Headache after removal of vestibular schwannoma via the
retrosigmoid approach: A long-term follow-up-study
BERNHARD SCHALLER, MD, and ARIANE BAUMANN, MD,
OBJECTIVE: Our goal was to study the occurrence
and source of origin of postcraniotomy headache
syndrome after removal of vestibular schwannoma
via the retrosigmoid approach.
METHODS: A retrospective chart analysis was con-
ducted of all patients with headache at 3 months
after removal of vestibular schwannoma from Jan-
uary 1981 through March 1997 and with a minimum
of 24 months of follow-up. Diagnosis was made ac-
cording to the headache classification and was
graded using the HARNER scale. Recovery out-
come was compared in selected groups of patients
with and without headache. A descriptive statistical
analysis was used to analyze differences between
groups.
RESULTS: Of the patients who underwent retrosig-
moid craniotomy for removal of vestibular schwan-
nomas, 52 of 155 patients (34%) reported having
severe headache of requiring medication every
day and/or feeling incapacitated 3 months after
surgery. Headache was more prevalent in those
who had the bone flap replaced (94% versus 27%),
if there was duraplastic or direct dura closure (0%
versus 100%). Laboratory-proven aseptic meningi-
tis, most likely due to the use of fibrin glue and
drilling of posterior aspect of the internal auditory
canal, was mainly associated with postoperative
headache (81% versus 2%). In 75% of these cases,
calcifications along the brainstem had been noted.
CONCLUSION: The origin of postoperative head-
aches after retrosigmoid vestibular schwannoma
resections is not yet fully understood. Different fac-
tors may play a role in preventing or reducing
headache: dural adhesions to nuchal muscles or to
subcutaneous tissues and dural tension in the case
of direct dural closure may explain postoperative
headache from dural tension. Intradural drilling and
the use of fibrin glue may be the source of aseptic
Reprint requests: B. Schaller, MD, Max-Planck-Institute for
Neurological Research, Gleuelerstrasse 50, D-50931 Co-
logne, Germany; e-mail, Bernhard.Schaller@pet.mpin-
koeln.mpg.de.
Copyright © 2003 by the American Academy of Otolaryn-
gology–Head and Neck Surgery Foundation, Inc.
0194-5998/2003/$30.00 ⫹ 0
doi:10.1067/mhn.2003.104
Berne, Switzerland
meningitis as the etiology of persistent postopera-
tive headache. Prevention of postoperative head-
ache may include the replacement of bone flap at
the end of surgery, duraplastic instead of direct
dural closure, and prevention of the use of fibrin
glue or extensive drilling of the posterior aspect of
internal auditory canal. (Otolaryngol Head Neck
Surg 2003;128:387-395.)
T he evolution of postoperative care for patients
who have a vestibular schwannoma is increasingly
of interest. Before 1960, the possibility of removal
of the tumor from the patients was considered a
success. Now it is recommended that the tumor be
completely removed without any facial nerve
damage and that hearing be preserved whenever
possible. The surgical approach to the posterior
fossa has changed greatly during the past decades.
