The HEAD SAFE Protocol: A Proposed Instrument for Standardization of Mobilization of Head Neurosurgical Practice

Today's practice is highly inconsistent institutionally and between clinicians and is frequently anecdotal tradition, personal habit, or defensive conservatism rather than evidence-based or physiology-led practice. This inconsistency puts patients at unnecessary risks of venous outflow obstruction, hematoma expansion after surgery, cerebrospinal fluid (CSF) leak, and wound dehiscence as well as delay in early rehabilitation and recovery of function.[1] [2] In neurosurgical critical care, the postoperative period is a window of risk where patient outcome decisions by positioning, mobilization, and monitoring are mandatory.[3] Among these, mobilization of the head after craniotomy or cranial surgery is yet to be standardized. Although seemingly simple, head position has profound physiological impacts on cerebral venous drainage, intracranial pressure (ICP), cerebral perfusion pressure (CPP), and CSF dynamics—all of which are critical to maximizing neurological recovery.[3] Although mobilization of the surgical patient in the early period is a well-established standard for advanced recovery practices in many specialties now, no guidelines have ever been universally adopted for mobilization of the head in neurosurgical postoperative patients, especially during the initial 72 hours.[4]

Conceptual Foundations

Any protocol should take into consideration the impact of rotation, flexion, and elevation on ICP and CPP.[5] [6] [7] The concept behind this proposal remains the time-tested standards of care in neurosurgical practice including physiological fidelity, that is, cerebral movement has a direct impact on intracranial dynamics, graded progression, that is, mobilization should be based on a program based on the patient's physiological and anatomical condition as well as the nature of surgery undertaken, and team communication, that is, mobilization should be with agreement between the neurosurgical, critical care, nursing, and physiotherapy teams.[5] [7] [8] To address this unsatisfied requirement, we present here the systematic quality enhancement tool, the HEAD SAFE Protocol (Head Elevation And Direction – Safe Algorithm For early mobilization), to direct the early and step-by-step mobilization of the adult neurosurgical patient's head after craniotomy or comparable interventions.

The HEAD SAFE Protocol—Three Essential Elements

READY Checklist: Premobilization Screening

There is an emergency five-point safety check before any attempt at repositioning the patient's head to confirm that the patient is clinically stable and mobilization is safe. This is the first safety gate of the protocol. The protocol is designed to serve as a reproducible decision-support tool for intensive care teams, bedside staff, physiotherapists, and senior neurosurgeons. Mobilization should be done only if all five groups are well. Otherwise, reassessment or review by the initial neurosurgical team should be performed.

R – Resection/Region

Identify the extent and location of craniotomy. A posterior fossa or parasagittal case may require higher caution based on venous sinus proximity and brainstem structures.

E – Edema

Look for pericranial edema, scalp swelling, or evidence of subgaleal collections that worsen on head movements.

A – Alertness and Neurological Status

Verify an intact neurological examination, especially in nonsedated patients.

D – Drains and Devices

Ensure external ventricular drain (EVD), ICP monitor, subdural, or subgaleal drain is in good position and repositioning will not harm their functioning.

Y – Yes to Hemodynamic Stability

Monitor for absence of bradycardia, hypertension, or other indicators of increased ICP.

H.E.A.D. Mobilization Algorithm—Progressive Stages of Head Movement

The protocol includes a four-stage process timeline for progressing head mobilization, utilizing a mnemonic that captures the sequential process of recovery and the requirement for graded intervention ([Table 1]).

Table 1 H.E.A.D. mobilization algorithm—progressive head movement phases

Phase	Timeline	Action	Rationale
H – Hold	0–24 h	Maintain head in midline, elevated 30°, avoid lateral rotation or flexion	Minimizes ICP fluctuations, supports venous return
E – Evaluate	24–48 h	Perform passive head elevation or minor lateral rotation under monitoring	Assesses tolerance, neuroimaging review recommended
A – Assist	48–120 h	Begin assisted repositioning (lateral, seated), with physical therapy support	Promotes perfusion redistribution, prevents complications of immobility
D – Drive	> 5 d	Encourage active movement, sitting, and gradual ambulation as tolerated	Supports rehabilitation, improves pulmonary and venous function

Abbreviation: ICP, intracranial pressure.

HEAD-MOVE Bedside Checklist—Final Safety Confirmation

To be completed immediately before repositioning a neurosurgical patient's head postcraniotomy:

• Surgical wound intact and clean, with no active bleeding

• No signs of intracranial hypertension (e.g., Cushing's triad, rising ICP trends)

• All drains secured and monitored

• No new neurological deficits

• Imaging reviewed (if recent clinical change)

• Communication with physician team documented

In summary, the HEAD SAFE Protocol is a practical, adaptable instrument to tackle a generic but not well-visited clinical problem. It brings together some knowledge of neurophysiology, postoperative safety policy, and interprofessional communication into one package. It is not intended to be a replacement for clinical decision-making, but to minimize practice variability and shape decision-making. It can be an area of future research to evaluate the effect of this protocol on postoperative complication, ICP profiles, intensive care unit stay, and functional outcome, with possible integration into more extended neurosurgical Enhanced Recovery After Surgery protocols.[9] [10] The protocol may be modified/adapted for application in pediatric neurosurgery or in cases of skull base, vascular, or trauma.

Conflict of Interest

None declared.

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Publication History

Article published online:
22 December 2025