pediatric-cranial-fixation

Cranial Fixation: Understanding the Key Facts

Cranial fixation, a critical aspect of cranial neurosurgery, is the set of surgical techniques and devices that secure and stabilize cranial bones, ensuring proper healing and reducing the risk of complications. In this comprehensive guide, Let’s accompany UpSurgeOn to delve into the key aspects of cranial fixation, from its purpose to the types of fixation methods, surgical techniques, and how to prevent complications. By the end of this article, you’ll be well-equipped with the knowledge necessary for optimal cranial fixation outcomes.

Understanding the Purpose of Cranial Fixation

Details on cranial flap fixation. Source: American Association of Neurological Surgeons

Cranial fixation serves a crucial purpose in ensuring the cranial bone flap remains securely in place following a craniotomy or craniofacial surgery. By providing stability and support to the skull, it not only safeguards the underlying brain tissue but also facilitates proper healing and bone fusion. The techniques employed for cranial fixation are diverse, ranging from the utilization of plates, screws, wires, absorbable sutures, and adhesive materials. The ultimate objective is to achieve a firm and rigid fixation while minimizing potential complications like bone resorption, infection, or any cosmetic deformities that may arise. Rest assured, cranial fixation is a vital step in the recovery process, ensuring the best possible outcome for patients. [19]

Types of Cranial Fixation 

Cranial fixation encompasses several techniques, each tailored to specific patient needs and surgical requirements:

  • Plates and screws: This is a common method where metal plates and screws are used to secure the cranial bone flap in its original position. Titanium is often used due to its strength and biocompatibility.
  • Wires: Stainless steel wires can be used to fixate the cranial bone flap. They are twisted or tied together to provide stability.
  • Absorbable Materials: Absorbable sutures, plates, and screws made of materials like poly-L-lactic acid (PLLA) and polyglycolic acid (PGA) can be used for fixation. These materials gradually degrade over time, eliminating the need for removal.
  • Bone Shims: Bone chips harvested from the inner edge of the bone flap can be used to bridge the kerf created by the craniotomy. These bone shims provide stability and promote bone fusion.
  • Adhesive Materials: Adhesive materials, such as fibrin glue or cyanoacrylate glue, can be used to secure the cranial bone flap. These materials create a strong bond between the bone flap and the skull.
  • Tacks: Biodegradable tacks made of materials like polylactic acid (PLA) can be used for fixation. These tacks provide secure fixation while eliminating concerns about migration or the need for tapping drill holes.
  • Occipital Condyle Fixation: In cases of craniocervical stabilization, the occipital condyles can be used as the sole cranial fixation points. This technique is used to treat craniocervical instability.

It’s important to note that the choice of fixation technique depends on various factors, including the patient’s condition, the type of surgery, and the surgeon’s preference [1017].

Considerations for cranial fixation

Cranial fixation on Pediatric simulator. Source: UpSurgeOn

Here are several critical considerations that influence the choice of cranial fixation technique:

  1. Patient Age: Pediatric patients have unique considerations due to the actively growing skull and dynamic bony contour changes. Proper selection of plating systems and fixation techniques is crucial [3] [5] [10].
  2. Imaging Compatibility: Metallic implants used for cranial fixation should not interfere with imaging techniques such as computerized axial tomography (CAT) scans and magnetic resonance imaging (MRI). Safety and image quality should be considered [10].
  3. Complications: Complications associated with cranial fixation include cranial fractures, epidural or subdural hematoma, scalp laceration, and cerebrospinal fluid leak. Guidelines for safe use and minimizing complications are lacking [3].
  4. Technique: Different techniques and materials can be used for cranial fixation, such as rigid cranial fixation using skull pins or the use of absorbable plates and bone cement. The choice of technique depends on the specific case and surgeon preference [5] [13] [18].
  5. Anatomical Considerations: Anatomical variations in the skull and cervical spine should be taken into account when planning cranial fixation. Precise measurements and preoperative planning are essential for safe and effective surgical intervention [14].

It is important to note that these considerations may vary depending on the specific surgical procedure and patient characteristics. Surgeons should carefully evaluate each case and make individualized decisions based on the patient’s needs and available evidence.