Different surgical approaches have been success-
fully applied to enable access to the cerebellopon-
tine angle for tumor removal: the suboccipital, the
middle fossa, the retrosigmoid, and the translaby-
rinthine approach.1,2 The discussion regarding
which approach may be better continues. The ret-
rosigmoid approach to the posterior fossa is a
modification of the traditional neurosurgical sub-
occipital craniotomy. It represents the most versa-
tile surgical approach for tumors of the cerebel-
lopontine angle1,3-8 and can be used for any size
tumor, from intracanalicular to 40 mm or more
from the porus.8 In dealing with larger tumors, the
skin incision may be lengthened to allow an infe-
rior craniotomy, and the superoinferior diameter
of the craniotomy may be extended to 50 mm or
more.8 The wide exposure of the posterior fossa
gives excellent visualization of the tumor bed and
the cranial nerves ranging from nerves V above,
IX, X, and XI below.8 In addition, posterior fossa
vessels are well visualized.8 At the present time,
the mortality rate for tumor resection in the cer-
ebellopontine angle is very low.6-9 Main risks in-
clude complete loss of auditory function in the
affected ear, facial nerve paralysis, worsened bal-
ance, other neurologic disabilities, infection, and
387

388 SCHALLER and BAUMANN
cerebrospinal fluid (CSF) leak.9,10 Recently, there
has been considerable debate regarding the rate of
postoperative headache resulting from the ret-
rosigmoid approach compared with the translaby-
rinthine and other skull base approaches. Several
authors indicate that the rate of headache is less
when the translabyrinthine approach is used.11-14
However, the origin of these headaches and the
difference in the incidence between the surgical
approaches have not been well characterized and
remain controversial. Despite recent investigations
on the origin and management of postoperative
headache, there remains a lack of complete under-
standing of their pathophysiology, how to prevent
their occurrence, and how to treat them success-
fully. In the present study, we evaluated retrospec-
tively the clinical/neurologic factors of postoper-
ative headache persisting 3 months or longer after
resection of vestibular schwannomas via the ret-
rosigmoid approach.
PATIENTS AND METHODS
Patient Population
We retrospectively reviewed the case histo-
ries of 167 patients with the histologic diagnosis
of vestibular schwannoma, which were operated
on by an otoneurosurgical team from January
1981 to March 1997 at the University Hospital
Basel. There were 64 women (51%) and 61 men
(49%). Their average age was 50 years (SD, 15
years; range, 14 to 75 years). Preoperatively, all
patients underwent vestibular testing (eye track-
ing test, optokinetic reflex, vestibulo-ocular re-
flex), audiologic testing (pure tone audiogram
[PTA], speech discrimination score [SDS],
brainstem auditory evoked potentials) and neu-
roradiologic examinations (computed tomogra-
phy [CT], magnetic resonance imaging [MRI],
or digital subtraction arteriography of cerebral
vessels).6
Tumor size was measured by the largest diam-
eter and categorized into small (⬍20 mm; n ⫽ 38;
30%), medium (20 to 30 mm; n ⫽ 41; 33%), or
large (⬎30 mm; n ⫽ 38; 30%). A fourth group
consisted of tumors exclusively localized in the
internal auditory canal (IAC) (n ⫽ 8; 7%). The
average tumor diameter was 30 mm (SD, 18 mm;
range, 5 to 70 mm). Hearing function was mea-
Otolaryngology–
Head and Neck Surgery
March 2003
sured by PTA (average hearing level at 250 and
500 Hz, 1.2 and 4 kHz) and SDS (maximum
score) and classified according to Gardner and
Robertson15: class I, PTA with 0 to 30 dB and SDS
with 70% to 100%; class II, PTA with 31 to 50 dB
and SDS with 69% to 50%; class III, PTA with 51
to 90 dB and SDS with 49% to 5%; class IV: PTA
with 91 to maximum loss and SDS with 4% to 1%;
and class V, PTA and SDS with no response.
Facial nerve function was classified according to
the House and Brackmann grading system.16 Pa-
tients were evaluated just before and 1 year after
surgery.
Detailed analysis of headache in all patients’
charts included principal location (eg, frontal, oc-
cipital), locality (eg, unilateral or bilateral, alter-
nating), projection (eg, arising from the neck pro-
jecting to frontal), quality (eg, pulsatile, pressing,
heightening), precipitation or aggravation (eg,
physical or mental activity, tiredness), and possi-
ble additional symptoms (eg, nausea, sensitivity to
light or noise). In addition, patients’ charts were
analyzed to establish whether patients had had
headache before the surgery, and if so, details of
its type and frequency was determined. Further-
more, patients were asked about medication pre-
scribed for their headache after surgery and
whether they were compliant. If headache was
sufficiently documented in a patient’s chart (fre-
quency of at least twice a week), diagnosis was
made according to the headache classification17
and was graded using the scale of Harner et al12:
grade 1, a relatively minor annoyance; grade 2,
headache present almost every day; grade 3, the
patient required medication every day; and grade
4, the patient felt incapacitated. All headache pa-
tients with grade 3 and 4 severity (n ⫽ 52) met the
diagnostic criteria for the postcraniotomy head-
ache syndrome.18 Objectively verified macro-
scopic surgery-related intracranial mass lesion, ep-
ileptic seizures, and bacterial infections or other
major complications of surgery were exclusion
criteria in 3 cases. Headaches that were present
before surgery and persisted afterward, such as
migraine headaches, tension headache, and postic-
tal headaches, were not considered as new head-
aches and were excluded from the present study
(n ⫽ 9).
