Head slippage following displacement of a Mayfield head clamp leading to a unique complication of laryngeal edema in an intubated patient: case report

Abstract

Introduction: The Mayfield head clamp (MHC) is a three-pin skull clamp that allows excellent cranial stabilization during head and neck surgery and is the most frequently used head clamp in neurosurgery. In many cases, surgery is performed with complete reliance on the safety of the MHC. However, potentially serious or life-threatening complications, such as scalp lacerations, depressed skull fractures, venous emboli, or extradural hematoma can rarely occur. We describe a case in which the MHC displaced downwards due to sudden loss of grip during postoperative removal with a brief review of the literature. Case report: The patient was a 60-year-old male who was scheduled to undergo tumor resection of a recurrent bilateral parasagittal parafalcine meningioma via a bicoronal approach. While removing the MHC, the lower screw stabilizing the arm of the MHC system displaced downwards (when force was applied from both directions) leading to an extension of flexed neck along with jerking of the cervical spine despite hand stabilization of the head in an intubated patient with slight upward displacement of a tightly fixed endotracheal tube. Conclusion: We emphasize the importance of properly managing and maintaining instruments to prevent fatal injury.