital craniectomy and C1 laminectomy. The dura mater was closed in a watertight fashion in 10 patients (91%). No CSF leak or pseudomeningocele were reported. In nine SAH patients, two (22%) had postoperative dysphagia and required long-term percutaneous endoscopic gastrostomy tube placement. One patient (11%) had chronic respiratory failure and required a tracheostomy. Three patients (33%) developed hydrocephalus and required a ventriculoperitoneal shunt. Conclusions The C-shaped incision is a valid alternative to the classic reverse hockey-stick incision to gain exposure for far-lateral craniotomies. Knowing the anatomy and dissection techniques can provide an easy and safe route to address anterior lateral cranial-cervical lesions. Our results suggest the C-shaped incision is reliable in preventing CSF leak and the formation of pseudomeningocele.