Perspectives and practices in pediatric cranial fixation

OBJECTIVE: Cranial fixation is essential to many neurosurgical procedures for ensuring patient head immobilization and optimal surgical outcomes. However, complications such as skull fractures, scalp lacerations, and clamp slippage remain underreported and understudied in the pediatric patient population. This study aimed to identify pediatric neurosurgeon perspectives on skull clamping risks and protocols. METHODS: An anonymous 19-question survey was distributed to 295 pediatric neurosurgeons with an email address registered with the American Board of Pediatric Neurological Surgery and/or the American Society of Pediatric Neurosurgeons. Questions addressed clamping practices, injury experiences, perceptions of current safeguards, and attitude toward injury detection and prevention systems. RESULTS: Of the 295 pediatric neurosurgeons contacted, 64 (21.7%) responded, and 48 (16.3%) completed the full survey. The median age at which respondents reported clamping pediatric skulls without additional support was 2 years, and the median minimum clamping pressure was reported to be 40 pounds. Surgeons reported substantial variability in clamping practices, particularly in minimum and maximum pressure thresholds, often citing patient-specific skull thickness as a key determinant. Injury reporting revealed that 31.5% of respondents experienced at least one skull fracture annually, 48.1% reported at least one scalp laceration annually, and annual slippage or clamp loosening was reported by > 70% of respondents. Additionally, surgeons who provided preoperative counseling regarding clamping risks were more likely to experience related risks. Overall, these surgeons expressed dissatisfaction with existing clamping technologies, citing inadequate safeguards for both injury prevention and detection. Seventy-three percent of surgeons expressed eagerness to adopt technologies capable of mitigating risks, and 65% expressed eagerness to adopt technologies capable of injury detection. These findings highlight the burden of clamp-related complications in pediatric neurosurgery and an interest in the development of safer, more reliable cranial fixation systems. CONCLUSIONS: There are substantial challenges associated with the utilization of cranial fixation in pediatric patients. Exploring real-time intraoperative monitoring technologies may offer a promising avenue for improving patient safety and surgical outcomes.