Understanding Retromastoid Craniectomy (RMC)
Your doctor thinks you may need a surgical procedure called retromastoid craniectomy (REH-tro-MASS-toyd KRAY-nee-ECK-toh-mee) or RMC. This page will tell you what to expect before and after your operation. Please share this information with your family members. Talk to your doctor or nurse about your questions or concerns. Patients who know what to expect tend to be less worried before their operations and have smoother recoveries.
About the Operation
There are 12 pairs of nerves that carry information between your brain and areas in your head and neck. These are called cranial (KRAY-nee-uhl) nerves, and they are very important for sensation (feeling) and for motor control (movement). Each cranial nerve controls a different sensation or motor control function.
In most patients who have a cranial nerve disorder, a blood vessel is pushing against the cranial nerve. This pressure is called vascular (VAS-kyoo-lar) nerve compression. Pressure against any of these nerves may cause pain, facial spasms, or other cranial nerve problems.
Microvascular decompression (MY-croh-VAS-kyoolar dee-com-PREH-shun) is an operation that tries to relieve pressure against a cranial nerve. To get to the cranial nerve, an RMC is performed. A small patch of hair is shaved and an incision is made behind your ear. A small amount of bone is removed from your skull, just behind your ear, on the same side of the head as the nerve that is affected. This opening creates a small “window,” about the size of a half-dollar, in your skull. The surgeon works through this window using a microscope and at times a special telescope, called an endoscope. The microscope and endoscope are used to see the nerve that is being compressed.
The surgeon gently lifts the part of the blood vessel that has been pressing against the nerve. Small pieces of felt are placed next to or under the blood vessel to keep it from pressing against the nerve. The opening in the bone is closed with a mesh plate. The mesh plate is made of titanium (ti-TAY-nee-um). The titanium mesh will not set off metal detectors. People with a titanium mesh plate can have an MRI because the material is MRI-compatible. After the mesh plate is inserted, the surgeon will close the incision behind your ear with stiches.
Can I Have This Kind of Surgery?
Not everyone can have microvascular decompression. Whether you can have the surgery will depend upon the nature and type of pain or spasm that you have. Your past medical history could prevent you from having general anesthesia, which would also prevent you from having RMC. To find out if you are a candidate, you must send your MRI films and medical records relating to your diagnosis to:
The Center for Cranial Nerve Disorders and Microvascular Surgery
Attention: Lois Burkhart, RN
UPMC Presbyterian, Suite B-400
200 Lothrop St.
Pittsburgh, PA 15213-2582
Please include a short letter with your records that includes your name, address, and telephone number so we can contact you after we review your records. This review will take 1 to 2 weeks. Once the decision is made, we will call you to discuss a possible visit to our clinic and/or a surgery date.
If you are a surgical candidate and you live more than 2 hours away from Pittsburgh, you will need to plan to stay in the Pittsburgh area for 10 days for the complete procedure. Of those 10 days, generally only 1 or 2 days are spent in the hospital. The rest of the time is spent on testing before your surgery and recovery after your surgery.
Before Your Operation
Don’t take aspirin or ibuprofen, and don’t smoke
It’s important that you do not take aspirin, ibuprofen, or any herbal medication for 14 days before your surgery. If you are taking any of these medications, you should check with your doctor or cardiologist before you stop taking them. Do not drink any alcoholic beverages for 24 hours before surgery. If you smoke, try to stop smoking or at least smoke less the week before surgery.
Giving your consent
Before your operation, the surgeon will describe the surgery and its risks and benefits. It is very important that you fully understand this information. You need to ask about anything that is not clear to you, and be sure your concerns are discussed. You will be asked to sign a written consent form that says you agree to have the operation and you understand the risks involved. The most common risks are numbness in the face, hearing loss on one side, difficulty swallowing, loss of balance, headache, infection, and spinal fluid leak. These occur in less than 5 percent of patients, depending on the cranial nerve that has pressure on it. More serious risks such as stroke, death, facial paralysis, and double vision occur very rarely.
