Pinning in pediatric neurosurgery: the modified rubber stopper technique

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  • 1 Department of Neurosurgery, Baylor College of Medicine, Houston;
  • | 2 Division of Pediatric Neurosurgery, Texas Children’s Hospital, Houston, Texas;
  • | 3 Department of Neurosurgery, Northwestern University Feinberg School of Medicine, Chicago; and
  • | 4 Division of Pediatric Neurosurgery, Ann and Robert H. Lurie Children’s Hospital, Chicago, Illinois
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Head immobilization devices with skull pins are commonly used by neurosurgeons to stabilize the head for microsurgical techniques and to maintain accurate intraoperative neuronavigation. Pediatric patients, who may have open fontanelles, unfused sutures, and thin skulls, are vulnerable to complications during placement in pins. We review the various methods of pinning in pediatric neurosurgery and revisit the modified rubber stopper technique using a commonly available rubber stopper from a medication bottle over a standard adult pin of a Mayfield head clamp to prevent the pins from plunging through the thin pediatric skull.

ABBREVIATIONS

HID = head immobilization device.

Head immobilization devices with skull pins are commonly used by neurosurgeons to stabilize the head for microsurgical techniques and to maintain accurate intraoperative neuronavigation. Pediatric patients, who may have open fontanelles, unfused sutures, and thin skulls, are vulnerable to complications during placement in pins. We review the various methods of pinning in pediatric neurosurgery and revisit the modified rubber stopper technique using a commonly available rubber stopper from a medication bottle over a standard adult pin of a Mayfield head clamp to prevent the pins from plunging through the thin pediatric skull.

ABBREVIATIONS

HID = head immobilization device.

In Brief

The authors provide a review of the history, development, and variation in head immobilization devices and pinning techniques and an overview of the special considerations of pinning in pediatric patients, along with a description of the modified rubber stopper pin technique to diffuse pressure and minimize the risk of injury. This information is important because cranial characteristics of pediatric patients, including open fontanelles, unfused sutures, and thin skulls, must be taken into account to avoid pinning complications, which are more common in the pediatric population.

Cranial pins used with head immobilization devices (HIDs) during neurosurgery serve to stabilize the cranium, fixing the head in a set position to enable microsurgical treatment of various intracranial pathologies and posterior cervical spine surgeries. HIDs prevent unsteadying movements intraoperatively, give surgeons controlled access to specific areas of the brain and skull base, and allow for a variety of retraction adaptors to be used. Over time, the use of HIDs has greatly changed intracranial surgery.

The history of HIDs dates back to the late 19th century when Sir Victor Horsley devised a headrest to immobilize the patient’s head during brain surgery.1,2 In 1905, Dr. Charles Frazier first described a horseshoe to cradle the face of patients in the prone position during posterior fossa surgery.3 Dr. James Gardner later built a chair fastened with a 3-point cushioned headrest in 1938 for sitting surgery.4,5 The application of the microscope in neurosurgery during the 1950s further advanced microsurgical techniques that require complete immobilization of the skull.6 Gardner, along with Elmer Ries, subsequently developed a pinned head clamp, called the Gardner clamp, that had 2 pins spaced on a rocker arm on the opposite side of the third pin.5,7 The Gardner clamp was superseded by the Mayfield clamp, which allowed the rocker arm with 2 pins to rotate, providing adaptability and customization of pin insertion (pinning).8,9 These 3-point head fixation devices increased access to the cranial vault while firmly steadying the head and preventing the pressure-related complications to the face and eyes sometimes encountered with the horseshoe headrest during prone positioning. Today, a variety of skull clamps and adaptive connected devices are widely used within neurosurgery.

Pinning has dramatically changed the field of neurosurgery, enabling previously difficult surgery to become commonplace and allowing for the use of registration of intraoperative navigation to assist with surgical planning and execution. While pinning is a common act in neurosurgery, this process is not without consequences and can most certainly continue to be improved. We present a review of considerations when pinning pediatric patients in neurosurgery as well as a useful modification to pinning that we believe can offer an additional safety measure when placing a pediatric patient in pins.