Otolaryngology–
Head and Neck Surgery
Volume 128 Number 3
Table 1. General characteristics of the study groups
Headache group*
Characteristic
Gender, male
Side, left
Average age (range) (y)
Tumor size, average (mm)
Neurofibromatosis type 2
Preoperative headache
Symptomatic degenerative disease
of high cervical spine
Mean operative time (min)
*Persistent headache 3 months after surgery (HARNER grade 3 or 4).
Surgical Technique: Intraoperative
and Perioperative Management
For all patients, a retrosigmoid approach with
the patient in the supine position was used. The
surgical technique has been previously described
in detail.2 Intraoperative nerve integrity monitor-
ing of the facial nerve (Xomed NIM-2, Xomed-
Treace, Jacksonville, FL or Neurosign 100, Mag-
stim Teningen, Maxtim, Germany) and the
cochlear nerve (Nicolet Compact Four; Nicolet
Instruments, Madison, WI) was initiated on a rou-
tine basis in 1986 to the end of the study. Intra-
cranial dissection was carried out under micro-
scopic magnification (Zeiss/Contraves; Carl Zeiss,
Inc, Wetzikon, Switzerland). At the end of sur-
gery, the removed bone flap was replaced when-
ever possible. After surgery, patients were super-
vised in the intensive care unit for the first 24
hours and in the neurosurgical recovery room for
the next 24 to 72 hours.
Anesthetic Technique
Patients fasted for at least 6 hours and were
premedicated orally with midazolam before sur-
gery. Routine monitoring during surgery included
electrocardiography, heart rate (69; SD, 8; range,
56 to 92 beats/min), end-tidal concentration of
CO2 (PETCO2; range, 3.8 to 4.1 kPa) and isoflurane
(PETISO), pulse oximetry (O2 saturation ⬎96%),
and esophageal temperature (Spacelabs, Red-
mond, WA). An indwelling radial artery catheter
was inserted to allow continuous invasive mean
arterial blood pressure (79; SD, 14; range, 69 to
142 mm Hg) measurements and intermittent blood
gas level sampling. All hemodynamic parameters
SCHALLER and BAUMANN 389
No headache group
(n ⴝ 52) (n ⴝ 103)
19 (37%) 42 (41%)
28 (54%) 23 (22%)
49 (21-73) 50 (14-75)
29 33
2 (4%) 3 (3%)
10 (19%) 23 (22%)
3 (6%) 9 (9%)
407 353
were monitored continuously and recorded
throughout the surgical procedure.
Anesthesia was induced with thiopental (3 to 4
mg/kg) followed by fentanyl (3 mg/kg) and
atracrium (0.5 mg/kg). After the trachea was intu-
bated, the lungs were mechanically ventilated
(Sulla 808V, Drāger Medical Lübeck, Germany)
with a mixture of air and O2 (FIO2 ⫽ 0.5). Anes-
thesia was maintained with isoflurane 0.8-1.2%
and, when it seemed clinically necessary, an ad-
ditional bolus of fentanyl and atracrium was ad-
ministered.
Statistical Evaluation
All descriptive statistical analysis was per-
formed using statistical software (StatView II
1.01; Abacus Concepts, Inc, Berkeley, CA) on a
commercially available computer. Data are pre-
sented as mean ⫾ SD unless otherwise indicated.
