- Email: [email protected]
Epidural hematoma following use of a three-point skull clamp
Case reports / Journal of Clinical Neuroscience 14 (2007) 691–693
691
Epidural hematoma following use of a three-point skull clamp Hwa-Jeng Yan
*
Department of Neurosurgery, Changhua Christian Hospital, 133 Nanhsain Street, Changhua, 500, Taiwan Received 13 December 2005; accepted 14 February 2006
Abstract We report an unusual case of epidural hematoma secondary to the use of a three-point skull-fixation device. Initially, a posterior-fossa brain tumor with hydrocephalus was diagnosed in a 15-year-old boy. Midline suboccipital craniectomy was performed with the patient placed in the prone position. A Mayfield (Ohio Medical Instrument Co., Cincinnati, OH, USA) skull clamp was used for fixation of the head during the surgical procedure, following which, a huge epidural hematoma developed within 6 hours of surgery, due to skull penetration and fracture at one of the clamp’s pin sites located proximate to the coronal suture. 2006 Elsevier Ltd. All rights reserved. Keywords: Epidural hematoma; Skull fixation; Posterior-fossa tumor; Hydrocephalus
1. Introduction The pin-type head-holder has been widely used and is recognized as indispensable equipment in neurosurgical practice. Such a device is typically used to clamp the patient’s skull to some rigid structure, in order to stabilise and hold the patient’s head and neck in a particular position during surgical procedures. Only a few rare complications have been attributed to the use of such a pin-type head-holder. Herein, we report an unusual case of epidural hematoma arising as a complication of the use of a Mayfield (Ohio Medical Instrument Co., Cincinnati, OH, USA) three-point skull clamp. To the best of our knowledge, this is only the second time that such a complication has been reported in the literature.
choroid plexus papilloma. The patient’s neurological examination was performed 6 hours subsequent to surgery; revealing a Glasgow Coma Scale (GCS) score of 6, pupil sizes (right/left) of 6.0 mm/5.0 mm and the absence of any light reflex. Oozing of blood from the pin site over the right temporal area was also noted. A brain CT scan was repeated and it revealed a large epidural hematoma over the right fronto-temporo-parietal area (Fig. 2). Bone
2. Case report A 15-year-old boy was admitted to hospital due to progressive memory impairment and unsteady gait over a period of a month immediately prior to admission. Computed tomography (CT) scan revealed a posterior-fossa midline tumor with associated hydrocephalus (Fig. 1). External ventricular drainage was commenced on the day following admission, and a midline suboccipital craniectomy for tumor removal was performed 5 days later. During this surgical procedure, the patient was placed in the prone position with the head supported by a Mayfield three-point skull clamp. A clamping force of 60 pounds was applied to the skull during surgery, and the tumor was grossly totally removed. The subsequent pathology report indicated a
*
Tel.: +886 4 7238595. E-mail address: [email protected].
Fig. 1. The enhanced brain CT scan taken preoperatively revealing a posterior-fossa tumor of homogenous enhancement and associated hydrocephalus.
692
Case reports / Journal of Clinical Neuroscience 14 (2007) 691–693
the epidural hematoma, the patient experienced a progressive regaining of consciousness.
3. Discussion
Fig. 2. A post operative brain CT scan following initial craniectomy surgery for removal of the posterior-fossa tumor, the scan shows a huge epidural hematoma over the right fronto-temporo-parietal area.
Fig. 3. Bone window of the CT scan in Fig. 2 revealing a small impression fracture (white arrow) at the skull-clamp pin-location site proximate to the right coronal suture.
