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Garg B, Bansal T, Mehta N, Sharan AD. Patient Positioning in Spine Surgery: What Spine Surgeons Should Know? Asian Spine J 2023; 17:770-781. [PMID: 37226380 PMCID: PMC10460667 DOI: 10.31616/asj.2022.0320] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Accepted: 09/15/2022] [Indexed: 05/26/2023] Open
Abstract
Spine surgery has advanced tremendously over the last decade. The number of spine surgeries performed each year has also been increasing constantly. Unfortunately, the reporting of position-related complications in spine surgery has also been steadily increasing. These complications not only result in significant morbidity for the patient but also raises the risk of litigation for the surgical and anesthetic teams. Fortunately, most position-related complications are avoidable with basic positioning knowledge. Hence, it is critical to be cautious and take all necessary precautions to avoid position-related complications. We discuss the various position-related complications associated with the prone position, which is the most commonly used position in spine surgery, in this narrative review. We also discuss the various methods for avoiding complications. Furthermore, we briefly discuss less commonly used positions in spine surgery, like the lateral and sitting positions.
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Affiliation(s)
- Bhavuk Garg
- Department of Orthopaedics, All India Institute of Medical Sciences, New Delhi,
India
| | - Tungish Bansal
- Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi,
India
| | - Nishank Mehta
- Department of Orthopaedics, All India Institute of Medical Sciences, New Delhi,
India
| | - Alok D. Sharan
- Spine and Orthopedics, NJ Spine and Wellness, Matawan, NJ,
USA
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Ayala K, Redding J, Lynch W, MacKinney T. Brachial plexus injury and facial breakdown as a consequence of proning during COVID-19 treatment. J Am Assoc Nurse Pract 2022; 34:452-456. [PMID: 34636344 DOI: 10.1097/jxx.0000000000000654] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Accepted: 08/13/2021] [Indexed: 11/26/2022]
Abstract
ABSTRACT By early 2020, the novel SARS-CoV-2 virus (COVID-19) was spreading rapidly worldwide, and its effects proved devastating. In many critically ill patients afflicted with COVID-19, treatment often involves prolonged periods of proning that, along with other interventions, can lead to improved oxygenation. However, sustaining this position predisposed patients to increased complications. We present a case of an older patient with respiratory failure secondary to COVID-19 who developed rapidly forming facial and knee wounds and a brachial plexus injury from proning. The pressure injuries were unresponsive to standard wound care treatments and resulted in full-thickness wounds. During outpatient posthospital follow-up, a facial eschar was debrided, and weakness of the left shoulder and arm secondary to a brachial plexus injury was identified. This case highlights various complications associated with prolonged proning and the importance of close attention to follow-up by both inpatient and outpatient providers.
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Affiliation(s)
- Kelly Ayala
- Department of Medicine, Froedtert and the Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Jill Redding
- Department of Medicine, Froedtert Hospital, Menominee Falls, Wisconsin
| | - Whitney Lynch
- Department of Medicine, Froedtert and the Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Theodore MacKinney
- Department of Medicine, Froedtert and the Medical College of Wisconsin, Milwaukee, Wisconsin
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Bithal PK, Ravees J, Daniel WV, Samar E, Alaa AT, Yanbawi AA. Incidence of Pressure-Related Skin Injuries in Patients Operated for Spine Surgery in Prone: A Retrospective Analysis of 307 Patients. Anesth Essays Res 2020; 14:33-37. [PMID: 32843789 PMCID: PMC7428119 DOI: 10.4103/aer.aer_11_20] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Revised: 02/03/2020] [Accepted: 02/05/2020] [Indexed: 01/29/2023] Open
Abstract
Background: Spine surgery in prone position frequently results in pressure skin lesions (PSLs). No study from Arabic world has published their incidence in literature. Methods: We retrospectively analyzed patients who underwent prone position spine surgery from December 1, 2017, to November 30, 2018. They received standardized anesthesia care and were made prone on Jackson table. The face was supported on a nonface contoured foam device, whereas the chest and pelvis were supported on soft cushions. Following completion of surgery, they were turned supine and their skin was inspected for any skin lesions. The lesions were categorized into five grades depending on severity. Results: Data of 307 patients were analyzed. Their mean age and weight was 41.5 years and 71 kg, respectively. The mean duration of prone positioning was 470 min. One hundred and three PSLs were observed in 45 patients (14.7%), giving a PSL incidence of 43.7% in affected patients. Majority of patients (18, 40%) with lesions remained in prone position between 421 and 600 min. Multiple lesions were observed in 53.3% of the affected patients. The highest number of patients (21, 46.7%) had one lesion only and it was restricted to face. All lesions were of Grade I, II, or III. Body weight >71 kg was more prone to developing PSLs. Females were more prone to PSLs. Conclusion: PSLs in prone position spine surgery occur frequently, and their incidence is proportional to the duration of positioning and weight of the patients. Face is the most commonly affected area.