RESULTS
Of the patients who underwent retrosigmoid
craniotomy for the removal of vestibular schwan-
nomas, 52 of 155 patients (33%) reported having
a severe headache that required medication every
day and/or feeling incapacitated (Harner grade 3
to 4) 3 months after surgery. According to this, we
divided the patients into 2 subgroups: headache
(n ⫽ 52) versus no headache (n ⫽ 103). The
general characteristics of the 2 patient groups are
shown in Table 1. There was no correlation be-
tween gender, tumor location, age, or tumor size
and appearance of postoperative headache. Over-
all, the patients with headache tended to have
smaller tumors.

390 SCHALLER and BAUMANN
Table 2. Follow-up related to surgical data of 52 patients with postoperative headache
Data item 3 mo
No. of patients 52
Operating time, average (min) 407
Facial nerve intact 50 (96%)
Cochlear nerve intact 32 (62%)
Complete tumor removal 49 (94%)
Cerebrospinal fluid fistula 3 (6%)
Aseptic meningitis 42 (81%)
Craniectomy 49 (94%)
Headache onset occurred typically in the imme-
diate postoperative period (90%), although 5 pa-
tients (10%) reported onset after 1 month. The
average headache rating was 7, with 10 represent-
ing the most severe pain experience. The headache
was described as stereotyped by 41 of the 52
patients (79%): beginning at the incision scar,
extending into the mid-occiput, and frequently
into the posterior mid-partial area of the skull.
Five patients (10%) complained primarily of fron-
tal pain. The other 6 (11%) thought that the pain
was “all over the head.” Headache was predomi-
nantly sensed as diffuse in the craniotomy group
(2 of 3 patients; 67%), whereas patients in the
craniectomy group mostly located their headache
on the operated side (36 of 49 patients; 73%). The
quality of headache was predominantly pressing
(47 of 52 patients; 90%). Of the 52 current head-
ache patients, none reported that their headaches
interfered with usual activities, such as sports,
work, and social functioning. Of those 36 patients
(69%) noted altered sleep patterns with early
morning awakening, 42 (81%) reported a negative
impact on mood. Exacerbating factors included
head movements (83%), fatigue (58%), and exer-
cise (40%). The follow-up of the headache at 3, 6,
12, and 24 months after surgery plus surgical data
are listed (Table 2). There was no correlation
between operating time, intact facial or cochlear
nerve, complete tumor removal, or CSF fistula and
improvement of headache over the months after
surgery. It is interesting that 10 of 52 patients
(19%) with postoperative headache had a head-
ache before surgery. However, there was a similar
incidence in patients without postoperative head-
ache (23 of 103 patients; 22%).
The incidence of headache after several varia-
tions of the retrosigmoid approach is listed in
Otolaryngology–
Head and Neck Surgery
March 2003
6 mo 12 mo 24 mo
35 10 9
389 365 372
34 (97%) 10 (100%) 9 (100%)
24 (69%) 8 (80%) 8 (89%)
34 (97%) 10 (100%) 9 (100%)
2 (6%) 1 (10%) 0
34 (97%) 9 (90%) 8 (89%)
32 (91%) 8 (80%) 7 (78%)
Table 2. No difference was noted based on the
skin incision being either trifurcate or sigmoid.
There was a difference in postoperative headache
based on whether the bone flap was or was not
replaced (94% versus 27%). In none of the 25
cases with duraplastic was there a persistent post-
operative headache. In all cases with postoperative
headache, there was a direct dura closure, com-
pared with 76% in the subgroup without postop-
erative headache (78 of 103 patients). The place-
ment or the duration of intermittent liquor
drainage showed no correlation to postoperative
headache. Laboratory-proven aseptic meningitis
(febrile meningeal inflammation characterized by
CSF mononuclear pleocytosis, normal glucose,
mild elevation in protein, and an absence of bac-
teria on examination and culture), most likely due
to the administration of fibrin glue (in 96% of the
cases) and drilling of the posterior aspect of IAC
(in 96% of the cases), was mainly associated with
postoperative headache (81% versus 2%) (Table
3). However, speclet calcifications along the
brainstem had been noted in 75% of the cases with
laboratory-proven aseptic meningitis.