Complications of the wrong cranial fixation

During surgery, there are several potential complications that can arise with cranial fixation devices. These complications may include:

  • Brain tissue, nerve, and blood vessel damage: Improper placement or movement of the fixation device can cause damage to the surrounding brain tissue, nerves, and blood vessels
  • Scalp laceration: In some cases, the fixation device may cause a scalp laceration during placement or removal.
  • Subcutaneous hematoma: Hematoma formation beneath the skin can occur as a result of trauma or injury caused by the fixation device.
  • Device slippage: The fixation device may become unstable or slip out of position, compromising its effectiveness and potentially leading to complications.
  • Infection: Infection at the site of the fixation device can occur, leading to complications such as wound infection or bone flap infection.
  • Allergic reactions: Some patients may experience allergic reactions to the materials used in the fixation device, which can lead to complications.
  • Device-related discomfort: The presence of the fixation device may cause discomfort or pain for the patient during the postoperative period.

The severity and frequency of these complications can vary depending on factors such as the type of fixation device used, surgical technique, and patient characteristics. Close monitoring and adherence to proper surgical techniques can help minimize the risk of these complications [19].

How to prevent complications related to cranial fixation 

Preventing complications related to cranial fixation devices during surgery can be achieved through several measures:

  • Proper selection and placement of fixation devices: Surgeons should carefully select the appropriate cranial fixation device based on the patient’s anatomy and the specific surgical procedure. The devices should be placed securely and in the correct anatomical location to ensure stability and minimize the risk of complications [19].
  • Adherence to surgical guidelines: Following established guidelines for the use of cranial fixation devices can help minimize the risk of complications. Guidelines may include recommendations for pin size, pressure applied, and specific techniques for placement [2].
  • Adequate training and experience: Surgeons should have sufficient training and experience in using cranial fixation devices. This includes knowledge of proper techniques, anatomical considerations, and potential complications. Continuous education and staying updated with the latest advancements can also contribute to safer surgical practices [19].
  • Teamwork and communication: Effective communication and coordination among the surgical team, including neurosurgeons, anesthesiologists, and nurses, are crucial for ensuring the stability of cranial fixation devices. Clear communication regarding patient positioning, device placement, and any concerns or issues during the surgery can help prevent complications [19].
  • Close monitoring and postoperative care: Close monitoring of the patient during and after surgery is essential to detect any signs of complications early. Prompt intervention and appropriate postoperative care, including wound care and infection prevention measures, can help minimize the risk of complications [2].

It is important to note that the prevention of complications related to cranial fixation devices requires a multidisciplinary approach, including the collaboration of neurosurgeons, anesthesiologists, nurses, and other healthcare professionals involved in the surgical procedure [2][19].

Conclusion 

To sum up, cranial fixation is a critical aspect of cranial neurosurgery, and understanding its purpose, types, surgical technique, potential complications, and preventive measures is essential for ensuring optimal patient outcomes. By prioritizing safety, precision, and collaboration among healthcare professionals, we can reduce the risk of complications and enhance the success of cranial fixation procedures. Join UpSurgeOn on a remarkable journey towards enhancing patient outcomes. Our cutting-edge surgical simulation technologies are designed to equip surgeons with the confidence, precision, and expertise they need to excel in their mission. Discover the incredible potential of surgical simulation with UpSurgeOn and stay at the forefront of the dynamic world of surgery!


References: 

