The most frequently used positions for approaches to the posterior skull base is the prone position with the head fixed in a head clamp and both shoulders protected by bolsters.
2. Skin incision
According to the anatomical region involved by the injury, the skin incision can be medial, paramedial, lateral, or far lateral. The medial skin incision can be straight or curved (dotted line) starting at the occipital protuberance and reaching the neck at the level of C2.
A classical suboccipital craniotomy including the foramen magnum is performed. Special attention has to be given to the major venous sinuses especially the superior sagittal, transverse, and the confluence of the sinuses.
The size of the craniotomy depends on the size of the fractures and can be either median or more lateral.
Note: The position of the burr holes is in most of the cases located below the transverse sinus.