16 month old patient undergoing bilateral craniotomy for scaphocephaly and sagittal craniosynostosis. Procedure is 4 hr 17 min. Ped. Neurosurgeon is primary surgeon with assistance from oral & maxillofacial surgeon. Head was placed prone in a Mayfield horseshoe head holder. Pressure points padded. No reference in op notes to alleviating pressure on patient's cheeks intraoperatively. Upon completion of the procedure and turing pt. to supine, noted pressure sites on bilateral cheeks with skin tear on left cheek. The right side resolved but the left became a pressure wound that has left a significant scar one year post-op. The photo below shows the wound at 10 months.
Florida would require the expert opinion to be rendered by a neurosurgeon with a subspecialty in pediatrics.
It would seem that even with padding, the surgeon would left the head slightly to alleviate any risk of ischemia. Or is padding sufficient to comply with the recognized standard of care?
Files:
Q: What material was used for facial padding and head holding? How was the head positioned?
A: Unknown specifically. Op note says, "All pressure points were padded appropriately and he was secured to the operative table using a lapbelt seatbelt." The op note relates that the pt's head was placed on a Mayfield horseshoe head holder.
Q: What was the surgical approach? A bilateral craniotomy is not the typical approach for treatment of saggital synostosis and the case seems excessively long for this treatment.
A: "bicoronal incision just posterior to the coronal sutures and guided by preoperative virtual planning." Under the "Operation" section the surgeon lists "Bilateral craniotomy, parieto and parietal occipital for posterior vault reconstruction".
Do you believe there might have been medical error?
Yes. typically these pressure ulcers are avoidable with adequate padding and paying attention to not placing much added pressure on the head while operating. These injuries are the result of an error or inattention to care.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Yes. there's not other reason for the patient to have developed this pressure ulcer.
What makes you a good expert for this case?
Board Certified in Pediatric Neurosurgery
How often do you encounter cases similar to this one in your practice?
I have not had such a complication in the past, but I do encounter craniosynostosis cases.
Do you believe there might have been medical error?
The surgical time is quite long and padding alone may not be sufficient to comply with the standard of care to reduce facial skin ischemia in prone cranial surgery. Adults are placed in skull pins without pressure on the face. The thin skull of pediatric patients prevent the use of pins, thus padding and other support measures become very important. Most crucially the face must be checked often during surgery and the head slightly repositioned. The injury is due not only to gravity but also due to multiple surgeons pressing down on the head during manipulations. Facial skin ischemia is a recognized risk of prone cranial surgery in infants, but several strategies can be employed based on evidence from the medical literature. Besides supportive padded headrests to minimize inappropriate pressure on the face, the bed inclination to elevate the head can be beneficial when possible. Another approach involves the use of a re-engineered boxing sports helmet adapted for infants, which provides a lightweight foam-based face mask. This device has been shown to maintain low skin surface pressure on facial structures, thereby potentially reducing the risk of skin damage or ischemia. Also use of a paraffin tulle gras dressing to cover bony prominences during surgery has been demonstrated to effectively prevent facial pressure ulcers, suggesting its utility in also preventing ischemia by reducing pressure and friction.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
The guidelines from the International Surgery journal emphasize that while supportive padded headrests can minimize inappropriate pressure on the face, the risk of pressure sores and ischemia still exists, particularly with prolonged surgery and increased facial edema. A study by Grisell and Place also highlights that different types of positioners can significantly affect tissue interface pressures, suggesting that the choice of specific protective equipment can impact the risk of developing pressure ulcers. A study by Zeng et al. indicates that newer technologies like fluidized positioners might offer better protection against skin damage compared to traditional gel pads, suggesting that advancements in padding technology are important for improving patient outcomes in prone positioning. While padding is a critical component of preventing facial skin ischemia, the type and quality of the padding, along with other surgical positioning techniques, play a crucial role in adhering to the standard of care. The surgeons in this case should have checked the face during a relatively long operation. Pressure from gravity and from applied pressure on the head during the surgical procedure likely caused the pressure sore which has become disfiguring. A combination of advanced positioning devices, and more careful techniques would have minimized this risk.
What makes you a good expert for this case?
I am aboard certified neurosurgeon with 12 years experience. I have reasonable experience as an expert witness on both side. I am however not specifically certified in pediatric neurosurgery.
How often do you encounter cases similar to this one in your practice?
I perform 4-6 prone surgeries per month.
Do you believe there might have been medical error?
If the child's head was positioned properly, in the appropriate head holder, and with the appropriate padding precautions, this injury should not have occured. Also, the duration of the case seems a bit excessive for correction of scaphocephaly, as well as the description of the technique (bilateral craniotomy) does not sound like the standard of care for sagittal synostosis.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Yes, depending on the positioning, padding, and surgical technique (and length), if in error, these would be a direct cause of this injury.
What makes you a good expert for this case?
I am a dual board certified pediatric neurosurgeon (ABNS, ABPNS 2019) with experience treating sagittal synostosis successfully and without complication.
How often do you encounter cases similar to this one in your practice?
I treat 5-10 cases of craniosynostosis a year, plus numerous additional pediatric cases (tumor resection, chiari decompression) that require prone positioning and hence attention to prevention of this type of injury (which I have never had or seen in my partner's cases).
Want to open a case or submit response?
Comments are accepted only from Neurological Surgery experts.