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An emergent CT head evaluation shows bilateral depressed skull fracture and a massive epidural hematoma with 40 mm thickness causing 10 mm midline shift to the left.
Source publication
Introduction:
A head fixation device containing pins is common equipment used in neurosurgical procedures. Previous reports analysed some of the complications associated with the application of this device for adults and children, even the indications for the use in pediatric are not well defined.
Case presentation:
An 11-year-old girl diagnosed...
Contexts in source publication
Context 1
... tumoral area. A right side anisocoria was noted and an emergency CT scan was performed while the patient was still under anesthesia, The head CT scan showed a massive subgaleal hematoma and a bilateral depressed fracture at the pin-site with a large right-sided epidural hematoma of over 40 mm thickness causing a 10 mm midline shift to the left (Fig. 3). An emergency craniotomy for the evacuation of the hematoma was conducted. During the surgery, it was noted that the bone was abnormally thin for the patient's age. A laceration of the dura under the depressed fracture was also ...
Context 2
... tumoral area. A right side anisocoria was noted and an emergency CT scan was performed while the patient was still under anesthesia, The head CT scan showed a massive subgaleal hematoma and a bilateral depressed fracture at the pin-site with a large right-sided epidural hematoma of over 40 mm thickness causing a 10 mm midline shift to the left (Fig. 3). An emergency craniotomy for the evacuation of the hematoma was conducted. During the surgery, it was noted that the bone was abnormally thin for the patient's age. A laceration of the dura under the depressed fracture was also ...
Citations
... Cranial fixation systems or devices employed in neurosurgical interventions for the purpose of immobilizing the skull during the neurosurgical procedure have been widely used [1,2,3]. ...
... The Mayfield-type system utilizes fixation pins and is a safe equipment extensively utilized in cranial surgeries [2,[4][5][6][7][8][9] and spinal surgeries [1,[10][11][12][13] in adults [1,3,7,10,14] and children [1,4,[15][16][17]. However, it is associated with systemic and intracranial complications: intracranial hypertension [18][19][20], cranial fracture/depression [2,3,6,10,[14][15][16][17][21][22][23][24], epidural hematoma [1,4,7,10,14,15,[17][18][19][20]22,[25][26][27][28][29], venous embolism [5,[30][31][32][33][34][35][36], and less commonly: cerebrospinal fluid leak (CSF) [37], arteriovenous fistula of the middle meningeal artery [38,39], head slippage [40], superficial temporal artery aneurysm [39,41], alopecia [42], asystole [43], and facial paralysis [11,13]. ...
... The Mayfield-type system utilizes fixation pins and is a safe equipment extensively utilized in cranial surgeries [2,[4][5][6][7][8][9] and spinal surgeries [1,[10][11][12][13] in adults [1,3,7,10,14] and children [1,4,[15][16][17]. However, it is associated with systemic and intracranial complications: intracranial hypertension [18][19][20], cranial fracture/depression [2,3,6,10,[14][15][16][17][21][22][23][24], epidural hematoma [1,4,7,10,14,15,[17][18][19][20]22,[25][26][27][28][29], venous embolism [5,[30][31][32][33][34][35][36], and less commonly: cerebrospinal fluid leak (CSF) [37], arteriovenous fistula of the middle meningeal artery [38,39], head slippage [40], superficial temporal artery aneurysm [39,41], alopecia [42], asystole [43], and facial paralysis [11,13]. ...
Introduction: Cranial fixation systems are instruments frequently used in cranial and spinal neurosurgical interventions to allow rigid fixation of the patient's head, despite their careful use, they are not free from systemic and intracranial complications. Method: A literature review was carried out in the PubMed database to extract original articles published between the years 1990 to 2021 with the following terms: “Mayfield skull clamp”, “Mayfield head clamp”, “Skull clamp” and “Pin-type head fixation device”. Results: 47 articles were selected that met the citation criteria, respective impacts, and content. Conclusion: The meticulous use of the cranial fixation system has greatly reduced its complications.
... As shown in TABLE 1, nine of 15 papers documented hydrocephalus or other elevated ICP. 11,13,17,18,20,21,[24][25][26] Chronic elevation of ICP appears to lead to calvarial bone thinning, increasing fragility. 4) Chronic disease/medication: There are two case reports that mentioned intracranial hemorrhage in patients with chronic renal disease requiring regular dialysis. ...
