Early CR has been made possible thanks to the development of new surgical techniques and anaesthetic management but even considering that, patient’s position on the operating table with regard to the treatment area, as well as in regard to the floor plane, and stabilization, is paramount for correct anaesthetic and surgical management preventing associated complications.
The use of head frames and classical stabilisation is not always possible in younger children a MSP, may involve complications and it is also completely impossible in newborns.
The two positions procedures, with SD for access to the anterior cranial vault and prone position (PP) for access to the posterior portion prevent cervical hypertension and jugular venous return is not compromised. However, simple PP fails to prevent increased intraocular pressure and lesions to the optical nerve and a second surgical procedure or re-positioning during surgery is required.
We have had very good results with a MSP. It that can be used in newborns and older children and does not require cranial stabilisation. Obviosuly, highly expert surgeons need to be involved to ensure that the head is always supported when there is a greater risk of pressure. (Fig. 2). In any case, and particularly in smaller children, it is normal practice for experienced paediatric neurosurgeons.
It consists of a PP with cervical extension – though not hyperextension – being thus suitable for patients with cervical abnormalities. Greater calvarial exposure is achieved by using a reverse Trendelenburg position with an inclination of 30–45° instead of hyperextension. In our series, no variation in the patient’s position on the table was required during surgery, and we experienced no problems related with insufficient cranial access.
The head is supported on the malar region, resting on a padded surface customised to adapt perfectly to the size of each patient better that market solutions, ,. avoiding changes in position and periodical head lifting.
MSP offers a balance between controlling the risk of venous haemorrhaging and VAE 4. Except in one case, we have found no reports of serious complications when the head was supported in this position.
In MSP there is no over-extension of the cervical region, as we verified by CT scans (Fig. 4). Interestingly, we observed no changes in patients in the SD/MSP, possibly because posterior deformations in scaphocephalic children are associated with changes in the head-neck relationship. As far as we know, no studies objectively evaluating the cranial-spinal relationship in this type of surgery have been performed.
The tube placed between the two rings and combined with the non-hyperextended position helps to prevent accidental extubation without airway compromise. (Fig. 5).