Furthermore, there was a great variability in
both prescribed and self-administered medication
for posttraumatic headache, including the fre-
quency with which they were applied (eg, only
now and these during each attack). Postoperative
analgesic medication during hospitalization did
not differ between craniotomy and craniectomy. In
the follow-up period, postoperative consumption
of analgesic medication was higher in the crani-
ectomy group (33 of 49 patients; 67%) compared
with the craniotomy group (0 patients).
Most patients had a broad spectrum of psycho-
logic symptoms, frequently referred to as dys-
phonic mood. Psychiatric assistance was given to
Otolaryngology–
Head and Neck Surgery
Volume 128 Number 3
Table 3. Relation of different skin incisions and different craniotomies to postoperative headache
Headache group*
Characteristic
Craniectomy
Craniotomy
Laboratory-proven aseptic meningitis†
Administration of fibrin glue
Drilling of posterior aspect of IAC
Positive CT or MRI‡
Cerebrospinal fluid fistula
Dural plastic
Direct dural closure
IAC, Internal auditory canal; CT, computed tomography; MRI, magnetic resonance imaging.
*Persistent headache 3 months after surgery (HARNER grade 3 or 4).
†Febrile meningeal inflammation characterized by cerebrospinal fluid mononuclear pleocytosis, normal glucose, mild elevation in protein, and an
absence of bacteria on examination and culture.
‡Speckled calcification along the brainstem or dural enhancement.
2 patients with persistent postoperative headache
after 12 months; both had a long history of prob-
lems preoperatively. One of these 2 had received
therapy for major depression (fulfilled the diag-
nostic criteria) and required further assistance.
One patient had had major anxiety (fulfilled the
diagnostic criteria) preoperatively and required as-
sistance postoperatively.
DISCUSSION
In the present series, we could show, for the first
time, several different factors that influence the
occurrence of headache after the removal of ves-
tibular schwannoma via the retrosigmoid ap-
proach. There have been only a few reports in
recent years5,11,12,14,18-23 that discussed possible or-
igins of postoperative headache after use of the
retrosigmoid approach. Postoperative headache is
not a consideration when the results of vestibular
schwannoma surgery were evaluated, because it
does not prolong hospitalization or require addi-
tional hospitalization, both of which were the hall-
marks of surgical complications in most of the
studies. On the other hand, headache represents a
subjective complaint that is difficult to quantify
and to document. It can be present for many dif-
ferent reasons. The fact that headache exists after
craniectomy does not necessarily signify a cause-
effect relationship; the individual response to this
symptom also varies tremendously. Understanding
the nature of postsurgical headache may help us to
understand its underlying pathophysiology, and
SCHALLER and BAUMANN 391
No headache group
(n ⴝ 52) (n ⴝ 103)
49 (94%) 28 (27%)
3 (6%) 75 (73%)
42 (81%) 2 (2%)
50 (96%) 3 (3%)
45 (96%) 5 (5%)
39 (75%) 0
3 (6%) 16 (15%)
0 25 (24%)
52 (100%) 78 (76%)
knowledge of both could be helpful for indications
of treatment.
Incidence
In published series of patients with vestibular
schwannoma, the incidence of headache lasting
beyond the initial postoperative period ranges
widely from 0% to 65% (Table 4). The reported
rates vary considerably depending on the popula-
tion of the study, method of data collection, defi-
nition of headache, and duration of follow-up.
