Head fixation device complications

Pin fixation and rigid immobilization of the head is desirable in many neurosurgical procedures. However, these techniques are associated with complications in infants and young children. A simple modification of a commonly used cranial fixation system allows rigid, safe immobilization of the head in infants and children.

Beuriat et al. performed a literature review via PubMed and Google Scholar using the terms “Mayfield skull clamp”, “Sugita head holders”, “head holder complications” and “skull clamp complications”. Twenty-six complications directly related to the use of head holders were identified through 19 papers published from 1981 to 2014: mainly skull fractures with or without a dural laceration (50%), epidural hematomas (23.8%), skull fractures with or without a dural laceration (50%), and air embolism (9.5%). The authors propose recommendations for the safe use of head holders 1).

The Mayfield clamp, often causes brief intense nociceptive stimulation, hypertension and tachycardia. Blunting this response may help prevent increased intracranial pressure, cerebral aneurysm or vascular malformation rupture, and/or myocardial stress.

A remifentanil bolus is more effective than a propofol bolus in blunting hemodynamic responses to Mayfield placement, and possibly for other short, intense nociceptive stimuli 2).

Skull fracture 3) 4)

Epidural hematoma 5). 6).

A 67-year-old Asian male patient with a history of dialysis-dependent chronic renal failure over 36 years suffered from severe cervical myelopathy. Neurological examination and radiographic images revealed cervical spondylotic myelopathy due to dialysis-related spondyloarthropathy. Laminoplasty was planned on patient consent. A Mayfield skull clamp was applied with the patient supine. Torque was applied to the screws with gentle care, but there was no resistance and it was not easy to reach the standard 60 lb (267 N) to 80 lb (356 N). Because a skull fracture was suspected, we canceled the surgery. Emergency head computed tomography showed depressed skull fractures underlying the single-pin sites with an associated epidural hematoma. The fractures and epidural hematoma were treated conservatively, and spontaneous resolution of the hematoma was confirmed. Cervical laminoplasty was performed successfully using a mask-type head holder on the subsequent day.

As a precaution for fractures and epidural hematoma in neurosurgical patients with bone fragility or a thin skull, use of a mask-type fixing device or halo ring is recommended 7).

see Head fixation device complications in pediatric neurosurgery.

Beuriat PA, Jacquesson T, Jouanneau E, Berhouma M. Headholders' - complications in neurosurgery: A review of the literature and recommendations for its use. Neurochirurgie. 2016 Dec;62(6):289-294. doi: 10.1016/j.neuchi.2016.09.005. Epub 2016 Nov 17. Review. PubMed PMID: 27865516.
Berger M, Philips-Bute B, Guercio J, Hopkins TJ, James ML, Borel CO, Warner DS, McDonagh DL. A novel application for bolus remifentanil: blunting the hemodynamic response to Mayfield skull clamp placement. Curr Med Res Opin. 2014 Feb;30(2):243-50. doi: 10.1185/03007995.2013.855190. Epub 2013 Oct 30. PubMed PMID: 24161010.
Mohcine S, Brahim EM. Depressed skull fracture secondary to the Mayfield three-pin skull clamp. Pan Afr Med J. 2015 Mar 19;20:262. eCollection 2015. PubMed PMID: 26161185.
Matouk CC, Ellis MJ, Kalia SK, Ginsberg HJ. Skull fracture secondary to application of a Mayfield skull clamp in an adult patient: case report and review of the literature. Clin Neurol Neurosurg. 2012 Jul;114(6):776-8. doi: 10.1016/j.clineuro.2011.12.036. Epub 2012 Jan 18. PubMed PMID: 22261664.
Lee MJ, Lin EL. The use of the three-pronged Mayfield head clamp resulting in an intracranial epidural hematoma in an adult patient. Eur Spine J. 2010 Jul;19 Suppl 2:S187-9. doi: 10.1007/s00586-010-1323-z. Epub 2010 Feb 14. PubMed PMID: 20155477; PubMed Central PMCID: PMC2899644.
Yan HJ. Epidural hematoma following use of a three-point skull clamp. J Clin Neurosci. 2007 Jul;14(7):691-3. Epub 2007 Apr 25. PubMed PMID: 17462901.
Furuya T, Yamazaki M, Nemoto T, Okawa A, Ohtori S. Skull fracture and epidural hematoma caused by use of a Mayfield skull clamp in an adult patient with chronic hemodialysis: a case report. J Med Case Rep. 2021 Apr 9;15(1):154. doi: 10.1186/s13256-021-02776-8. PMID: 33832515; PMCID: PMC8033709.
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