|Year : 2020 | Volume
| Issue : 3 | Page : 169-170
Sitting position for posterior fossa tumor in infants: A technical report
Dattatraya Muzumdar1, Shyle Mehta2, Dikpalsingh Jadhav1
1 Department of Neurosurgery, Seth GS Medical College and King Edward VII Memorial Hospital, Mumbai-400012, Maharashtra, India
2 Graduate medical education, Drexel University College of Medicine, Philadelphia, USA
|Date of Submission||24-Sep-2020|
|Date of Acceptance||25-Sep-2020|
|Date of Web Publication||06-Nov-2020|
Dr. Dattatraya Muzumdar
Department of Neurosurgery, King Edward VII Memorial Hospital and Seth Gordhandas Sunderdas Medical College, Parel, Mumbai, Maharashtra.
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Surgery for posterior fossa tumors in sitting position is performed in very few neurosurgical centers all over the world. It carries the potential risk of air embolism with consequent related morbidity. However, posterior fossa surgery in the sitting position is still performed in neurosurgical centers with considerable expertise including neurosurgeons and neuroanesthesiologists. In older children and young adults, the sitting position is given with the appropriate modifications in the operating surgical table and the head fixation system. In infants, due to the small size of the baby and delicate physiology, the sitting position using standard protocol is challenging. A custom designed chair and its suitability for sitting position in infants is described. The chair assembly is secured to the operating surgical table. It is meant to align the infant in sitting position in an appropriate manner. The relevant surgical details including the advantages and limitations are discussed.
Keywords: Brain tumor, posterior fossa, sitting position
|How to cite this article:|
Muzumdar D, Mehta S, Jadhav D. Sitting position for posterior fossa tumor in infants: A technical report. J Pediatr Neurosci 2020;15:169-70
Posterior fossa tumor surgery is formidable due to the relationship of the tumor to important neurovascular structures in close proximity. The brainstem and posterior cerebellar inferior artery need to be safeguarded for successful outcome. The surgical challenges can be met if appropriate preoperative and perioperative preparations are precisely followed.
The position of the patient during surgery is crucial for defining the anatomical relationship of the tumor to the critical neurovascular structures in the vicinity. The surgery can be performed in the sitting, prone, or the park bench position. Sitting position is avoided in most centers worldwide due to fear of air embolism and its drastic consequences, which can inflict morbidity and sometimes mortality as well. The preliminary requisite of posterior fossa tumor surgery in a sitting position is a good positioning for surgery, which is comfortable to the surgeon for excision of the tumor as well as the anesthesiologist for monitoring and early detection of air embolism.
The positioning for surgery poses different challenges for very young and older children. The older children can lie recumbent on the mechanized neurosurgery operation table, which can be gradually elevated into the sitting position with the help of pillow support underneath the pelvic region, while monitoring the blood pressure. However, the small size of the child, low weight, and delicate physiology in infants pose a difficulty. In such a situation, the sitting position can be avoided and prone position can be adopted. However, surgery in the sitting position is possible with aid of a custom-made sitting chair, which can be mounted on the neurosurgery-operating table.
The sitting chair has a rectangular steel alloy slab, which forms the base measuring about 35 cm × 25 cm [Figure 1]. The superior surface of the slab is split into three compartments by vertical slabs measuring 10 cm × 10 cm placed 5 cm from the edge of the slab. They are secured to the base by plate and screws. The inferior aspect of the slab is fitted with fenestrated elongated rectangular steel bars. The bars in the front are long and short at the rear. The bars stabilize the chair on the operating table. The front bars rest on the operating table while the posterior bars are secured to the cranial end of the table by a robust long flat transverse steel rod with screws at either end [Figure 2]A.
|Figure 1: Sitting chair assembly: (A) front view, (B) lateral view, (C) superior view, and (D) along with the elongated steel rod with screws|
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|Figure 2: Sitting position of the patient placed on the sitting chair: (A) lateral view and (B) posterior view|
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While giving the sitting position in infants, the operating table is partially flexed at 30°–45° and then the infant is made to sit in the chair. The infant needs to be held gently and care should be taken to prevent any unnecessary torsional movements at the head, neck and the pelvic region. The remainder of the sitting position is then completed with monitoring of vital parameters. The head can be stabilized comfortably in a horse- shoe headrest attached to the operating table as done in other situations [Figure 2B]. Pin fixation is usually avoided to prevent inadvertent penetrating injury to the soft skull, underlying dura and brain.,
The sitting chair offers a viable alternative for posterior fossa tumor surgery in infants. The precautions to be taken are the same as for any other posterior fossa surgery in children. The anesthesiologist needs to be alert and monitor these infants closely. The surgeon needs to be vigilant about the positioning, blood loss and air embolism. There are no obvious disadvantages of the assembly or the positioning, if proper protocols are followed.
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Conflicts of interest
There are no conflicts of interest.
Declaration of Patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
| References|| |
Muzumdar D, Deshpande A, Kumar R, Sharma A, Goel N, Dange N, et al
. Medulloblastoma in childhood––King Edward Memorial hospital surgical experience and review: comparative analysis of the case series of 365 patients. J Pediatr Neurosci 2011;6:S78-85.
Muzumdar DP, Bhatjiwale MG, Goel A Plaster of Paris mould for stereotactic frame fixation. Pediatr Neurosurg 2005;41:229-32.
Muzumdar DP Simple technique of head fixation for image-guided neurosurgery in infants. Childs Nerv Syst 2007;23:611.
[Figure 1], [Figure 2]
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|[Pubmed] | [DOI]|