Rigid head fixation during posterior cervical spine surgery is critical to achieve optimal surgical access and success, and to maintain patient safety. A multitude of other factors such as patient’s medical comorbidities, preoperative functional status, intraoperative anesthesia care, and postoperative rehabilitation also play a pivotal role in dictating the success and safety of cervical spine surgery. Although this article focuses on the comparison of common head fixation techniques in the cervical spine, a brief overview of the history of head fixation is critical as it directly informs our current surgical practice.

Throughout the early 1900s, there were rapid advancements in neurosurgical techniques and technologies. In 1906, Dr. Charles Frazier pioneered an operating table with a horseshoe-like headrest to assist in the prone posterior fossa surgical approach.1 Later, William James Gardner, one of Charles Frazier’s mentees, developed a neurosurgical chair with a head clamp for rigid fixation in response to adverse effects he noticed with the posterior fossa surgical approach.2 In 1955, Dr. Gardner revisited his original device and created a chair that could be converted to multiple different intraoperative positions with stable, rigid head fixation with pressurized liquid-filled head clamps that allowed for easier access to notable structures.3 The increasing application of the microscope in neurosurgical procedures necessitated complete head immobilization, driving further innovation. Gardner then developed the Gardner-Wells tongs, introducing a 2-point pin fixation for head immobilization.4 Thereafter, in 1973, George Kees and Dr. Frank Mayfield developed the 3-pin skull clamp, known today as the Mayfield head clamp.5

Despite newly introduced 3-6 pin systems, such as the Doro Headrest and Sugita multipurpose headframe, the Mayfield and Gardner-Wells tongs are still the most common head immobilization devices used in cervical spine surgery.6 However, the first significant innovation to head fixation in posterior cervical spine surgery since the 1960s came in 2017, with Mizuho’s introduction of the Levó Head Positioning system.7 The device introduced a novel approach to cranial stabilization, tackling safety and intraoperative flexibility issues introduced by other head clamps. This article explores the foundational principles, critical surgical considerations, and complications of using the Mayfield skull clamp, Gardner Well tongs, and the Levó head positioning system; the three most common head fixation techniques during cervical spine surgery.