Airway Management with Leksell Frame in situ with or without Frontal Bar: A Mannequin Study

Abstract

Background: The use of stereotactic headframes for neurosurgical procedures requiring targeted localization continues to grow with new advancements in technology and treatment modalities. A configuration of the Leksell stereotactic G frame with a straight front bar, useful in epilepsy and laser cases, almost completely obscures oral access and presents a significant airway challenge for the anesthetist. Although previous papers have suggested that the entire headframe should be removed during an airway emergency, we describe a novel method to remove only the front bar. Methods: We performed an observational mannequin study. Anesthesia personnel from a single center were asked to intubate a mannequin with the Leksell frame fully in situ and again with the front bar removed. In addition, the time to remove the entire frame versus only the front bar was investigated. Results: Eighteen anesthesia personnel participated in the study as well as four neurosurgeons. The average time to intubate the mannequin in the frame was 23.5 (11.4) seconds and with the front bar removed, 10.9 (2.5) seconds (p < 0.001). The average time taken to remove just the front bar by the neurosurgeons was 35.4 (7.3) seconds compared to an average of 83.3 (18.6) seconds to remove the headframe entirely (p < 0.001). Conclusion: Our study demonstrates that intubating with the Leksell front bar in situ is possible with videolaryngoscopy under an ideal situation. More importantly, the removal of just the front bar is a simpler more streamlined approach requiring statistically less time to secure an airway.

The Use of the Shikani Video-Assisted Intubating Stylet Technique in Patients with Restricted Neck Mobility

“…The stereotactic headframe used to stabilize the head and neck during stereotactic brain surgery makes accessing the airway a challenge, and conventional DL is of limited use in such scenarios [ 42 , 43 ]. Few studies proposed alternative airway management modalities, including using a flexible FOB, an intubating laryngeal mask airway (ILMA), a gum elastic bougie, a lightwand (e.g., Trachlight™), and videolaryngoscopy (VL) in some difficult airway scenarios [ 44 , 45 , 46 , 47 , 48 ]. The airway operators should know in advance that the in-place headframe may make it difficult to access the upper airway and thus have a contingency plan to handle the airway, should the need unexpectedly arise.…”

“…A mannequin study showed that intubating with VL under an ideal situation for the Leksell front bar in situ is possible [ 48 ]. To remove just the front bar is a simpler and more streamlined approach to provide a quicker airway control in case of emergency.…”

Innovations in diagnostic and treatment options for pediatric epilepsy and their anesthetic implications

“…Adding extensions to the anesthesia circuit and the intravenous tubing may be necessary. If an accidental extubation occurs, placement of an LMA may be the best rescue device, given the limitations of working in a magnetic field [12].…”

Targeting Accuracy of the Leksell Vantage Stereotactic System for Deep Brain Stimulation Surgery: A Retrospective Review

“…Perhaps most significant is that the frame itself is made of a nonmetallic, glass fiber–reinforced epoxy composite material that limits both MRI and computed tomography (CT) artifact, purportedly enhancing the fidelity of preoperative imaging. 1 The Vantage frame also lacks the G frame's front cross-bar, which blocks the patient's face, providing easier airway access in the event of an emergency 2 and allowing for better visualization of the patient's face, which can be beneficial during awake surgeries. The elimination of the front bar also increases patient comfort, as does the elimination of the G frame's notoriously uncomfortable ear bars, which are used during frame application.…”