ORIGINAL COMMUNICATION Landmarks for the Identification of the Cutaneous Nerves of the Occiput and Nuchal Regions R. SHANE TUBBS, * E. GEORGE SALTER, JOHN C. WELLONS III, JEFFREY P. BLOUNT, AND W. JERRY OAKES Pediatric Neurosurgery, Children’s Hospital, Birmingham, Alabama Although surgical procedures are often performed over the posterior head and neck, surgical landmarks for avoiding the cutaneous nerves in this region are surprisingly lacking in the literature. Twelve adult cadaveric specimens under- went dissection of the cutaneous nerves overlying the posterior head and neck, and mensuration was made between these structures and easily identifi- able surrounding bony landmarks. All specimens were found to have a third occipital nerve (TON), lesser occipital nerve (LON), and greater occipital nerve (GON), and we found that the TON was, on average, 3 mm lateral to the external occipital protuberance (EOP). Small branches were found to cross the midline and communicate with the contralateral TON inferior to the EOP in the majority of sides. The mean diameter of the main TON trunk was 1.3 mm. This trunk became subcutaneous at a mean of 6 cm inferior to the EOP. The GON was found to lie at a mean distance of 4 cm lateral to the EOP. On all but three sides, a small medial branch was found that ran medially from the GON to the TON *1 cm superior to a horizontal line drawn through the EOP. The GON was found to pierce the semispinalis capitis muscle on average 2 cm superior to the intermastoid line. The mean diameter of the GON was 3.5 mm. The GON was found to branch into medial and lateral branches on average 0.5 cm superior to the EOP. The LON was found to branch into a medial and lateral component at approximately the midpoint between a horizontal line drawn through the EOP and the intermastoid line. The main LON trunk was found on average 7 cm lateral to the EOP. In specimens with a mastoid branch of the great auricular nerve (GAN), this branch was found at a mean of 9 cm lateral to the EOP. The main trunk of this branch of the GAN was found to lie on average 1 cm superior to the mastoid tip. Easily identifiable bony land- marks for identification of the cutaneous nerves over the posterior head and neck can aid the surgeon in more precisely identifying these structures and avoiding complications. Although the occipital nerves were found to freely com- municate with one another, avoiding the main nerve trunks could lessen post- operative or postprocedural morbidity. Moreover, clinicians who need to localize the occipital nerves for the treatment of occipital neuralgia could do so more reliably with better external landmarks. Clin. Anat. 20:235–238, 2007. V V C 2006 Wiley-Liss, Inc. Key words: neck; head; skin; iatrogenic; injury; anatomy INTRODUCTION The posterior head and neck is an area where neurosur- gical intervention often occurs (e.g., approaches to the fora- men magnum, cerebellopontine angle, and upper cervical spine). In addition to these surgical approaches, procedures *Correspondence to: R. Shane Tubbs; Pediatric Neurosurgery, Children’s Hospital, 1600 7th Avenue South ACC 400, Birming- ham, AL 35233, USA. E-mail: rstubbs@uab.edu Received 26 July 2005; Revised 22 November 2005; Accepted 29 November 2005 Published online 30 August 2006 in Wiley InterScience (www. interscience.wiley.com). DOI 10.1002/ca.20297 V V C 2006 Wiley-Liss, Inc. Clinical Anatomy 20:235–238 (2007)