A Stitch in Time Saves Nine: Retrosigmoid Craniotomy with Layered Suboccipital Muscle Dissection to Prevent...

Numerous modifications to the retrosigmoid craniotomy (RSC) have been reported, including variations in skin incision, soft tissue dissection, craniotomy, and closure techniques. This study aims to demonstrate a modified suboccipital muscle dissection technique for RSC with a detailed anatomical description and to assess its effectiveness in minimizing postoperative wound complications.

Between January 2011 and December 2024, 140 consecutive retrosigmoid craniotomies performed at our institute using the standardized layered muscle dissection technique were included. All these cases were retrospectively reviewed for wound-related complications, such as cerebrospinal fluid (CSF) leak, pseudomeningocele, and infection, requiring surgical intervention, as well as postoperative headache, including occipital neuralgia requiring medications.

The cohort included 63 males and 77 females, with vestibular schwannoma being the most common diagnosis (73.5%). A total of 92 patients underwent ventriculoperitoneal shunt before the definitive surgery. The tailored muscle dissection approach was applied uniformly in all the cases. Duroplasty was done in all cases, using pericranial grafts if needed, and in five cases, bone was not replaced due to intraoperative brain bulge. The mean follow-up duration was 40 months. Wound complications occurred in five patients (3.5%): two developed pseudomeningocoele, and three had CSF leak with infection. No patient required additional medication for postoperative surgical site-specific pain. Cosmetic results were favorable, with no wound contracture or muscle atrophy.

Understanding and respecting anatomical muscle layers during suboccipital dissection significantly reduce wound-related complications and postoperative morbidity. This sharp dissection technique with minimal coagulation is safe, reproducible, and practical, offering functional and cosmetic benefits.