Decompressive craniectomy incisions: all roads lead to bone

Abstract

Introduction

Decompressive craniectomy and craniotomy are among the most common procedures in Neurosurgery. In recent years, increased attention has focused on the relationships between incision type, extent of decompression, vascular supply to the scalp, cosmetic outcomes, and complications. Here, we review the current literature on scalp incisions for large unilateral front-temporo-parietal craniotomies and craniectomies.

Methods

Publications in the past 50 years on scalp incisions used for front-temporo-parietal craniectomies/craniotomies were reviewed. Only full texts were considered in the final analysis. A total of 27 studies that met the criteria were considered for the final manuscript. PRISMA guidelines were adopted for this study.

Results

Five main incision types have been described. In addition to the question mark incision, other common incisions include the T-Kempe, developed to obtain wide access to the skull, the retroauricular incision, designed to spare the occipital branch, as well as the N-shaped and cloverleaf incisions which integrate with pterional approaches. Advantages and drawbacks, integration with existing incisions, relationships with the main arteries, cosmetic outcomes, and risks of wound complications including dehiscence, necrosis, and infection were assessed.

Discussion

The reverse-question mark incision, despite being a mainstay of trauma neurosurgery, can place the vascular supply to the scalp at risk and favor wound dehiscence and infection. Several incisions, such as the T-Kempe, retroauricular, N-shaped, and cloverleaf approaches have been developed to preserve the main vessels supplying the scalp. Incision choice needs to be carefully weighted based on the patient’s anatomy, position and size of main vessels, risk of wound dehiscence, and desired volume of decompression.

Keywords:

• Decompressive hemicraniectomy
• skin incision
• reverse question mark
• retroauricular

Acknowledgments

We thank the Shock Trauma Center for the support and guidance throughout the entire project.

Author contributions

RS acquired, analyzed, interpreted the data, and wrote the manuscript. RS and TC provided review and editing, and wrote the manuscript. All authors approved the final version of the manuscript.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Data availability statement

All data and materials included in these studies will be freely shared with any interested party. The data that support the findings of this study are available from the authors.

Additional information

Funding

There was no funding provided for this research except for the technical support of the Shock Trauma Center and the Department of Neurosurgery, University of Maryland School of Medicine.