Moreover, preoperative and postoperative head-
ache is not sufficiently documented in most of the
previous publications as they may not fulfill the
diagnostic criteria required for the correct diagno-
sis of headache. In addition, most of the patients
have a shorter follow-up than 24 months, as rec-
ommended by AAO-HNS guidelines. However,
our literal review gives evidence that long-term
follow-up indicates a gradual improvement in the
severity of headache in most of the patients over
months but generally gives no convincing reason
for the improvement. The described neurologic
symptoms are predominantly of the tension-type
headache, although there may occasionally be
other forms of headache. The problem of postop-
erative headache persisting over 3 months is
mainly limited to the use of retrosigmoid-suboc-
cipital approach, as there is only a small number of
patients with postoperative headache after the
translabyrinthine and middle fossa approach for
the removal of vestibular schwannoma.
 Otolaryngology–
Head and Neck Surgery
392 SCHALLER and BAUMANN March 2003

Table 4. Literature report of incidence of postoperative headache (HARNER grade 3 or 4) after removal
of vestibular schwannoma
Incidence (%)

Author, year No. of cases 3 mo 6 mo 1y 2y

Retrosigmoid-suboccipital approach
Schessel et al,11 1992 58 65 NA NA NA
Glasscock et al,5 1993 147 22 NA NA NA
Harner et al,12 1993 331 23 NA 16 9
Pedrosa et al,23 1994 135 73 NA NA NA
Soumekh et al,20 1996 56 13 NA NA NA
Catalano et al,19 1996 84 30 NA NA NA
Ruckenstein et al,14 1996 35 NA 26 17 NA
Koperer et al,22 1999 29 48 NA 48 NA
Wazen et al,21 2000 60 43 NA NA NA
Jackson et al,18 2000 183 NA 70 44 21
Present series 125 42 NA 13 7
Total 1243 36 63 24 12
Translabyrinthine approach
Parving et al,13 1992 273 14 NA NA NA
Schessel et al,11 1992 40 0 NA 0 0
Pedrosa et al,23 1994 15 53 NA NA NA
Ruckenstein et al,14 1996 18 NA 6 13 NA
Total 346 16 6 3 0
Middle fossa approach
Glasscock et al,5 1993 15 0 NA NA NA
Weber and Gantz,29 1996 49 1 NA NA NA
Total 64 1 NA NA NA
NA, Not available.

Pathophysiology only a few of them tried to explain their result in

There has to be pathophysiologic differentiation
of postoperative head pain according to corre-
sponding factors and time. Head pain during the
initial postoperative period is anticipated and ex-
perienced by virtually all patients. This pain is
generally due to the incision, slight reduced CSF
pressure, dural irritation, neck muscle spasm, CSF
otorhinorrhea, or incisional leak and meningitic
pain. Persistent postoperative incision pain is
present several weeks to months after removal of
vestibular schwannoma and occurs as a conse-
quence of a traumatic occipital nerve neuronal
syndrome or occipital nerve entrapment syn-
drome. These different pain syndromes have to be
clinically and pathophysiologically strictly differ-
entiated from headache, as it is a clearly defined
entity. For this reason, we have excluded all pa-
tients with forms other than postcraniotomy head-
ache syndrome or other possible head pain from
the present series.
Until now, only a very few studies have dealt
with the origin of postoperative headache, and
the light of a pathophysiologic background. Vi-
jayan24 reported on the clinical characteristics of
postoperative headaches after vestibular schwan-
noma surgery, suggesting an origin of a combina-
tion of tension-type, neuralgic, and vascular com-
ponents. Baldwin26 reduced severe postoperative
headache after use of the retrosigmoid approach
with several general factors (without any statisti-
cal significance), including dissection technique,
retraction, and the use of physiologic Ringer’s
solution warmed to body temperature. In the
present series, we could show several factors that
influenced the persistent postoperative headache.