window images of the brain CT scan revealed a small impression fracture at the site of location of one of the clamp’s three pins, proximate to the right coronal suture (Fig. 3). Emergency craniotomy for the removal of the epidural hematoma was then performed, with a subgaleal hematoma being noted to be located around the pin site adjacent to the right coronal suture. A slight penetration of the skull with associated surrounding small bone chips from this comminuted fracture was observed just at the site where one of the Mayfield skull clamp’s pins had been situated. Two days subsequent to the surgical removal of
The Mayfield skull clamp is a standard three-point skull-fixation device that has seen widespread use during neurosurgical procedures. It is designed to anchor the outer table of the cranial vault. There are commercially available adult-size and child-size pins for use with the head clamp. However, its use is not recommended for children under the age of 5 years because the cranial vault of a child’s skull is thin, consisting of a single, pliable layer without dipole, up until the age of around four years.1 For the stable fixation of the heads of young children and infants for surgical purposes, Aoki and Sakai describe a modification of the Mayfield skull clamp which used rubber plugs over the skull pins.2 However, Lee et al. recommends that the use of pin fixation for the heads of very young children and infants, less than 18 months, should be avoided due to the mobile sutures and open fontanelles in such young individuals.3 Further, for such individuals, a reduction of intracranial contents such as occurs during the draining of cerebrospinal fluid or the removal of space-occupying lesions may result in compensatory movement of skull bones and the consequent loss of secure fixation. The recommended clamping force for the Mayfield skull clamp lies somewhere between 60 and 80 pounds for adult patients, although there exists no definite guidelines for the force level to be used for the pediatric group. From our experience, 40–60 pounds of clamping force is the appropriate level of force to be applied for children younger than 15 years. Several complications would appear to have been related to the use of three-point skull clamps, including depressed skull fracture,3 middle meningeal arteriovenous fistula,4 venous air embolism,5,6 and epidural hematoma.7 Most of these reported complications would appear to have been related to fracture and/or penetration of the cranial vault.3,4,6,7 As was the case for the 15-year-old child reported herein, the thin coronal suture constitutes a potential location for the risk of skull fracture and/or penetration while employing skull-clamp head fixation by pin(s) located at or near that suture. In order to attempt to prevent such a complication from arising, the thinner areas of the skull, including the temporal squama, frontal sinus and coronal suture, should be avoided as possible skull-clamp pin-location sites.8,9 References 1. Soames RW. Skeletal system. In: Williams PL, editor. Gray’s Anatomy. 38th ed. Edinburg: Churchill Livingstone; 1995. p. 607. 2. Aoki N, Sakai T. Modified application of three-point skull clamp for infants. Neurosurgery 1989;25:660–2.
Case reports / Journal of Clinical Neuroscience 14 (2007) 693–696 3. Lee M, Rezai AR, Chou J. Depressed skull fractures in children secondary to skull clamp fixation devices. Pediatr Neurosurg 1994;21:174–8. 4. Inagawa T, Takeda T, Taguchi H, et al. Traumatic middle meningeal arteriovenous fistula caused by three-point skull fixation. Case report. J Neurosurg 1984;60:853–5. 5. Grinberg F, Slaughter TF, McGrath BJ. Probable venous air embolism associated with removal of the Mayfield skull clamp. Anesth Analg 1995;80:1049–50.
693
6. Pang D. Air embolism associated with wounds from a pin-type headholder. Case report. J Neurosurg 1982;57:710–3. 7. Baerts WD, de Lange JJ, Booij LH, et al. Complications of the Mayfield skull clamp. Anesthesiology 1984;61:460–1. 8. Garfin SR, Botte MJ, Centeno RS, et al. Osteology of the skull as it affects halo pin placement. Spine 1985;10:696–8. 9. Garfin SR, Roux R, Botte MJ, et al. Skull osteology as it affects halo pin placement in children. J Pediatr Orthop 1986;6:434–6.