Tests you will need before the operation
Before the operation, an appointment will be made for you to have most or all of the following:
- A medical history and physical performed by a physician or physician assistant
- An assessment made by a nurse
- A talk with an anesthesiologist (AN-es-thee-zee-OL-oh-jist)
- Blood tests
- EKG (electrocardiogram) and chest x-ray
- Audiogram (hearing test)
- BSER (brain stem-evoked response)
- SSEP (somatosensory-evoked response)
- EMG (electromyogram)
- Medical clearance
The Day Before Surgery
The day before surgery, a nurse from Same Day Services will call you. If you are not called by early afternoon, call 412-647-0817. The nurse will answer any questions you have. She or he will tell you what time to arrive at the hospital and what time you will have surgery. You also can ask what medications, if any, you may take the morning of surgery.
Showering and hair
The night before surgery, bathe or shower, and shampoo your hair. Do not use conditioner, spray, or any other hair care product on your hair after shampooing. You may set your hair (use curlers) as long as no setting lotion is used. Hair clips and pins must be removed before surgery. In the operating room, your hair will be shaved in the area where the incision will be made.
Don’t eat or drink before surgery
Do not eat or drink anything after midnight the day before your operation. You will not be allowed to eat or drink anything until after your operation. Your stomach just be empty when you have anesthesia. You may take medicine by mouth if it is ordered by the anesthesiologist. A maximum of 2 tablespoons of water may be taken with the medication.
You may brush your teeth and use mouthwash before your operation, but do not swallow anything. If you have concerns about taking medicine by mouth during this time, please tell your nurse or doctor.
If you smoke, try to stop smoking for at least 24 hours before surgery. Under anesthesia, your lungs will not fully expand and will be irritated by the anesthesia gases. This will create extra secretions that will make your lungs work harder to breathe. Smoking leads to even more secretions and makes it harder for you to cough them up. This can cause problems in your lungs.
The Day of Your Operation
Please leave all valuables at home.
Please leave all jewelry at home, including wedding rings. Remove all jewelry from body piercings. You may not wear these during surgery, and they can be lost if removed in the hospital.
If you wear contact lenses, please take them out before you arrive at the hospital. You will not be able to put in contact lenses until you are discharged.
Where do I go?
You will be told where to report on the day of your surgery. We suggest that you bring only a robe and slippers with you. Ask a family member to hold your belongings during your operation. If you are unable to leave valuables at home, you may ask Security to store your valuables for you. After registering, you and one or two family members (no young children) will be directed to the Same Day Surgery unit, where you will be prepared for surgery.
Where will my family be during my surgery?
Your family will go to the Family Lounge on the first floor. Please make sure that a family member is in the waiting room at all times so the doctor may speak with your family after the operation. You will be in the operating room for about 3 to 4 hours.
After Your Operation
By the time you awaken from the anesthesia, the doctors will have already spoken with your family members. They will have explained how the surgery went.
What will happen after my surgery?
You will awaken in the recovery room. It’s a large, open area with many beds and pieces of equipment. You will hear beeping, clicking, and other unfamiliar noises. The lights may seem bright, and your vision may be blurry for a short while. This is from the protective ointment that was put in your eyes in the operating room. You also may have a plastic tube in your mouth to help you breathe.
As soon as you are fully awake, a nurse will remove the plastic tube from your mouth. He or she will keep checking your neurologic function, along with your blood pressure, heart rate, and breathing rate. You will not be allowed to eat or drink while you are in the recovery room. You will stay there for 2 to 4 hours.
In the neurosurgical patient care unit
When you are fully awake (usually 2 to 4 hours after you arrive in the recovery room), you will be moved to the neurosurgical (nuh-ro-SUR-ji-kel) patient care unit. You will have patches placed on your chest to monitor your heart. If a monitored bed is not open on the patient unit, you will remain in the recovery room overnight. Nurses will continue to check you every hour.
Once you are settled in the unit, your family can visit you. Because patients need a great deal of rest and visits are tiring, the length of visits is limited.