Standard Techniques

Many types of HIDs employing skull pins are commercially available (Table 1). The Mayfield skull clamp (Integra LifeSciences) is the most widely used HID in the world.9,10 It is equipped with a force gauge integrated in the torque screw on the side with 1 pin. The 80-lb (36 kg) and the 18-lb (8 kg) torque screw options are recommended for adults and toddlers, respectively. The company also produces the Mayfield Triad skull clamp, which has clamping force indicators and allows adjustment of the force of all 3 pins. Any of the Mayfield clamps accommodate simultaneous use of a horseshoe headrest and skull pins to support the weight of the head and allow for reduction of the torque screw load, while maintaining immobilization.

TABLE 1.

Comparison of pinning techniques in pediatric neurosurgery

Pinning TechniqueRolesProsCons
3-Point fixation
 Mayfield skull clampMicrosurgical resection2-pinned arm may rotate for flexible positioningIncreased force on single-pinned arm
Navigated surgeryMay use w/ horseshoe head holder to reduce loadRequires 2-pinned arm to ideally be on dependent side of head for positioning/pinning
Ability to attach self-retaining retractorsTorque gauge
 Mizuho Freedom clampMicrosurgical resection2-pinned arm may rotate for flexible positioningRequires 2-pinned arm to ideally be on dependent side of head for positioning/pinning
Navigated surgeryEqually distributed force across frame
Ability to attach self-retaining retractorsTorque gauge
 Doro headrest systemMicrosurgical resection2-pinned arm may rotate for flexible positioningRequires 2-pinned arm to ideally be on dependent side of head for positioning/pinning
Navigated surgeryTorque gauge
Ability to attach self-retaining retractorsRadiolucent frame
Can be MRI compatible
Built-in navigation adaptor
 Modified Mayfield techniqueMicrosurgical resection2-pinned arm may rotate for flexible positioningRequires 2-pinned arm to ideally be on dependent side of head for positioning/pinning
Navigated surgeryMay use w/ horseshoe head holder to reduce loadNot studied in engineering/biomechanical models
Ability to attach self-retaining retractorsTorque gaugeStopper surface may cause local pressure on skin
Modified stopper technique can provide buffer to distribute force from pin to wider area to prevent plunging
4-Point fixation
 Leksell coordinate frameStereotactic targetingStereotactic frame to allow for accurate & precise localizationCircumferential frame can be challenging to place in patients w/ large heads
RadiosurgeryLarger range of entry trajectories to head than MayfieldAdjustable 4 bars may limit flexion/extension of head in positioning
In awake cases, head frame partially covers face & may lead to discomfort
6-Point fixation
 Sugita multipurpose head frameMicrosurgical resectionUse of 4–6 pin sites relatively off-loads individual pin sites compared to 3-point pinsNo force gauges
Navigated surgeryLess ability to flex head in prone positioning
Ability to attach self-retaining halo retractor systemResults in more pin sites

With the Sugita multipurpose head frame system (Mizuho America, Inc.), the head is held in the center of a semicircular head holder by at least 4 head pins. Unlike the Mayfield, it does not have an integrated force gauge to guide the surgeon during pinning. The common practice is to apply “two-finger” tightness. The head holder has 6 pin slots to choose from depending on the head position. More pins can be utilized to provide the same rigid fixation with less insertional torque pressure at each pin site. A basal frame is fastened to the head holder for attachment of self-retaining retractors, hand rests, trays for patties, and instrument receptacles.

The Mizuho Freedom clamp (Mizuho America, Inc.), also called the Dinkler Surgical Freedom clamp, has 2 of the 3 pins directly opposing each other. Tightening of the torque knob applies equal forces to both sides of the clamp and thus requires less pin force than would be required with clamps with a rocker arm. The third pin is located on an arc that can pivot 360° along the axis to allow the 3 pins to be placed independent of each other.

The Doro headrest system (Pro Med Instruments) is another HID with 3 points of fixation. Similar to the Mayfield, with a deeper frame to allow for a longer gantry, the Doro has radiolucent and MRI compatibility, enabling safety and ease of transfer into intraoperative MRI or CT suites. Additionally, the clamp has built-in navigation adaptors, minimizing the need for additional reference arrays.

The Leksell Coordinate frame (Elekta) is fixed to the patient’s head circumferentially with 4 adjustable fixation posts and pins. The rectangular frame enables highly accurate target localization but limits cranial access. It is ideal for stereotactic neurosurgery, such as brain biopsy, endoscopic surgery, electrode implantation, and radiosurgery.

