To the Editor:—

We would like to present a report of two cases with an unusual intraoperative complication. A 12-yr-old boy with American Society of Anesthesiologists physical status I presented for tonsillectomy and adenoidectomy. After induction of anesthesia, the operating room (OR) table was rotated 90° to facilitate surgery. While moving the table, the head attachment of the table came off, causing the patient’s head to drop into an extreme extended position. When the headpiece was repositioned, cervical and upper thoracic spine radiography was performed, and the patient was allowed to awaken until he was seen to be moving all four limbs. An emergency neurosurgical consult was sought, and serious injury was ruled out. The incident was discussed with the family, and surgery was performed without complications. The postoperative course was uneventful.

A 3-yr-old boy with American Society of Anesthesiologists physical status I presented for tonsillectomy and adenoidectomy with general anesthesia. Again, while rotating the OR table to facilitate surgery; the headpiece of the table came away, resulting in hyperextension of the patient’s neck. Radiographs of the cervical and thoracic spine were examined by a neuroradiologist, who detected no abnormalities. The depth of anesthesia was decreased to facilitate neurologic examination. After confirming absence of injury, anesthesia depth was increased, and surgery was completed. The postoperative course was uneventful.

The operating table used in our OR (Quantum 3080; Steris Ltd., Mentor, OH) has the headpiece attached with two polished stainless steel pins. The manufacturer does not recommend moving the OR table while holding the headpiece. Obviously, in these two cases, the fixating screws were not tight enough, permitting the head attachment to come off during table repositioning. This situation has a potential for traumatic extubation, cervical spinal cord injury, and head trauma. Operating room personnel should be aware of the possibility of this complication, which can occur with any OR table with a detachable headpiece, and they are encouraged to verify attentively the integrity of the OR table.