  1. Winston, K. R., & Wang, M. C. (1999). Cranial bone fixation in infants and children. Pediatric Neurosurgery, 31(5), 225–230. https://doi.org/10.1159/000028867
  2. Berry, C., Sandberg, D. I., Hoh, D. J., Krieger, M. D., & McComb, J. G. (2008). USE OF CRANIAL FIXATION PINS IN PEDIATRIC NEUROSURGERY. Neurosurgery, 62(4), 913–919. https://doi.org/10.1227/01.neu.0000318177.95288.cb
  3. Aldana, P. R., Roy, S., Postlethwait, R., & James, H. E. (2009). Ultrasound-aided fixation of a biodegradable cranial fixation system: uses in pediatric neurosurgery. Journal of Neurosurgery, 3(5), 420–424. https://doi.org/10.3171/2009.2.peds08230
  4. Smith, T. R., Foley, K. T., Boruah, S., Slotkin, J. R., Woodard, E. J., Lazor, J. B., Cavaleri, C., Brown, M. C., McDonough, B., Hess, B., & Van Citters, D. W. (2022). Use of adhesive cranial bone flap fixation without hardware to improve mechanical strength, resist cerebrospinal fluid leakage, and maintain anatomical alignment: a laboratory study. Journal of Neurosurgery, 1–11. https://doi.org/10.3171/2022.10.jns221657
  5. Alexander, H., Fayed, I., & Oluigbo, C. (2019). Rigid cranial Fixation for Robot-Assisted Stereoelectroencephalography in Toddlers: Technical Considerations. Operative Neurosurgery, 18(6), 614–620. https://doi.org/10.1093/ons/opz247
  6. Khader, B. A., & Towler, M. R. (2016). Materials and techniques used in cranioplasty fixation: A review. Materials Science and Engineering: C, 66, 315–322. https://doi.org/10.1016/j.msec.2016.04.101
  7. Sultan, A., & Mohamed, A. A. (2017). Efficacy and safety of using n-butyl cyanoacrylate in fixation of cranial following trauma and other pathologies. Turkish Neurosurgery. https://doi.org/10.5137/1019-5149.jtn.20117-17.1
  8. Aldana, P. R., Wieder, K. J., Postlethwait, R., James, H. E., & Steinberg, B. (2011). Ultrasound-Aided fixation of biodegradable implants in pediatric craniofacial surgery. Pediatric Neurosurgery, 47(5), 349–353. https://doi.org/10.1159/000337874
  9. [Preliminary application of absorbable fixation system on cranial bone flap reposition and fixation after craniotomy]. (2012, October 1). PubMed. https://pubmed.ncbi.nlm.nih.gov/23167103/
  10. Special considerations in pediatric cranial fixation: a technical overview. (n.d.). PubMed. https://pubmed.ncbi.nlm.nih.gov/11951449/
  11. Cohen, Re, H., Amis, P., Fitchner, H., & Em, S. (2001b). Tacks: a new technique for craniofacial fixation. Journal of Craniofacial Surgery, 12(6), 596–602. https://doi.org/10.1097/00001665-200111000-00019
  12. Iqbal, M., & George, K. J. (2021). Considerations in revising occipitocervical fixation for dysphagia. Surgical Neurology International, 12, 135. https://doi.org/10.25259/sni_43_2021
  13. Cohen, A., Dickerman, R. D., & Schneider, S. J. (2004b). New method of pediatric cranioplasty for skull defect utilizing polylactic acid absorbable plates and carbonated apatite bone cement. Journal of Craniofacial Surgery, 15(3), 469–472. https://doi.org/10.1097/00001665-200405000-00025
  14. Şenoğlu, M., Karadağ, A., Kınalı, B., Bozkurt, B., Içke, Ç., Savran, D. H., & Middlebrooks, E. H. (2017). C1 lateral mass screw insertion from the caudal–dorsal to the cranial–ventral direction as an alternate method for C1 fixation: A quantitative anatomical and morphometric evaluation. Journal of Clinical Neuroscience. https://doi.org/10.1016/j.jocn.2017.04.041
  15. Nout, E., & Mommaerts, M. Y. (2018). Considerations in computer-aided design for inlay cranioplasty: technical note. Oral and Maxillofacial Surgery, 22(1), 65–69. https://doi.org/10.1007/s10006-017-0668-4
  16. Greenberg, B. M., & Schneider, S. J. (2006). Trigonocephaly. Journal of Craniofacial Surgery, 17(3), 528–535. https://doi.org/10.1097/00001665-200605000-00024
  17. Thijs, D., & Menovsky, T. (2021). The Mayfield Skull Clamp: A Literature Review of Its Complications and Technical Nuances for Application. World Neurosurgery, 151, 102–109. https://doi.org/10.1016/j.wneu.2021.04.081
  18. Iqbal, M., & George, K. J. (2021). Considerations in revising occipitocervical fixation for dysphagia Surgical Neurology International, 12.
  19. Cheng, G., Hao, S., Ye, Z., Wang, B., Huangpu, B., Zhang, P., … & Hao, Q. (2021). Potential risk analysis and experience summarization of unstable factors of cranial fixation devices in neurosurgical operations: three-case reports and systematic review. Chinese Neurosurgical Journal, 7(1), 1-7.

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