A dynamic reference frame can be attached to HIDs for registration for accurate intraoperative navigation, as long as the head remains affixed to the clamp, which does not change position during the surgery. The two most common systems are the Brainlab system (Brainlab) and the StealthStation surgical navigation system (Medtronic). Both require various reference arrays to be secured to the HID, and they are then registered to 3D-acquired imaging with 1-mm axial cuts at the 0° gantry angle for proper registration of anatomical landmarks. Electromagnetic systems such as AxiEM (Medtronic) are also available, which require adhering a reference array to the patient without the need for rigid 3-point head fixation. Additionally, other adapters, such as the Greenberg retractor system (Symmetry Surgical, Inc.), provide a base for fixed brain retractors and other accessories that is similar to the Sugita basal frame but can be attached to the arm of any HID model.

HID manufacturers provide an option of skull pins designed for use on a child. The tips of pediatric pins are more obtuse than adult pins and have a flat surface at the base to prevent full penetration of the skull. However, with enough torsional force the pins can cause the skull to fracture. Also, because the pin tip is short, the hard base can exert constant pressure on the skin and cause necrosis during long operations.11

Considerations in Pediatric Patients

There are several key considerations when using pinning in pediatric patients during neurosurgery. First and foremost, the youngest of neurosurgical patients will have an open cranial vault with open sutures and fontanelles. The posterior fontanelle closes first, at 2–3 months after birth.12 This is followed by the frontolateral fontanelle at 6 months of age, and then the posterolateral fontanelle at 6–18 years of age. The anterior fontanelle closes last, between the 1st and 3rd years of life.10 The sutures fuse more slowly than the fontanelles, starting with the metopic suture, followed by the coronal sutures, lambdoidal sutures, and finally, the sagittal suture.13,14 Most sutures do not become completely ossified until adulthood. However, as interdigitation across the sutures progresses, a child’s cranium can withstand greater external forces.15,16 Until the fontanelles and sutures close, these membranous areas of the skull cannot support skull pins and are easily pierced. If the sutures are not adequately fused, the bone plates can displace or collapse under the pins during the operation, especially in operations where CSF is drained, causing a decrease in intracranial pressure or a loss of skull fixation.17

The flat bones of the skull form during embryologic development by intramembranous ossification and are thin and weak in the newborn.18 CT scans of children younger than 6 years have shown that the skull can be as thin as 1.1 mm.19 The skull rapidly increases in thickness during the first 20 years of life, and the growth then plateaus between the 3rd and 6th decades.17,19–22 However, there are large variations in thickness at any particular area of the skull between children of the same age group and between those of different age groups.17,19 Because of this, it is important to consider a preoperative CT scan of the skull to guide placement of the pins in pediatric patients.

In addition to normal variations in infants, including thin flat bones and open sutures, certain neurosurgical diseases more commonly seen in pediatric patients can further contribute to skull changes. Hydrocephalus is perhaps the most commonly treated pediatric neurosurgical disease that can most certainly change the thickness and shape of the skull. In infancy, hydrocephalus can influence intracranial pressure, thinning the bones of the skull and widely splaying sutures, further limiting the use of pinning in these patients. Figure 1A demonstrates these findings in CT images of the head of a 4-month-old child with intraventricular hemorrhage of prematurity and subsequent shunted hydrocephalus. Additionally, pediatric patients with chronic obstructive hydrocephalus may present with a “copper-beaten” or “scalloped” skull that has thinned over time due to raised intracranial pressure from chronic hydrocephalus. Figure 1B demonstrates the thin skull of a 16-year-old patient after resection of a third ventricle tumor and shunting for obstructive hydrocephalus.

FIG. 1.
FIG. 1.

Images obtained in pediatric patients showing cranial conditions that increase restrictions on the use of cranial pinning. A: 3D reconstructions of CT scans of the head of a 4-month-old child with intraventricular hemorrhage of prematurity and subsequently shunted hydrocephalus. B: Axial and coronal CT scans demonstrating the thin skull of a 16-year-old patient with subsequently shunted obstructive hydrocephalus after resection of a tumor in the third ventricle.

In young patients with thin skulls, the use of HIDs with pins has led to complications. The incidence of these complications reported in the literature is from 0.65% to 1.1%, which is higher than that seen in adult patients.11,18 The most prevalent complication is depressed skull fracture, most often involving the thin temporal bone.6,23 Penetration of the inner table by the pins can cause a CSF leak, air embolism, traumatic aneurysm, or arteriovenous fistula.24 A tear of the middle meningeal artery can result in an epidural hematoma that can be particularly deleterious if the hematoma is large and goes undetected during a long operation.23,25 Warning signs to be aware of include a cracking sound during HID placement, appearance of a pin going too deep, drop in HID pressure gauge readings, pins found loose at the end of the case, or unexplained brain edema during the operation.23 These findings should prompt an immediate CT scan of the head to identify any injuries.

