P06.05 The Sitting Position in the Very Young Pediatric Population: Pearls and Pitfalls of a 10-Years’ Experience

Abstract BACKGROUND To investigate pearls and pitfalls of the sitting positioning in the pediatric population with special focus on related morbidity and surgical practicability. MATERIAL AND METHODS A retrospective analysis of a prospectively maintained internal database was performed. All pediatric patients younger than 18 years at date of surgery, who underwent procedures in sitting position between 01/2010 and 10/2020 were included into this analysis. RESULTS A total of 42 of posterior fossa surgeries were performed in 38 children between 01/2010 and 10/2020. Mean age at surgery was 8.9 years (13 months - 18 years). Mean height and weight were 134.4 (± 30.2) cm and 36.6 (± 21.7) kg respectively. Three children (7.9%) were diagnosed with persistent foramen ovale. Electrophysiologic monitoring was unremarkable during positioning in all cases. Mean time needed for anesthesiologic preparation and positioning was 84.5 (± 20.6) minutes. Perioperative blood transfusion was needed in 5 cases (11.9%). Incidence of VAE was 11.9%. There was no VAE related severe complication. One child (2.4%) showed postoperative skull fracture and epidural bleeding due to skull clamp application. Clinical status immediately after surgery was favorable or stable in 33 of the cases (78.6%). CONCLUSION Attentive performance and an experienced surgical team provided; the sitting position remains a safe variant for posterior fossa surgery in the pediatric population. Precautious skull clamp application and appropriate monitoring is highly recommended. Considering eloquent aspects, the sitting position offers excellent anatomical exposure and is ideal for combination with endoscopic techniques.

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The semisitting position in pediatric neurosurgery: pearls and pitfalls of a 10-year experience

Journal of Neurosurgery Pediatrics ◽

10.3171/2021.6.peds21161 ◽

2021 ◽

pp. 1-10

Author(s):

Fritz Teping ◽

Stefan Linsler ◽

Michael Zemlin ◽

Joachim Oertel

Keyword(s):

Prone Position ◽

Posterior Fossa ◽

Pediatric Population ◽

Clinical Status ◽

Skull Fracture ◽

Pediatric Neurosurgery ◽

Time Frame ◽

Special Focus ◽

Posterior Fossa Surgery ◽

Venous Air Embolism

OBJECTIVE The authors sought to investigate the pearls and pitfalls of using the semisitting position in pediatric neurosurgery, with special focus on related morbidity and surgical practicability. METHODS All pediatric cases at a single institution were evaluated retrospectively. Those patients who underwent procedures in the semisitting position between December 2010 and December 2020 were included in the final analysis. Results were compared with all children who underwent surgery in the prone position for posterior fossa lesions within the same time frame. RESULTS A total of 42 posterior fossa surgeries were performed in 38 children in the semisitting position between December 2010 and December 2020. The mean patient age at the time of surgery was 8.9 years (range 13 months–18 years). The data of 24 surgeries performed in the prone position in 22 children during the same time frame were analyzed in comparison. Three children (7.9%) were diagnosed with a persistent foramen ovale preoperatively. The surgery was completed in all cases. The incidence of venous air embolism (VAE) was 11.9%. There was no VAE-related hemodynamic instability, infarction, or death. Endoscopic techniques were applied safely in 14 cases (33.3%). Postoperative pneumocephalus occurred significantly more frequently in patients who had undergone procedures in the semisitting position (p < 0.05), but without the need for intervention. During 1 surgery (2.4%), the patient experienced a postoperative skull fracture and epidural bleeding due to the skull clamp application. Clinical status of the patients immediately after surgery was improved or stable in 33 of the 42 surgeries (78.6%) performed in the semisitting position. CONCLUSIONS With attentive performance and an experienced surgical team, the semisitting position is a safe option for posterior fossa surgery in the pediatric population. With a comparable complication profile, the semisitting position offers excellent anatomical exposure, which is ideal for the application of endoscopic visualization. Careful skull clamp application and appropriate monitoring are highly recommended.

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EXTENSIVE SPINAL CORD INFARCTION AFTER POSTERIOR FOSSA SURGERY IN THE SITTING POSITION: CASE REPORT

Neurosurgery ◽

10.1227/01.neu.0000125008.93625.5e ◽

2004 ◽

Vol 54 (6) ◽

pp. 1512-1516 ◽

Cited By ~ 26

Author(s):

Xavier Morandi ◽

Laurent Riffaud ◽

Seyed F.A. Amlashi ◽

Gilles Brassier

Keyword(s):

Spinal Cord ◽

Case Report ◽

Posterior Fossa ◽

Spinal Cord Infarction ◽

Posterior Fossa Surgery ◽

Sitting Position

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Experiences with the Sitting Position in Posterior Fossa Surgery in 310 Patients

Journal of Neurological Disorders ◽

10.4172/2329-6895.s1-002 ◽

2015 ◽

Vol s1 ◽

Author(s):

Petridis AK

Keyword(s):

Posterior Fossa ◽

Posterior Fossa Surgery ◽

Sitting Position

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Occurrence and management of postoperative pneumocephalus using the semi-sitting position in vestibular schwannoma surgery

Acta Neurochirurgica ◽

10.1007/s00701-020-04504-5 ◽

2020 ◽

Vol 162 (11) ◽

pp. 2629-2636

Author(s):

Kathrin Machetanz ◽

Felix Leuze ◽

Kristin Mounts ◽

Leonidas Trakolis ◽

Isabel Gugel ◽

...