Herein, we describe a case of epidural hematoma associated with the use of a Mayfield head clamp. An 18-year old patient with an upper brainstem tumour causing obstructive hydrocephalus underwent a routine third ventriculostomy, which unexpectedly revealed an intracranial hemorrhage. We outline potential risk factors, propose an algorithm for preventing complications associated with the use of pin-type fixation, and conducted a structured review of the literature to identify similar clinical scenarios.
... The recommended torque screw force for the Mayfield system is 60 to 80 lb for adults, unlike the Sugita system, which does not have an integrated force gauge to guide the surgeon during pinning. 1 Complications related to the usage of head pins are quite uncommon ranging from 0.65 to 1.1% and are frequently seen in the pediatric population due to the variability and inconsistency in the thickness of the developing cranial vault, especially the squamous temporal bone, frontal sinus, and coronal suture. 2 Thinning of the cranial vault may also be seen in adults with long-standing intracranial hypertension or those on high-dose antiepileptic drugs, 2 both of which were absent in our patient. The coagulation profile was also reported to be normal. ...
... Many modifications of head pin fixation systems have been described like the use of rubber plugs, plaster of Paris cast interface, and usage of six pins or a padded horseshoe headrest simultaneously to equally disperse the forces. 2 These modifications still do not completely eliminate the risk of slippage of the pins. ...
Head fixation devices are frequently used to immobilize the position of the head in neurosurgery. We report a rare complication of a four-pin Sugita device causing epidural hematoma (EDH) in a young adult male undergoing transcranial excision of a craniopharyngioma manifesting intraoperatively as an intractable tense brain. Decreased bone mineral density secondary to the metabolic consequences of craniopharyngioma could have increased the susceptibility to breach of the bony cortex. The index case highlights the essential role of a preoperative computed tomography (CT) scan review for the thickness of the cranial vault and the identification of weaker zones in high-risk groups.
... The first technique requires fixation of the head with pins, and the second requires mounting a frame. Both techniques require sufficient skull thickness to allow fixation and avoid complications such as skull fracture or intracranial haemorrhage [25][26][27]. This is why most clinical reports of LiTT in the paediatric population have a minimum age of 2 years [9,28]. ...
Hypothalamic hamartomata (HH) not only are usually associated with drug-resistant epilepsy but can also cause precocious puberty and developmental delay. Gelastic seizures are the most common type of seizures. Magnetic resonance image (MRI)-guided laser interstitial thermal therapy (LiTT) is a technique whereby a laser fibre is stereotactically implanted into a target lesion and heat is used to ablate whilst tissue temperature is monitored using MRI thermography. MRI-guided LiTT has proven to be an effective and safe method to treat HH. To use the LiTT system, highly accurate stereotactic fibre implantation is required. This can be achieved by the use of frame-based or frameless neuronavigation techniques. However, these techniques generally involve rigid head immobilisation using cranial pin fixation. Patients need sufficient skull thickness to safely secure the pins and sufficient skull rigidity to prevent deformation. Hence, most of the clinical reports on the use of LiTT for children describe patients aged 2 years or older. We report a novel and practical technique of using a paste cast helmet to securely place a stereotactic frame in a 5-month-old infant with HH and drug-resistant epilepsy that allowed the successful application of MRI-guided LiTT.
... According to the results of this study, especially in pediatric cases, the complications of the 3 pin head clamps are not as low as expected according to the literature. We think that this difference may occur as a result of surgeons avoiding reporting complications [11][12][13]. ...
The head clamp system is one of the indispensable equipment of neurosurgery in terms of stabilizing the head and positioning it. In addition, in neurosurgery clinics, the use of pin head clamp is required to use the navigation system effectively. In pediatric cases, complications after the use of pins head clamp are rare, as reported in the literature. This paper presents a pediatric patient with posterior fossa tumor and hydrocephalus, who developed depression fracture and epidural hematoma after the use of Mayfield 3-pin clamp head. For this reason, the patient underwent emergency surgery a second time and the epidural hematoma was evacuated to obtain decompression. Epidural bleeding, which is a complication of the pinned clamped head, is frequently described in the literature, often in the pediatric cases accompanied by posterior fossa tumor and hydrocephalus. In this type of pediatric cases, a safe study for the use of pin clamp head is not yet available in the literature.