To avoid complications due to pinning, the first step would be to use pinless HIDs, such as horseshoe head holders or donuts, for cases that do not require intraoperative navigation and when prolonged skin and eye pressure is not of concern. If pinning is warranted, pins should be inserted perpendicular to the skull surface to avoid scything or slippage. A preoperative CT scan can be used to assess areas of thin skull and sites for viable pin placement locations, especially in high-risk patients with multiple prior surgeries or thinned skulls due to hydrocephalus or slow-growing tumors. The use of phantom pinning with a digital millimetric caliber adjusted to the width of the rocker pins has been reported for planning appropriate pin sites prior to application.26 Locations to avoid include open fontanelles and cranial sutures, thin squamous temporal bone, frontal sinuses, mastoid air cells, and the supraorbital and supratrochlear nerves. When using the Mayfield or other 3-point fixation HIDs, the arm with 2 pins should be placed on the dependent side of the head. Application of 4 or more pins, such as with the Sugita clamp, will provide rigid immobilization of the head with less pin force. Use of a horseshoe headrest or suction beanbag in conjunction with the HID will also permit reduced pin pressure.27,28

Due to these aforementioned considerations and no clear guidelines in the literature, there is wide variability regarding pinning in pediatric neurosurgical practice. Although many pediatric neurosurgeons limit the use of pin-type HIDs to children older than 3 years of age, some have used head pins in children younger than 1 year.10,11,23,24,29 Based on the results of a survey of 156 pediatric neurosurgeons, Berry et al. suggest avoiding the use of pinning in children younger than 2 years.10 Additionally, a common rule of thumb when using Mayfield clamps is to apply 10–20 lbs of pin force for children 2–3 years old, 21–30 lbs for those 3–4 years old, and 21–40 lbs of force for children 4–5 years old, though this rule has not been universally adopted. Tapered pediatric pins are sometimes used until the age of 10 years, while some neurosurgeons do not use pediatric pins at all.10

Conversely, there is no recommended appropriate torque to administer when pinning the pediatric skull with the Sugita clamp. For long-term head fixation onto a halo with screw pins to stabilize cervical spine injury, torque of 4–6 inch-lb applied to 6 pins is recommended for children 3–5 years of age.21 The insertion torque can be increased to 6–8 inch-lb for older children.20,21 Although the head pins for the Sugita clamp are threaded screws inserted similarly to those used with a halo, the Sugita clamp pins are typically tightened manually without a torque screwdriver. Therefore, the force applied during pin insertion can differ widely even among experienced surgeons.19 Also, increased friction at the threads between pins and the head holder, from damage or lubrication of the thread from fluid, can affect the vertical force unpredictably with the same applied torque pressure.

Modified Techniques

While each of the aforementioned modalities have their benefits, there remains room for improvement and further development. Modifications and adjustments to pinning in pediatric populations have been reported in the literature. For example, to prevent injuries caused by penetrating pins, Sgouros et al. placed thick pads of soft felt, backed by 3-cm-diameter machined Perspex discs, over the 3 pins of the Mayfield clamp to brace the head, with the weight of the head then supported by a suction beanbag.28 Okudera et al. used modified L-shaped carbon fiber pin heads to reduce intraoperative CT artifacts when using the Sugita HID.30

We revisited another modified technique for pinning in this population, which uses a commonly available device as a modifier to the standard Mayfield 3-point HID. The modified rubber stopper technique was first described in 1996, when it was used in the case of a 5-month-old infant undergoing a stereotactic biopsy, for which rubber stoppers were applied to the 4-point fixation pins of a stereotactic frame, thus more widely diffusing pressure, providing stable fixation, and reducing risk of skin or bone damage.31 In this approach, a commonly discarded rubber stopper from a medication bottle or Vacutainer tube is retained and used to modify the pins normally used in the Mayfield skull clamp. A normal adult pin pierces the rubber stopper, which is hubbed at the base of the pin, leaving a smaller tip of the adult pin exposed, which is surrounded by a soft rubber buffer to further distribute force from pinning to a wider area while preventing the adult pin from plunging with excess force or plunging too deep in patients with thinner skulls. This modification minimizes the risk of skull fractures secondary to pinning in this vulnerable population and also minimizes potential damage to the skin from scything or slippage of pins when less pressure is applied. While there is risk of pressure on the skin from the rubber stopper with the contact area, we have not personally encountered anything more injurious than some transient self-resolving skin erythema at these sites during longer procedures. Figure 2 shows the modified rubber stopper pin described above. This modification is applied to all 3 adult pins and the pins are placed in the Mayfield skull clamp as demonstrated in Fig. 3. The patient’s head is then affixed in the Mayfield clamp in the standard fashion.

