Skull fracture and epidural hematoma caused by use of a Mayfield skull clamp in an adult patient with chronic hemodialysis: a case report

Pin penetration depths in the neurocranium using a three-pin head fixation device

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.

Characterizing complications associated with skull clamps: A review of the manufacturer and user facility device experience database

OBJECTIVE

Head immobilization with skull clamps is a prerequisite of many neurosurgical procedures. Adverse events relating to the use of skull clamps have been reported, however, given the paucity of published reports, we sought to conduct a more comprehensive analysis using the Manufacturer and User Facility Device Experience (MAUDE) database.

METHODS

The MAUDE database was queried for neurosurgical skull clamp events over a 10-year period between January 2013 and December 2022. Reports were qualitatively analyzed and categorically assigned by the study authors as 'mechanical failure,' 'slippage,' 'contamination,' 'insufficient information,' and 'other.' Patient injury reports were also classified as 'abrasion,' 'laceration,' 'hematoma,' 'fracture,' 'intracranial hemorrhage (ICH),' 'other,' 'insufficient information,' and 'death.'

RESULTS

Of 3672 reports retrieved, 2689 (73.2%) were device malfunctions, with mechanical failure (50.7%) and slippage (47.7%) being the most common causes. There were 983 reports (26.8%) involving patient injury which included lacerations (n = 776, 78.9%), fractures (n = 24, 2.4%), abrasions (n = 23, 2.3%), hematomas (n = 7, 0.71%), ICH (n = 3, 0.31%), and other causes (n = 6, 0.61%). Five (0.1%) deaths due to skull clamp related complications were also reported.

CONCLUSIONS

This study provides a more comprehensive picture of adverse events in neurosurgical procedures relating to the use of skull clamps. Mechanical failures of device parts were the most common device-related complication, and lacerations the most common adverse patient-related event. While more severe patient-related events were reported, they are relatively rare. The MAUDE database is useful for characterizing underreported device-related and patient-related adverse events.

Epidural Hematoma, a Rare Complication After the Use of Mayfield Clamp: A Case Report and Review of the Literature

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.