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

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.