Keyword(s):

Posterior Fossa ◽

Supine Position ◽

Tumor Size ◽

Clinical Symptoms ◽

Neurosurgical Procedures ◽

Posterior Fossa Surgery ◽

Sitting Position ◽

Tension Pneumocephalus ◽

Replacement Procedure ◽

Duration Of Surgery

Abstract Background The semi-sitting position in neurosurgical procedures is still under debate due to possible complications such as venous air embolism (VAE) or postoperative pneumocephalus (PP). Studies reporting a high frequency of the latter raise the question about the clinical relevance (i.e., the incidence of tension pneumocephalus) and the efficacy of a treatment by an air replacement procedure. Methods This retrospective study enrolled 540 patients harboring vestibular schwannomas who underwent posterior fossa surgery in a supine (n = 111) or semi-sitting (n = 429) position. The extent of the PP was evaluated by voxel-based volumetry (VBV) and related to clinical predictive factors (i.e., age, gender, position, duration of surgery, and tumor size). Results PP with a mean volume of 32 ± 33 ml (range: 0–179.1 ml) was detected in 517/540 (96%) patients. The semi-sitting position was associated with a significantly higher PP volume than the supine position (40.3 ± 33.0 ml [0–179.1] and 0.8 ± 1.4 [0–10.2], p < 0.001). Tension pneumocephalus was observed in only 14/429 (3.3%) of the semi-sitting cases, while no tension pneumocephalus occurred in the supine position. Positive predictors for PP were higher age, male gender, and longer surgery duration, while large (T4) tumor size was established as a negative predictor. Air exchange via a twist-drill was only necessary in 14 cases with an intracranial air volume > 60 ml. Air replacement procedures did not add any complications or prolong the ICU stay. Conclusion Although pneumocephalus is frequently observed following posterior fossa surgery in semi-sitting position, relevant clinical symptoms (i.e., a tension pneumocephalus) occur in only very few cases. These cases are well-treated by an air evacuation procedure. This study indicates that the risk of postoperative pneumocephalus is not a contraindication for semi-sitting positioning.

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Occipital condyle to cervical spine fixation in the pediatric population

Journal of Neurosurgery Pediatrics ◽

10.3171/2013.9.peds131 ◽

2014 ◽

Vol 13 (1) ◽

pp. 45-53 ◽

Cited By ~ 16

Author(s):

Libby Kosnik-Infinger ◽

Steven S. Glazier ◽

Bruce M. Frankel

Keyword(s):

Cervical Spine ◽

Posterior Fossa ◽

Pediatric Population ◽

Occipital Bone ◽

Occipital Condyle ◽

Type I ◽

Posterior Fossa Surgery ◽

Clinical Scenarios ◽

Spine Fixation ◽

Cervical Spine Fixation

Fixation at the craniovertebral junction (CVJ) is necessary in a variety of pediatric clinical scenarios. Traditionally an occipital bone to cervical fusion is preformed, which requires a large amount of hardware to be placed on the occiput of a child. If a patient has previously undergone a posterior fossa decompression or requires a decompression at the time of the fusion procedure, it can be difficult to anchor a plate to the occipital bone. The authors propose a technique that can be used when faced with this difficult challenge by using the occipital condyle as a point of fixation for the construct. Adult cadaveric and a limited number of case studies have been published using occipital condyle (C-0) fixation. This work was adapted for the pediatric population. Between 2009 and 2012, 4 children underwent occipital condyle to axial or subaxial spine fixation. One patient had previously undergone posterior fossa surgery for tumor resection, and 1 required decompression at the time of operation. Two patients underwent preoperative deformity reduction using traction. One child had a Chiari malformation Type I. Each procedure was performed using polyaxial screw-rod constructs with intraoperative neuronavigation supplemented by a custom navigational drill guide. Smooth-shanked 3.5-mm polyaxial screws, ranging in length from 26 to 32 mm, were placed into the occipital condyles. All patients successfully underwent occipital condyle to cervical spine fixation. In 3 patients the construct extended from C-0 to C-2, and in 1 from C-0 to T-2. Patients with preoperative halo stabilization were placed in a cervical collar postoperatively. There were no new postoperative neurological deficits or vascular injuries. Each patient underwent postoperative CT, demonstrating excellent screw placement and evidence of solid fusion. Occipital condyle fixation is an effective option in pediatric patients requiring occipitocervical fusion for treatment of deformity and/or instability at the CVJ. The use of intraoperative neuronavigation allows for safe placement of screws into C-0, especially when faced with a challenging patient in whom fixation to the occipital bone is not possible or is less than ideal.

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