Cushing vs Adson Forceps: Neurosurgical Tissue Handling

Why does a craniotomy tray carry two pairs of fine forceps that look almost identical from a metre away?

Both are slender. Both are around 18 cm. Both have serrated tips a scrub nurse could confuse at speed. And yet handing over the wrong one during a dural closure is the kind of small error that slows a case and irritates a surgeon.

The difference is length, taper and intent — and once you have seen it, the two are impossible to mix up again.

Cushing vs Adson forceps: the short answer

Adson forceps are short-shanked, broad-handled, and built for the surface. They are the instrument of choice for skin edges, subcutaneous tissue and scalp closure, where the surgeon works close to their own hands and wants leverage.

Cushing forceps are longer, narrower through the shank, and built for the depth. They exist because Harvey Cushing needed to grasp tissue at the base of a craniotomy without his knuckles filling the exposure.

That is the whole distinction: reach. Everything else follows from it.

Specifications side by side

Look at the handle row rather than the length row. The broad Adson handle is a deliberate ergonomic choice for repeated, high-frequency use at the surface — closing a scalp involves dozens of grasps and the wide platform reduces pinch fatigue. The narrow Cushing handle sacrifices exactly that comfort to keep the surgeon’s fingers out of a 5 cm opening.

Where each one belongs

In a standard craniotomy the two instruments hand off to each other as the case moves through its layers.

Opening: Adson. Scalp incision, galea, raising the flap — all surface work, all Adson territory, usually the toothed 1×2 pattern for secure purchase on scalp edges.

Once the bone flap is off and the dura is open, the field drops several centimetres and the exchange happens. Handling dural edges for tack-up sutures, manipulating arachnoid, retracting a small tissue fold near the base — this is Cushing work. Serrated, non-toothed tips, because teeth have no business anywhere near neural tissue or a cortical vessel.

Closing: back to Adson for the galea and skin.

A well-run neurosurgical tray reflects that rhythm in its quantities. Two or three Adson pairs are enough, because the surface phases are short. Cushing pairs are usually stocked in greater number — they are in the field for the longest part of the case, they are the ones most likely to be set down on a drape and lost under a swab, and a surgeon who has to wait for a replacement mid-dissection remembers it.

The same pattern repeats in spinal surgery. Adson at the fascia and skin, Cushing once the surgeon is working down in the canal. In deep ENT approaches the split falls along similar lines.

Bayonet variants of the Cushing pattern take the logic one step further, offsetting the shank so the surgeon’s hand sits entirely clear of the line of sight down a narrow corridor — the standard geometry across bayonet-handled microsurgical instruments.

The naming trap: dressing versus tissue

Here is where catalogues create genuine confusion, and where most ordering errors originate.

Both patterns come in a “dressing” and a “tissue” version, and the words do not mean what a new buyer assumes.

• Dressing forceps have serrated, non-toothed tips. Despite the name, they are used constantly on delicate tissue — the serration grips without perforating. The name describes an origin, not a restriction.
• Tissue forceps have interlocking teeth, most commonly 1×2. They hold dense tissue securely and they puncture whatever they hold.

So a Cushing dressing forceps is the atraumatic one and the correct choice for neural tissue, while a Cushing tissue forceps has teeth and is for fascia and dura where a firm bite is wanted. Ordering “tissue forceps” for a delicate neurosurgical application, on the reasonable assumption that tissue means soft tissue, delivers exactly the wrong instrument.

The safe habit when raising a requisition is to specify the tip: “serrated, non-toothed” or “1×2 teeth”. Names vary between suppliers; tip geometry does not. We cover the broader distinction in our note on toothed versus non-toothed tissue forceps.

Choosing between them in practice

Ask one question: how far below the skin is the tissue I need to hold?

Under about 3 cm, Adson wins on control and comfort. The short shank means the tip does exactly what the fingers do, with no lever arm amplifying tremor.

Beyond that, the long shank stops being a liability and becomes the point. A surgeon working at 6 cm with Adson forceps has their hand in the exposure, blocking the microscope light and their own view.

A note on grip pressure

One habit separates surgeons who tear tissue from those who do not, and it applies to both patterns: the tips do the holding, not the hand.

Fine forceps are spring instruments. Squeezing harder past the point of contact does not improve grip — it deflects the shanks, which lifts the tips out of parallel and reduces the contact area at exactly the moment the surgeon thinks they are holding more securely. On a 20 cm Cushing this effect is pronounced, because the long shank flexes more per unit of applied force.

If tissue keeps slipping, the answer is a different tip pattern rather than a firmer squeeze. Serrations that will not hold dura suggest a toothed pattern is needed; teeth that are tearing skin suggest the opposite.

There is a further trade-off worth naming. Longer shanks amplify tremor and reduce tactile feedback — the surgeon feels less of what the tips are holding. That is the price of reach, and it is why Cushing forceps are not simply used for everything.

Most neurosurgical sets therefore carry both, in multiples, and the question of cushing vs adson forceps is settled by depth on a case-by-case basis rather than by preference. For the full range of Adson variants, including the DeBakey-jaw pattern used in vascular work, see our Adson forceps guide.

Fizza Surgical manufactures both patterns in Sialkot under ISO 13485, CE marked, with tip alignment and serration pitch verified at final inspection — the two dimensions that decide whether fine forceps grip or slip.