FIG. 2.
FIG. 2.

Modified rubber stopper pin technique. Figure is available in color online only.

FIG. 3.
FIG. 3.

Modified rubber stopper pin technique used with the Mayfield skull clamp. Figure is available in color online only.

While this modified rubber stopper technique has not been specifically validated and remains untested in biomedical and engineering models, it can be applied in select cases. At our institution, no set protocol for its use exists, in favor of use according to individual physician preferences and practices; however, when applied, this modified technique is more commonly used in younger children, typically in those aged 2–5 years, though it has been used in children up to 10 years of age with thin skulls and in cases of underlying chronic hydrocephalus, in whom pin fixation is necessary for navigation or microsurgery.

Conclusions

There are many ways to secure and immobilize a patient’s head intraoperatively. While a variety of HIDs exist, ranging from 3-point to 6-point fixation, each HID has specific applications and uses. Special considerations must be taken into account when using these devices in pediatric patients, as pinning complications are more common in the pediatric population due to anatomical characteristics. We have reviewed the standard methods, equipment, and caveats applicable to the use of pinning in pediatric patients and highlighted a novel modification to the standard approach, the modified rubber stopper technique, which can help minimize the risks of this technique in these patients.

Disclosures

The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.

Author Contributions

Conception and design: Lam, LoPresti. Acquisition of data: LoPresti, Nyugen. Analysis and interpretation of data: LoPresti, Nyugen. Drafting the article: LoPresti, Nyugen. Critically revising the article: Lam, LoPresti. Reviewed submitted version of manuscript: Lam, LoPresti. Approved the final version of the manuscript on behalf of all authors: Lam. Administrative/technical/material support: Lam. Study supervision: Lam.

References

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    Sir Victor Horsley’s clinic at the National Hospital for the Paralyzed and Epileptic, Queen Square. Br J Surg. 1913;1(3):515517.

  • 2

    Singh G. Positioning in neurosurgery. In: Prabhakar H, ed. Essentials of Neuroanesthesia. 1st ed. Academic Press; 2017:184204.

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    Nathoo N, Mayberg MR, Barnett GH. W. James Gardner: pioneer neurosurgeon and inventor. J Neurosurg. 2004;100(5):965973.

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    Vitali AM, Steinbok P. Depressed skull fracture and epidural hematoma from head fixation with pins for craniotomy in children. Childs Nerv Syst. 2008;24(8):917923, 925.

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    Jaslow CR. Mechanical properties of cranial sutures. J Biomech. 1990;23(4):313321.

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    Wong WB, Haynes RJ. Osteology of the pediatric skull. Considerations of halo pin placement. Spine. 1994;19(13):14511454.

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    Gupta N. A modification of the Mayfield horseshoe headrest allowing pin fixation and cranial immobilization in infants and young children. Neurosurgery. 2006;58(1)(suppl):E181.

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    Sgouros S, Grainger MC, McCallin S. Adaptation of skull clamp for use in image-guided surgery of children in the first 2 years of life. Childs Nerv Syst. 2005;21(2):148149.

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    Okudera H, Kobayashi S, Kyoshima K, Sugita K. Modified head fixation system for intraoperative CT scanning—technical note. Neurol Med Chir (Tokyo). 1992;32(1):3839.

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Contributor Notes

Correspondence Sandi K. Lam: Lurie Children’s Hospital, Northwestern University Feinberg School of Medicine, Chicago, IL. sandilam@gmail.com; slam@luriechildrens.org.

INCLUDE WHEN CITING Published online April 10, 2020; DOI: 10.3171/2020.1.PEDS19541.

Disclosures The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.

