How I do it—the posterior question mark incision for decompressive hemicraniectomy

BACKGROUND: Decompressive hemicraniectomy (DHC) is a lifesaving procedure which every neurosurgeon should master early on. As indications for the procedure are growing, the number of patients eventually requiring skull reconstruction via cranioplasty also increases. The posterior question mark incision is a straightforward alternative to the classic trauma-flap and can easily be adopted. Some particularities exist one should consider beforehand and are discussed here in detail. METHODS: Surgical steps, aids, and pitfalls are comprehensively discussed to prepare surgeons who wish to gain experience with this type of incision. CONCLUSION: Due to the lower complication rate after cranioplasty, the posterior question mark incision has superseded the traditional pre-auricular starting anterior question mark incisions, in our department for the performance of decompressive hemicraniectomies. SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at 10.1007/s00701-021-04812-4.