doi:10.1016/j.jocn.2006.02.012
Intradural extramedullary arachnoid cyst of the thoracic spine associated with cord compression Markus Wenger a, Noemi Zobor b, Regula Markwalder c, Emanuel Vogt d, Thomas-Marc Markwalder e,* a Neurosurgery, Hirslanden Group, Klinik Beau-Site, Bern, Switzerland Service d’Orthope´die, Hoˆpital Re´gional de Porrentruy, Porrentruy, Switzerland c Pathologisches Institut La¨nggasse, Bern, Switzerland d Anaesthesia, Hirslanden Group, Klinik Beau-Site, Bern, Switzerland Attending Neurosurgeon FMH, Thunstrasse 160, CH-3074 Bern-Muri, Switzerland b
e
Received 1 December 2005; accepted 28 February 2006
Abstract In this report, a 55-year-old Caucasian women with an arachnoid cyst of the thoracic spine is presented. This cyst remained undiagnosed because of the nonspecific nature of her symptoms over approximately three months. Only when she started to complain of ataxia, a posterior fluid collection compressing the spinal cord was found in MRI. Even though preoperative diagnosis remained uncertain, this additional neurological dysfunction warranted surgical treatment. Surgery was successful with respect to in-toto removal of the intradural, extramedullary cyst, reversal of cord compression and symptoms. Histological diagnosis was of an arachnoid cyst. 2006 Elsevier Ltd. All rights reserved. Keywords: Arachnoid cyst; Spinal cord compression; Pain; Ataxia; Spine surgery; Histology
1. Introduction Thoracic spinal cord compression only rarely occurs in patients who do not suffer from malignant disease, an infection, a degenerative disorder or trauma. Therefore, a high index of suspicion is required to detect other causes of thoracic cord compression, probably as, at an early stage of disease, symptoms may be nonspecific, change over time and affect almost any location caudad to the lesion. In this way, arachnoid cysts (AC) within the thoracic spinal canal may mimic various neurological and non-neurological disorders and hamper prompt diagnosis.1–7 *
Corresponding author. Tel.: +41 0 31 951 50 57; fax: +41 0 31 951 50
58. E-mail address: [email protected] (T.-M. Markwalder).
We present a patient with a thoracic intradural, extramedullary AC and we discuss the symptoms, differential diagnosis, histology and successful surgical treatment. 2. Case report 2.1. History, clinical findings, radiological assessment A 55-year-old Caucasian woman presented with a 3month history of pain and dysaesthesia in the area of the thoracic spine radiating into the thoracic outlet, the lumbar spine, the right abdomen, the right hemipelvis and the right leg. Defecation and micturition were normal. Symptoms did not alter on postural changes.5 Because of the nonspecific nature of these complaints, radiological examinations of several anatomical areas were performed. Whereas computed tomography (CT)
691
Epidural hematoma following use of a three-point skull clamp Hwa-Jeng Yan
*
Department of Neurosurgery, Changhua Christian Hospital, 133 Nanhsain Street, Changhua, 500, Taiwan Received 13 December 2005; accepted 14 February 2006
Abstract We report an unusual case of epidural hematoma secondary to the use of a three-point skull-fixation device. Initially, a posterior-fossa brain tumor with hydrocephalus was diagnosed in a 15-year-old boy. Midline suboccipital craniectomy was performed with the patient placed in the prone position. A Mayfield (Ohio Medical Instrument Co., Cincinnati, OH, USA) skull clamp was used for fixation of the head during the surgical procedure, following which, a huge epidural hematoma developed within 6 hours of surgery, due to skull penetration and fracture at one of the clamp’s pin sites located proximate to the coronal suture. 2006 Elsevier Ltd. All rights reserved. Keywords: Epidural hematoma; Skull fixation; Posterior-fossa tumor; Hydrocephalus
1. Introduction The pin-type head-holder has been widely used and is recognized as indispensable equipment in neurosurgical practice. Such a device is typically used to clamp the patient’s skull to some rigid structure, in order to stabilise and hold the patient’s head and neck in a particular position during surgical procedures. Only a few rare complications have been attributed to the use of such a pin-type head-holder. Herein, we report an unusual case of epidural hematoma arising as a complication of the use of a Mayfield (Ohio Medical Instrument Co., Cincinnati, OH, USA) three-point skull clamp. To the best of our knowledge, this is only the second time that such a complication has been reported in the literature.