We documented that patients with craniectomy
and without duraplasty are prone to have severe
postoperative headache. This may be due to the
observation that cervical muscles might form a
thick scar-like bank that is strongly attached to the
dura and is rich in pain-sensing receptors and
nerve fibers.11,12 Schessel et al11 could show a
histologic adherence of nuchal musculature to the
dura in one patient with persistent severe headache
Otolaryngology–
Head and Neck Surgery
Volume 128 Number 3
undergoing reoperation for tumor recurrence. This
is in concordance with observations during neuro-
surgical procedures that mechanical or electrical
stimulation of the dura mater or blood vessel of
conscious humans leads to pain referred to the
ophthalmic (first) division of the trigeminal
nerve.25 Similarly, stimulation of dural elements
of the posterior fossa whose innervation derives
largely from branches of the C2 root can also lead
to pain in the anterior head.25 According to this
theory, traction on the dura with activation of the
neck muscles stimulates nociceptive fibers with
resultant pain in the occipital, vertex, frontal, and
retro-orbital regions. This is in accordance with
our observation that many of our patients noted
that coughing or straining aggravated their head-
ache. These mechanisms further support the the-
ory that increased intracranial pressure associated
with these maneuvers may cause distention of the
dura and resultant pain. However, the “nuchal-
dural-adhesion theory” does not explain persistent
headache in patients who have translabyrinthine
removal of tumor. In contrary to our observation
in the present series, some investigators have
failed to find any significant reduction in the inci-
dence of postoperative headache after incorporat-
ing replacement of calavarina bone or cranioplasty
in their retrosigmoid procedures.23 These findings
suggest that some other pathophysiologic distur-
bance is responsible for the long-term headache
that occurs in many patients.
As also seen in the present series, a few studies
have noted a seemingly paradoxical inverse rela-
tionship between tumor size and the occurrence of
postoperative headache.12 Recently, an attractive
hypothesis has been proposed to explain the gen-
erally lower incidence of headache associated with
the translabyrinthine compared with the retrosig-
moid approach, the inverse relationship between
the incidence of headache and tumor size, and the
relatively uncommon occurrence of headache after
retrosigmoid removal of posterior fossa tumors
other than vestibular schwannoma. It has been
proposed that bone dust trapped within the intra-
cranial cavity may cause a protracted inflamma-
tory response of the meninges, resulting in chronic
headache.19,27 By using the retrosigmoid approach
to remove vestibular schwannomas, drilling of the
posterior part of the internal auditory canal is
SCHALLER and BAUMANN 393
necessary after opening the dura. This allows bone
dust to circulate within the intracranial cavity and
to adhere to arachnoidal surfaces.27 The translaby-
rinthine approach, alternatively, involves comple-
tion of the major portion of bone removal before
opening the dura, and thus the potential for intra-
cranial contamination by bone particles is less-
ened. Removal of large tumors by the retrosig-
moid or translabyrinthine approach may block the
dissemination of bone dust intracranially by con-
fining it to the operative site and allowing ready
access and removal.27 In addition, large tumors are
generally associated with more erosion of the IAC
with a resultant reduced amount of bone requiring
removal and, again, a lessening in the volume of
potentially irritating bone dust. Positioning of the
patient may also contribute to the accumulation of
bone debris: patients in the supine position are
more likely to have bone dust collect intracranially
compared with those in the sitting position.27 It is
conceivable that chronic low-grade aseptic men-
ingitis could be initiated by these bone particles.27
In our patients with postoperative headache, CT
scans demonstrating calcification along the brain
stem and gadolinium MR images showing dural
enhancement inflammation seem to lend further
support to this proposed mechanism. We could
further show a strong clinical correlation to these
radiologic signs and the laboratory-proven aseptic
meningitis.
