Postoperative headache after the lateral suboccipital approach: craniotomy versus craniectomy

The lateral suboccipital approach to the cerebellopontine angle is typically performed as a small craniectomy. Incisional pain and headache following cerebellopontine angle surgery have been reported. Adherence of the cervical muscles to the dura, which is richly innervated, with consequent traction has been suggested to be responsible for postoperative headache. Therefore, postoperative headache probably could be reduced by replacing the bone flap between the muscles and the dura. In a prospective non-randomized study this hypothesis was tested by comparing craniectomy and craniotomy. 40 patients underwent removal of an acoustic neuroma via the retrosigmoid approach. Patients with a history of migraine, with additional intracerebral tumors or recurrencies as well as patients who developed a CSF fistula postoperatively were excluded. 29 patients were eligible for further evaluation. 13 patients underwent a craniotomy, 16 patients a craniectomy. All patients were subject to a standardized telephone interview three months and one year after surgery. Comparing the craniotomy group to the craniectomy group no difference was observed regarding age, sex, tumor size and duration of operation. 3 months as well as 12 months postoperatively headache was significantly (p < 0.05) less frequent in the craniotomy group as compared to the craniectomy group. In conclusion, an osteoplastic craniotomy significantly reduces postoperative headache and is therefore highly recommended.