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-====== Head fixation device complications in pediatrics ====== 
  
-[[Pin]] [[fixation]] and rigid [[immobilization]] of the [[head]] is desirable in many neurosurgical [[procedure]]s. However, these [[technique]]s are associated with [[complication]]s in [[infant]]s and young [[child]]ren. ​ 
- 
-Cranial fixation pins are widely used among pediatric neurosurgeons in patients younger than 5 years old. Guidelines for their safe use are not well defined despite common use and experience of significant complications associated with such devices 
-((Berry C, Sandberg DI, Hoh DJ, Krieger MD, McComb JG. Use of cranial fixation 
-pins in pediatric neurosurgery. Neurosurgery. 2008 Apr;​62(4):​913-8;​ discussion 
-918-9. doi: 10.1227/​01.neu.0000318177.95288.cb. PubMed PMID: 18496197. 
-)). 
----- 
-Gupta adapted a standard Mayfield horseshoe headrest and cranial fixation system to allow simultaneous use of the headrest and three-point pin fixation. The system is compatible with most neuronavigational systems. 
- 
-The combined horseshoe and pin system was used successfully in more than 30 patients ranging in age from 6 months to 14 years. No complications were encountered. 
- 
-Rigid immobilization is achievable in the pediatric population, facilitating intracranial and frameless stereotaxy procedures 
-((Gupta N. A modification of the Mayfield horseshoe headrest allowing pin 
-fixation and cranial immobilization in infants and young children. Neurosurgery. ​ 
-2006 Feb;58(1 Suppl):​ONS-E181;​ discussion ONS-E181. PubMed PMID: 16462615. 
-)). 
- 
-===== Case series ===== 
-Five of 766 children (0.65%) undergoing craniotomies with pin fixation of the head had depressed skull fractures and/or epidural hematomas from the pin fixation. Age ranged from 2.6 to 7.5 years; all fractures were temporal and occurred during posterior fossa craniotomies 
-((Vitali AM, Steinbok P. Depressed skull fracture and epidural hematoma from 
-head fixation with pins for craniotomy in children. Childs Nerv Syst. 2008 
-Aug;​24(8):​917-23;​ discussion 925. doi: 10.1007/​s00381-008-0621-9. Epub 2008 Apr 
-4. PubMed PMID: 18389258. 
-)) 
- 
-Lee et al. examined complications over the past 6 years, and encountered 5 children with depressed skull fractures secondary to the application of a skull clamp fixation device. There were 3 boys and 2 girls with ages ranging from 3 to 8 years (mean 5.8 years). Two patients had brainstem gliomas, 2 patients had hypothalamic gliomas and 1 patient had a medulloblastoma. Four of the children required separate cranial procedures for the exploration and elevation of the depressed fractures. There were no sequelae associated with the depressed fractures. We conclude that skull clamp fixation devices are safe, but should be used with caution in the pediatric patient. In addition, we present several modifications of existing skull clamps which may decrease the risk of depressed skull fractures 
-((Lee M, Rezai AR, Chou J. Depressed skull fractures in children secondary to 
-skull clamp fixation devices. Pediatr Neurosurg. 1994;​21(3):​174-7;​ discussion 
-178. PubMed PMID: 7803306. 
-)). 
- 
-===== Case reports ===== 
- 
-A 4-year-old girl who sustained a depressed skull fracture by penetration of a pin of the head holder. The fracture was noted at the end of the surgery performed for treatment of a cerebellar astrocytoma and was managed conservatively. 
- 
-Several factors seem to be involved in the production of this complication as are faulty application of the pins, excessive pin pressure, skull thinning, young patient'​s age, and pathological conditions that evolve with long-standing raised intracranial pressure 
-((Martínez-Lage JF, Almagro MJ, Serrano C, Mena L. Depressed skull fracture by a 
-three-pin head holder: a case illustration. Childs Nerv Syst. 2011 
-Jan;​27(1):​163-5. doi: 10.1007/​s00381-010-1213-z. Epub 2010 Jun 24. PubMed PMID: 
-20574740. 
-)). 
----- 
-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 pin]]s. 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. ​ 
- 
-Parenrengi et al. compared this [[case report]] with published [[literature]] in order to suggest a way to prevent this complication. 
- 
-[[Skull fracture]]s and associated [[epidural hematoma]]s 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 factor]]s, safe technique for application and management of complications will prevent a worse [[outcome]] 
-((Parenrengi MA, Adhiatmadja F, Arifianto MR, Apriawan T, Fauzi AA, Servadei F.  
-Bilateral skull fracture with massive epidural hematoma secondary to pin-type 
-head fixation in a pediatric patient: Case report and review of the literature. 
-Int J Surg Case Rep. 2019 Aug 13;​62:​43-49. doi: 10.1016/​j.ijscr.2019.07.079. 
-[Epub ahead of print] PubMed PMID: 31445499. 
-)).