In estimated 10-15% of neurosurgical interventions employing a conventional three-pin head fixation device (HFD) the patient's head loses position due to slippage. At present no scientifically based stability criterion exists to potentially prevent the intraoperative loss of head position or skull fractures. Here, data on the skull penetration depth both on the single and two-pin side of a three-pin HFD are presented, providing scientific evidence for a stability criterion for the invasive three-pin head fixation. Eight fresh, chemically untreated human cadaveric heads were sequentially pinned 90 times in total in a noncommercially calibrated clamp screw applying a predefined force of 270 N (approximately 60 lbf) throughout. Three head positions were pinned each in standardized manner for the following approaches: prone, middle fossa, pterional. Titanium-aluminum alloy pins were used, varying the pin-cone angle on the single-pin side from 36° to 55° and on the two-pin side from 25° to 36°. The bone-penetration depths were directly measured by a dial gauge on neurocranium. The penetration depths on the single-pin side ranged from 0.00 mm (i.e., no penetration) to 6.17 mm. The penetration depths on the two-pin side ranged from 0.00 mm (no penetration) to 4.48 mm. We measured a significantly higher penetration depth for the anterior pin in comparison to the posterior pin on the two-pin side in prone position. One pin configuration (50°/25°) resulted in a quasi-homogenous pin depth distribution between the single-and the two-pin side. Emanating from the physical principle that pin depths behave proportionate to pin pressure distribution, a quasi-homogenous pin penetration depth may result in higher resilience against external shear forces or torque, thus reducing potential complications such as slippage and depressed skull fractures. The authors propose that the pin configuration of 50°/25° may be superior to the currently used uniform pin-cone angle distribution in common clinical practice (36°/36°). However, future research may identify additional influencing factors to improve head fixation stability. Most craniotomies and dorsal approaches to the cervical spine are performed employing an invasive head fixation device (HFD) or skull clamp, respectively. The main function of HFDs is to retain the delicate anatomy of the brain and its adjacent structures motionless to the surgeon, while at the same time providing for stable attachments of auxiliary instruments, e.g., retractor systems or neuronavigation accessories. One common, yet underreported occurrence using HFDs is the intraoperative unintended dislocation of the head, so-called slippage. Slippage may lead to serious complications ranging from neuronavigation inaccuracies, scalp injuries to cranial fractures and epidural hematoma 1-3. The literature on incidence and extent of cranial slippage is scarce. It is estimated to occur in 10-15% of cases 4,5. A variety of influencing factors have been put into connection with the likelihood of slippage. Those include forceful maneuvers during bone work, unintentional pressing on the HFD, repositioning of the table intraoperatively and unexpected body movements of the patient 2. Skull fractures and their resulting comorbidities could be traced back to an inadequate application of pin force 6,7. Raabe et al. have identified a safe and expedient pinning zone on the neurocranium based on empirical data and mechanistic considerations 8. The delineated safe pinning zone, however, has not been corroborated by quantifiable biomechanical data yet.
Background
To our knowledge, this is the first documented report of an operative cranial epidural hematoma secondary to skull fracture due to placement of Gardner-Wells Tongs (GWT) in the setting of a spinal deformity reconstruction.PurposeThe objective is to illustrate the possibility of cranial pathology secondary to GWT placement and the need to properly correlate intraoperative neuromonitoring findings.Study designCase report.MethodsA 14-year-old male with Marfan’s Syndrome presented for three-column osteotomy spinal reconstruction for a large and stiff thoracic kyphoscoliosis. Gardner-Wells Tongs (GWT) was placed prior to prone positioning to provide neck stability without issue. During the lumbar posterior column osteotomies the patient began to lose upper and lower extremity motor data. This indicated a cranial pathology. A temporary rod was placed on the concavity and an emergent flip without closure was performed. Upon flip, the patient was fixed and dilated with only right corneal reflex. The patient was rushed to the CT scanner where a large right-sided epidural hematoma was noted with a temporal bone fracture at the pin site, with the patient’s right temporal bone noted to be only 1.3 mm in thickness.ResultsThe patient underwent emergent epidural hematoma evacuation by the Neurosurgical team. The patient was discharged to rehabilitation 1 week after his cranial epidural hematoma surgery with a complete recovery including with full strength examination of all extremities. He subsequently underwent a definitive posterior spinal fusion with posterior column osteotomies 8 weeks later.Conclusion
Cranial pin fixation has the rare possibility to produce cranial pathology and has a specific complication protocol. Proper utilization and interpretation of neuromonitoring is essential to aid in intraoperative decision-making.