choroid plexus papilloma. The patient’s neurological examination was performed 6 hours subsequent to surgery; revealing a Glasgow Coma Scale (GCS) score of 6, pupil sizes (right/left) of 6.0 mm/5.0 mm and the absence of any light reflex. Oozing of blood from the pin site over the right temporal area was also noted. A brain CT scan was repeated and it revealed a large epidural hematoma over the right fronto-temporo-parietal area (Fig. 2). Bone
2. Case report A 15-year-old boy was admitted to hospital due to progressive memory impairment and unsteady gait over a period of a month immediately prior to admission. Computed tomography (CT) scan revealed a posterior-fossa midline tumor with associated hydrocephalus (Fig. 1). External ventricular drainage was commenced on the day following admission, and a midline suboccipital craniectomy for tumor removal was performed 5 days later. During this surgical procedure, the patient was placed in the prone position with the head supported by a Mayfield three-point skull clamp. A clamping force of 60 pounds was applied to the skull during surgery, and the tumor was grossly totally removed. The subsequent pathology report indicated a
*
Tel.: +886 4 7238595. E-mail address: [email protected].
Fig. 1. The enhanced brain CT scan taken preoperatively revealing a posterior-fossa tumor of homogenous enhancement and associated hydrocephalus.
692
Case reports / Journal of Clinical Neuroscience 14 (2007) 691–693
the epidural hematoma, the patient experienced a progressive regaining of consciousness.
3. Discussion
Fig. 2. A post operative brain CT scan following initial craniectomy surgery for removal of the posterior-fossa tumor, the scan shows a huge epidural hematoma over the right fronto-temporo-parietal area.
Fig. 3. Bone window of the CT scan in Fig. 2 revealing a small impression fracture (white arrow) at the skull-clamp pin-location site proximate to the right coronal suture.
window images of the brain CT scan revealed a small impression fracture at the site of location of one of the clamp’s three pins, proximate to the right coronal suture (Fig. 3). Emergency craniotomy for the removal of the epidural hematoma was then performed, with a subgaleal hematoma being noted to be located around the pin site adjacent to the right coronal suture. A slight penetration of the skull with associated surrounding small bone chips from this comminuted fracture was observed just at the site where one of the Mayfield skull clamp’s pins had been situated. Two days subsequent to the surgical removal of
The Mayfield skull clamp is a standard three-point skull-fixation device that has seen widespread use during neurosurgical procedures. It is designed to anchor the outer table of the cranial vault. There are commercially available adult-size and child-size pins for use with the head clamp. However, its use is not recommended for children under the age of 5 years because the cranial vault of a child’s skull is thin, consisting of a single, pliable layer without dipole, up until the age of around four years.1 For the stable fixation of the heads of young children and infants for surgical purposes, Aoki and Sakai describe a modification of the Mayfield skull clamp which used rubber plugs over the skull pins.2 However, Lee et al. recommends that the use of pin fixation for the heads of very young children and infants, less than 18 months, should be avoided due to the mobile sutures and open fontanelles in such young individuals.3 Further, for such individuals, a reduction of intracranial contents such as occurs during the draining of cerebrospinal fluid or the removal of space-occupying lesions may result in compensatory movement of skull bones and the consequent loss of secure fixation. The recommended clamping force for the Mayfield skull clamp lies somewhere between 60 and 80 pounds for adult patients, although there exists no definite guidelines for the force level to be used for the pediatric group. From our experience, 40–60 pounds of clamping force is the appropriate level of force to be applied for children younger than 15 years. Several complications would appear to have been related to the use of three-point skull clamps, including depressed skull fracture,3 middle meningeal arteriovenous fistula,4 venous air embolism,5,6 and epidural hematoma.7 Most of these reported complications would appear to have been related to fracture and/or penetration of the cranial vault.3,4,6,7 As was the case for the 15-year-old child reported herein, the thin coronal suture constitutes a potential location for the risk of skull fracture and/or penetration while employing skull-clamp head fixation by pin(s) located at or near that suture. In order to attempt to prevent such a complication from arising, the thinner areas of the skull, including the temporal squama, frontal sinus and coronal suture, should be avoided as possible skull-clamp pin-location sites.8,9 References 1. Soames RW. Skeletal system. In: Williams PL, editor. Gray’s Anatomy. 38th ed. Edinburg: Churchill Livingstone; 1995. p. 607. 2. Aoki N, Sakai T. Modified application of three-point skull clamp for infants. Neurosurgery 1989;25:660–2.