  • View in gallery

    Images obtained in pediatric patients showing cranial conditions that increase restrictions on the use of cranial pinning. A: 3D reconstructions of CT scans of the head of a 4-month-old child with intraventricular hemorrhage of prematurity and subsequently shunted hydrocephalus. B: Axial and coronal CT scans demonstrating the thin skull of a 16-year-old patient with subsequently shunted obstructive hydrocephalus after resection of a tumor in the third ventricle.

  • View in gallery

    Modified rubber stopper pin technique. Figure is available in color online only.

  • View in gallery

    Modified rubber stopper pin technique used with the Mayfield skull clamp. Figure is available in color online only.

  • 1

    Sir Victor Horsley’s clinic at the National Hospital for the Paralyzed and Epileptic, Queen Square. Br J Surg. 1913;1(3):515517.

  • 2

    Singh G. Positioning in neurosurgery. In: Prabhakar H, ed. Essentials of Neuroanesthesia. 1st ed. Academic Press; 2017:184204.

  • 3

    Goodrich JT. History of posterior fossa tumor surgery. In: Ozek MM, Cinalli G, Maixner W, Sainte-Rose C, eds. Posterior Fossa Tumors in Children. 1st ed. Springer; 2015:360.

    • Search Google Scholar
    • Export Citation
  • 4

    Gardner WJ. A neurosurgical chair. J Neurosurg. 1955;12(1):8186.

  • 5

    Nathoo N, Mayberg MR, Barnett GH. W. James Gardner: pioneer neurosurgeon and inventor. J Neurosurg. 2004;100(5):965973.

  • 6

    Uluç K, Kujoth GC, Başkaya MK. Operating microscopes: past, present, and future. Neurosurg Focus. 2009;27(3):E4.

  • 7

    Ries EF, inventor; RIES Manufacturing CO, assignee. Surgical device. US patent 3,099,441. July 30, 1963.

  • 8

    Assina R, Rubino S, Sarris CE, et al. The history of brain retractors throughout the development of neurological surgery. Neurosurg Focus. 2014;36(4):E8.

    • Search Google Scholar
    • Export Citation
  • 9

    Mayfield skull clamp. Operative Neurosurgery. Accessed February 17, 2020. https://operativeneurosurgery.com/doku.php?id=mayfield_skull_clamp

    • Search Google Scholar
    • Export Citation
  • 10

    Berry C, Sandberg DI, Hoh DJ, et al. Use of cranial fixation pins in pediatric neurosurgery. Neurosurgery. 2008;62(4):913919.

  • 11

    Vitali AM, Steinbok P. Depressed skull fracture and epidural hematoma from head fixation with pins for craniotomy in children. Childs Nerv Syst. 2008;24(8):917923, 925.

    • Search Google Scholar
    • Export Citation
  • 12

    Beasley M. Age of fontanelles/cranial suture closure. Center for Academic Research & Training in Anthropogeny. Accessed February 17, 2020. https://carta.anthropogeny.org/moca/topics/age-fontanelles-cranial-sutures-closure

    • Search Google Scholar
    • Export Citation
  • 13

    Harth S, Obert M, Ramsthaler F, et al. Ossification degrees of cranial sutures determined with flat-panel computed tomography: narrowing the age estimate with extrema. J Forensic Sci. 2010;55(3):690694.

    • Search Google Scholar
    • Export Citation
  • 14

    Sim SY, Yoon SH, Kim SY. Quantitative analysis of developmental process of cranial suture in Korean infants. J Korean Neurosurg Soc. 2012;51(1):3136.

    • Search Google Scholar
    • Export Citation
  • 15

    Jaslow CR. Mechanical properties of cranial sutures. J Biomech. 1990;23(4):313321.

  • 16

    Margulies SS, Thibault KL. Infant skull and suture properties: measurements and implications for mechanisms of pediatric brain injury. J Biomech Eng. 2000;122(4):364371.

    • Search Google Scholar
    • Export Citation
  • 17

    Wong WB, Haynes RJ. Osteology of the pediatric skull. Considerations of halo pin placement. Spine. 1994;19(13):14511454.

  • 18

    LoPresti MA, Sellin JN, DeMonte F. Developmental considerations in pediatric skull base surgery. J Neurol Surg B Skull Base. 2018;79(1):312.

    • Search Google Scholar
    • Export Citation
  • 19

    Letts M, Kaylor D, Gouw G. A biomechanical analysis of halo fixation in children. J Bone Joint Surg Br. 1988;70(2):277279.

  • 20

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