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.
Previous reports analyzed 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.
An 11-year-old girl diagnosed with non-communicating hydrocephalus, caused by a posterior fossa tumor. During the surgery, complications were found in the form of acute epidural hematoma due to head fixation pins. So, the operation was stopped. An emergent CT scan was carried out and showed a bilateral skull fracture and a massive right-sided epidural hematoma. An emergency craniotomy for clot removal was performed and five days later, a second surgery was carried out uneventfully for the residual tumor. The patient fully recovered after the second surgery.
Complications due to the use of a pinhead fixation are easier to occur in pediatric patients because the bones are thinner and need a more careful strategy when pinning. With prompt identification of any complications and earlier treatment, a good outcome will be achieved.
Skull fractures and associated epidural hematomas in pediatric patients need to be considered as possible complications of the pin-type head fixation application. The head fixation devices in pediatric need to be used with great caution and knowing the risk factors, safe technique for application and management of complications will prevent a worse outcome 7).