Case reports / Journal of Clinical Neuroscience 14 (2007) 693–696 3. Lee M, Rezai AR, Chou J. Depressed skull fractures in children secondary to skull clamp fixation devices. Pediatr Neurosurg 1994;21:174–8. 4. Inagawa T, Takeda T, Taguchi H, et al. Traumatic middle meningeal arteriovenous fistula caused by three-point skull fixation. Case report. J Neurosurg 1984;60:853–5. 5. Grinberg F, Slaughter TF, McGrath BJ. Probable venous air embolism associated with removal of the Mayfield skull clamp. Anesth Analg 1995;80:1049–50.
693
6. Pang D. Air embolism associated with wounds from a pin-type headholder. Case report. J Neurosurg 1982;57:710–3. 7. Baerts WD, de Lange JJ, Booij LH, et al. Complications of the Mayfield skull clamp. Anesthesiology 1984;61:460–1. 8. Garfin SR, Botte MJ, Centeno RS, et al. Osteology of the skull as it affects halo pin placement. Spine 1985;10:696–8. 9. Garfin SR, Roux R, Botte MJ, et al. Skull osteology as it affects halo pin placement in children. J Pediatr Orthop 1986;6:434–6.
doi:10.1016/j.jocn.2006.02.012
Intradural extramedullary arachnoid cyst of the thoracic spine associated with cord compression Markus Wenger a, Noemi Zobor b, Regula Markwalder c, Emanuel Vogt d, Thomas-Marc Markwalder e,* a Neurosurgery, Hirslanden Group, Klinik Beau-Site, Bern, Switzerland Service d’Orthope´die, Hoˆpital Re´gional de Porrentruy, Porrentruy, Switzerland c Pathologisches Institut La¨nggasse, Bern, Switzerland d Anaesthesia, Hirslanden Group, Klinik Beau-Site, Bern, Switzerland Attending Neurosurgeon FMH, Thunstrasse 160, CH-3074 Bern-Muri, Switzerland b
e
Received 1 December 2005; accepted 28 February 2006
Abstract In this report, a 55-year-old Caucasian women with an arachnoid cyst of the thoracic spine is presented. This cyst remained undiagnosed because of the nonspecific nature of her symptoms over approximately three months. Only when she started to complain of ataxia, a posterior fluid collection compressing the spinal cord was found in MRI. Even though preoperative diagnosis remained uncertain, this additional neurological dysfunction warranted surgical treatment. Surgery was successful with respect to in-toto removal of the intradural, extramedullary cyst, reversal of cord compression and symptoms. Histological diagnosis was of an arachnoid cyst. 2006 Elsevier Ltd. All rights reserved. Keywords: Arachnoid cyst; Spinal cord compression; Pain; Ataxia; Spine surgery; Histology
1. Introduction Thoracic spinal cord compression only rarely occurs in patients who do not suffer from malignant disease, an infection, a degenerative disorder or trauma. Therefore, a high index of suspicion is required to detect other causes of thoracic cord compression, probably as, at an early stage of disease, symptoms may be nonspecific, change over time and affect almost any location caudad to the lesion. In this way, arachnoid cysts (AC) within the thoracic spinal canal may mimic various neurological and non-neurological disorders and hamper prompt diagnosis.1–7 *
Corresponding author. Tel.: +41 0 31 951 50 57; fax: +41 0 31 951 50
58. E-mail address: [email protected] (T.-M. Markwalder).
We present a patient with a thoracic intradural, extramedullary AC and we discuss the symptoms, differential diagnosis, histology and successful surgical treatment. 2. Case report 2.1. History, clinical findings, radiological assessment A 55-year-old Caucasian woman presented with a 3month history of pain and dysaesthesia in the area of the thoracic spine radiating into the thoracic outlet, the lumbar spine, the right abdomen, the right hemipelvis and the right leg. Defecation and micturition were normal. Symptoms did not alter on postural changes.5 Because of the nonspecific nature of these complaints, radiological examinations of several anatomical areas were performed. Whereas computed tomography (CT)