Watertight dural closure is a standard compo-
nent of the retrosigmoid approach. Despite efforts
to protect the dura from the drying effects of the
microscope light and ambient air, the dura usually
contracts after opening, which requires the place-
ment of some tension on it to close it tightly.28 In
addition, the dura is usually sutured up to the bone
edges during closure by this approach, which ex-
erts additional tension on it. Persistent headache
has not been common in patients undergoing re-
section of vestibular schwannoma via the middle
fossa or translabyrinthine approach, both of which
do not require dural closure.5,14,29 It is possible that
the tension placed on the dura during closure is the
source of chronic pain. The lack of dural closure
during translabyrinthine procedures and the lack
of dural opening in middle fossa approaches to the
IAC may prevent dural tension and resulting head-
ache. This hypothesis of dural tension as a source

394 SCHALLER and BAUMANN
Table 5. Literature report of incidence of postoperative headache after removal of vestibular
schwannoma compared for retrosigmoid/suboccipital craniotomy and craniectomy
Craniectomy
Author, year No. of cases 3 mo
Pedrosa et al,23 1994 18 53%
Soumekh et al,20 1996 56 13%
Catalano et al,19 1996 28 43%
Koperer et al,22 1999 16 69%
Total 118 34%
of postoperative headache may be underlined by
the fact that all of our patients with postoperative
headache did not have duraplastic closure and
instead had a direct dural closure. However, there
is good evidence that experimental stimulation of
trigeminal neurons can result in the release of
substance P from nerve terminals in the pia,30
which may be one of the transmitters of headache.
In the light of this investigation, direct dural clo-
sure should be abandoned in favor of a duraplasty
using the retrosigmoid approach.
Finally, there was a sizeable minority of pa-
tients who may have headache due to overuse of
different types of medications, some of which may
lead to a rebound headache.17 One unresolved
problem that emerged from the retrospective na-
ture of this study was the relationship between
presurgical and surgery-related headache. Most of
the patients in this study indicated that their head-
ache was exclusively due to surgery. This may be
disputed, because previous studies after craniocer-
vical acceleration/deceleration trauma have found
pretraumatic headache to be a significant risk fac-
tor for headache after trauma.31,32
Management
Replacement of calvarial bone or cranioplasty
with other materials has been reported to markedly
reduce the incidence of persistent postoperative
headache (Table 5). Also, secondary cranioplasty
relieved persistent headaches in several patients
who had undergone previous suboccipital craniec-
tomy without cranial reconstruction.20,33 Cranio-
plasty appeared to provide the solution to head-
aches resulting from dural scarring and adhesions.
Schessel et al11 reported a significant reduction in
postoperative headache with the placement of a
bone flap. Harner et al12 performed a cranioplasty
Otolaryngology–
Head and Neck Surgery
March 2003
Craniotomy
12 mo No. of cases 3 mo 12 mo
NA 117 71% NA
NA 50 0% NA
NA 56 18% NA
69% 13 23% 23%
69% 236 39% 23%
with methylmethacrylate to reduce the incidence
of postoperative headaches. They reported a 4%
incidence of headache in the cranioplasty group
compared with 17% in a matched group with no
cranioplasty. Ruckenstein et al14 reported that
within the first postoperative year, patients under-
going suboccipital craniotomies had significantly
more postoperative pain than those who under-
went translabyrinthine resections, despite the use
of cranioplasty. However, by 1 year after surgery,
the difference was no longer significant. Accord-
ing to our observation and the available literature,
a direct replacement of bone flap at the end of
surgery may be recommended. Secondary cranio-
plasty may be useful only in special indications.
CONCLUSION
The causes of postoperative headaches after ret-
rosigmoid vestibular schwannoma resections are
not yet fully evident. Different factors may play a
role in preventing or reducing headaches: dural
adhesions to nuchal muscles or to subcutaneous
tissues and dural tension in the case of direct dural
closure may explain postoperative headache due
to dural tension. Intradural drilling and adminis-
tration of fibrin glue may be sources of aseptic
meningitis as a cause of persistent headache. Pre-
vention of postoperative headache may include the
replacement of bone flap at the end of surgery,
duraplastic instead of direct dural closure, and
prevention of the use of fibrin glue and extensive
drilling of posterior aspect of IAC.
The authors thank Philippe Lyrer, MD, Departement of
Neurology, University Hospitals, Basel, for his help in the
methodology of this work and his helpful discussion of the
manuscript.
Otolaryngology–
Head and Neck Surgery
Volume 128 Number 3
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