You may have ice chips if your mouth feels dry. You may have pain medication, if you ask for it, every 3 to 4 hours, depending on your doctor’s orders. Pain medications work best if you take them before discomfort becomes severe. They will not be given automatically. Be sure to tell your nurse if you need pain medication before the pain gets very bad. There is also medication for nausea and vomiting. Please ask for it if you need it.
You will be taught how to do breathing exercises using a spirometer (spi-ROM-eh-ter). This instrument will help you clear your lungs of excess mucus after surgery.
To help prevent swelling and to help circulation in your legs, you will have special compression devices to wear. The devices will squeeze and then release your legs routinely to keep your blood circulating.
You must remember to turn your head from side to side and up and down 10 times every hour. This will be painful, but it is very important to prevent your muscles from tightening.
You should also do the following exercises 5 to 6 times every hour after surgery until you are walking again. These exercises are especially important if you have varicose veins or a history of phlebitis (inflammation of the veins). As you lie in bed on your back:
- Point your toes down, away from you, and then pull them back up toward you.
- Bend one leg at the knee and then straighten it. Repeat with the other leg. Exercise each leg.
- Push the back of your calf and knee into the mattress. Relax that leg and repeat with the other leg. Exercise each leg.
Unless your doctor tells you otherwise, you may stop the exercises when you begin walking regularly. You will spend much of your time in bed the day of surgery. Remember to do your leg exercises 5 to 6 times each hour and to do your breathing exercises with the spirometer 2 to 3 times each hour. Turning from side to side in bed also helps to expand your lungs. Do this about every 2 hours while you are awake. If you need help turning, ask your nurse.
Eating and drinking after surgery
You will be allowed to drink clear liquids as soon as you can tolerate them, probably by breakfast the day after your operation. Do not be surprised if you can take only a few sips at first. The IV lines in your arms will be removed if you are drinking enough fluids. You will probably be able to eat solid food by the second day after surgery.
After your operation you will be permitted to use the rest room with help. You will be encouraged to walk when you feel ready.
Your doctor will decide when to move you from the monitored area to a regular patient unit. You will usually spend one night in the monitored area.
You’ll feel weak and tired
The stress of the operation, the medications, and your inactivity after surgery will probably make you feel weak. You will probably tire easily. Most patients spend 1 to 2 days in the hospital after an RMC to recover from the operation and to regain strength.
Incision care after surgery
Before discharge from the hospital, the dressing over your incision will be removed. On the third day after surgery, you may take a shower and wash your hair using a mild shampoo. For 3 weeks, avoid using shampoos with conditioner, dandruff shampoos, or shampoos for oily scalps. Wash the incision gently; do not scrub it. Do not use hair coloring, conditioner, hair spray, relaxants, or permanent wave solutions for 3 weeks. Do not dunk your head in the water.
You may continue to receive pain medication by mouth or by injection for several days after surgery. Tell your doctor if the pain medication does not help your pain. Pain will most likely be caused by your incision or by a headache.
Your family should plan to pick you up before 11 a.m. the day you are to be discharged from the hospital. A nurse will give you discharge instructions and answer any questions you might have about your recovery. You should also have the list of discharge instructions from our office with you. If you live more than 2 hours away from Pittsburgh, we would prefer you stay at a hotel or at Family House (a guest house for patients and their families). If you live close by, someone should drive you home. Remember, you are not allowed to drive for 2 weeks after surgery. When you are able to travel, if you have a long drive home, you should stop every hour or so and walk for a few minutes to keep the blood moving in your legs.
One week after surgery, you will report back to the neurosurgical office at UPMC Presbyterian, A-402, at 10 a.m. to have your stitches removed. A hearing test will be done after that at Eye & Ear, 4th floor.
What to Expect During Your Recovery
Remember to give yourself time to heal and to recover from the operation you have had. Each patient is different and responds differently during the recovery period.
Be prepared for various aches and pains during the weeks following your surgery. You’ll have good days and bad days.
You may still have some pain at the incision site. This may last for weeks. Try using acetaminophen (Extra-Strength Tylenol) or ibuprofen (Motrin), and be patient. The pain will eventually go away.
