Basic Cranial Approaches

Midline suboccipital craniotomy

1. Soft tissue dissection
Midline suboccipital craniotomy. Soft tissue dissection. The most important part of the dissection is identification of the midline, which can be done by a small transverse incision of the fascia, thus exposing the midline nuchal ligament and the attachments of the trapezius muscle bilaterally.
2. Bone exposure
The dissection is done to the occipital bone with subperiosteal dissection of the C1 posterior arch. It is preferrable not to detach the muscles attachments on the C2 spinous process unless C2 laminectomy is required.
3. Craniotomy
Suboccipital craniectomy is done exposing the suboccipital dura.
4. Cerebellum exposure
C-shaped dural incision exposing the cerebellum, vermis and cerebellar tonsils. Care should be taken to properly ligate the cerebellar sinus on the midline in order to avoid excessive bleeding.