Wound dehiscence from a prominent external occipital protuberance: An indication for prophylactic drilling?

Background Wound complications including CSF leaks, pseudomeningoceles, and infections after a craniotomy is a known risk, but dehiscence after suboccipital approaches remain a rare event. Objective Here we present a patient whose exceptionally prominent external occipital protuberance caused wound breakdown after a suboccipital craniotomy, and suggest that prophylactic drilling of this protuberance would have prevented this complication. Methods A 52 year old male on Aspirin and Plavix presents with sudden onset headache, nausea, and vomiting, with a computed tomography (CT) scan of the head showing a 60 cm³ right cerebellar hemorrhage. He underwent a suboccipital paramedian craniotomy for hematoma evacuation, and external ventricular drain placement. His hospitalization was complicated by respiratory failure, pneumonia, bacteremia, and finally sterile wound breakdown over his prominent external occipital protuberance 5 weeks after his initial operation. Results The wound was debrided and his 14 mm tall occipital protuberance drilled flush allowing for excellent healing without further complications. Conclusion While the incidence of prominent external occipital protuberances is unknown, we suggest that surgeons consider prophylactic drilling of this prominence or making a paramedian incision when performing suboccipital approaches to prevent subsequent wound complications.