Ear “fullness” or discomfort may last for 5 to 6 weeks, and possibly longer. You should take an antihistamine or decongestant (Actifed) for 3 weeks, unless you are taking medication for high blood pressure. In this case, call your primary care doctor and ask him or her to prescribe a decongestant for you. Both antihistamines and decongestants may be bought over the counter — you don’t need a prescription.
You may continue to have headaches for a few weeks. Acetaminophen should be helpful in relieving your headache. If you have a very bad headache with a fever and/or a stiff neck, call your doctor.
Changes in your sense of taste and sleep patterns
You may have a temporary change in your sense of taste, which we cannot explain. You also may notice a change in your ability to sleep. Again, we do not know the reason for this. You can try using an antihistamine (Benadryl) to help you sleep, or ask your primary care doctor to prescribe a sleep medication. These changes are temporary and will eventually go away.
You may notice a small area of numbness behind your ear. This is from scalp nerves being cut during the operation. This will gradually improve, although it may not fully disappear.
When to Call Your Doctor
Call your doctor right away if:
- Your incision is red, swollen, or painful
- Your incision drains fluid
- Fluid drains out of your nose or down the back of your throat
These are signs of infection or spinal fluid leak.
Call your doctor if you experience any of the following:
- Temperature above 100 F for more than 24 hours
- Nausea and vomiting
- Any unusual sensations (feelings)
- Swollen, tender, or red incision or fluid draining from the incision
- Increasing neck stiffness
- Difficulty tolerating bright lights
- Fluid draining down your throat or out of your nose
Activities at Home
- Use common sense when it comes to what you can and can’t do.
- Walk every day. You may climb steps. You may golf after 3 weeks.
- You may return to work in 4 to 6 weeks, depending on the type of work you do.
- You may resume sexual activity as soon after discharge as you feel ready.
- You may have a permanent, relax your hair, or color your hair at the end of 3 weeks. Do not use conditioners, dandruff shampoos, or shampoos for oily hair for 3 weeks.
- Do not swim or take a bath (immerse your head in water) for 6 weeks following surgery.
- You may drive 2 weeks after your operation, depending on how you feel.
- You may do light housework. You should avoid running the vacuum for 3 weeks.
- You can do laundry, but have someone else carry the laundry baskets.
- You can go grocery shopping, but someone else will need to carry the grocery bags for you.
- You should avoid bending over to pick something up for 3 weeks. Remember to squat while holding on to something in order to lower yourself.
- You should avoid lifting anything heavier than 5 to 10 pounds for the first 2 weeks. For the following 2 weeks, do not lift anything heavier than 10 to 15 pounds.
- Don’t do any heavy lifting for at least 6 weeks. Use common sense in defining heavy (no straining).
- You should not engage in major physical exercise until 6 weeks following your surgery.
- You should not participate in the following activities for six weeks:
||Firing a rifle or shotgun|
||Construction work (heavy)|
||Riding lawn mower|
||Riding a tractor|
||Other similar activities|
Please see your primary care doctor or neurologist 1 to 2 weeks after you arrive home. Your family doctor can perform a quick checkup to make sure you are doing well.
If you are not having any problems, you should see the doctor again in 3 months. Please report to the same doctor so he or she can send us a note about your progress.
After recovery you can have any dental work or any medical or surgical treatment that you need. However, be sure to tell the dentist or doctor about your RMC and provide a list of any medications you are taking.
It may take some time for the symptoms of cranial nerve compression to go away or to lessen after surgery. It’s normal for some patients to experience a temporary return of their symptoms after surgery. If these symptoms persist or become severe, call us.
Keeping in touch
Be sure to let our office know if your address or phone number changes.
Important phone numbers
- Michael Horowitz,MD, and Paul Gardner, MD
- Lois Burkhart, RN (general questions and surgical information)
- Stephanie Henry, RN (general questions)
- Juliana Kovacs, RN (general questions)
- Debbie McHugh (appointments)
- Julie Martin (appointments)
- For more information, please go to our website