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Affiliation(s)
- Parmod Kumar Bithal
- Department of Anesthesiology and Perioperative Medicine, King Fahad Medical City, Riyadh, Kingdom of Saudi Arabia
| | - Jan Ravees
- Department of Anesthesiology and Perioperative Medicine, King Fahad Medical City, Riyadh, Kingdom of Saudi Arabia
| | - Ward Vandan Daniel
- Department of Anesthesiology and Perioperative Medicine, King Fahad Medical City, Riyadh, Kingdom of Saudi Arabia
| | - Eisa Samar
- Department of Anesthesiology and Perioperative Medicine, King Fahad Medical City, Riyadh, Kingdom of Saudi Arabia
| | - Al Talhi Alaa
- Department of Anesthesiology and Perioperative Medicine, King Fahad Medical City, Riyadh, Kingdom of Saudi Arabia
| | - Anwar Abdulhamid Yanbawi
- Department of Anesthesiology and Perioperative Medicine, King Fahad Medical City, Riyadh, Kingdom of Saudi Arabia
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Outcome and Complications following Vertical Rectus Abdominis Myocutaneous Flap Surgery to Reconstruct Sacrectomy Defects. Plast Reconstr Surg 2018; 142:1327-1335. [DOI: 10.1097/prs.0000000000004890] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Kamat AS, Ebrahim MZ, Vlok AJ. Thoracic disc herniation: An unusual complication after prone positioning in spinal surgery. Int J Spine Surg 2017; 10:39. [PMID: 28377853 DOI: 10.14444/3039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Neurological complications of the prone position have been well documented. Post-operative paraplegia and neurological deterioration unrelated to the site of surgery after proning in spinal surgery is a rare but potentially devastating complication. We describe the case of a 47 year old female who underwent an L4/5 discectomy and posterior instrumented fusion. A few hours after surgery she developed bilateral lower limb weakness with a T11 sensory level. Post-operative MRI revealed an acute disc herniation at the T11/12 level with associated spinal cord compression. This was not present on the pre-operative imaging. A subsequent T11/12 discectomy and instrumented fusion was performed and the patient's motor and sensory function returned to normal.
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Affiliation(s)
- Ameya S Kamat
- Division of Neurosurgery, Tygerberg Academic Hospital, Stellenbosch University, Cape Town, South Africa
| | - Mohammed Zahier Ebrahim
- Division of Neurosurgery, Tygerberg Academic Hospital, Stellenbosch University, Cape Town, South Africa
| | - Adriaan J Vlok
- Division of Neurosurgery, Tygerberg Academic Hospital, Stellenbosch University, Cape Town, South Africa
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The prone position during surgery and its complications: a systematic review and evidence-based guidelines. Int Surg 2016; 100:292-303. [PMID: 25692433 DOI: 10.9738/intsurg-d-13-00256.1] [Citation(s) in RCA: 151] [Impact Index Per Article: 18.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Surgery in the prone position is often a necessity when access to posterior anatomic structures is required. However, many complications are known to be associated with this type of surgery, as physiologic changes occur with increased pressure to anterior structures. While several studies have discussed postoperative vision loss, much fewer studies with lower levels of evidence have addressed other complications. A systematic literature review was conducted using 2 different databases, and 53 papers were regarded as appropriate for inclusion. Qualitative and quantitative analysis was performed. Thirteen complications were identified. Postoperative vision loss and cardiovascular complications, including hypovolemia and cardiac arrest, had the most number of studies and highest level of evidence. Careful planning for optimal positioning, padding, timing, as well as increased vigilance are evidence-based recommendations where operative prone positioning is required.
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DePasse JM, Palumbo MA, Haque M, Eberson CP, Daniels AH. Complications associated with prone positioning in elective spinal surgery. World J Orthop 2015; 6:351-359. [PMID: 25893178 PMCID: PMC4390897 DOI: 10.5312/wjo.v6.i3.351] [Citation(s) in RCA: 99] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2015] [Revised: 02/12/2015] [Accepted: 03/09/2015] [Indexed: 02/06/2023] Open
Abstract
Complications associated with prone surgical positioning during elective spine surgery have the potential to cause serious patient morbidity. Although many of these complications remain uncommon, the range of possible morbidities is wide and includes multiple organ systems. Perioperative visual loss (POVL) is a well described, but uncommon complication that may occur due to ischemia to the optic nerve, retina, or cerebral cortex. Closed-angle glaucoma and amaurosis have been reported as additional etiologies for vision loss following spinal surgery. Peripheral nerve injuries, such as those caused by prolonged traction to the brachial plexus, are more commonly encountered postoperative events. Myocutaneous complications including pressure ulcers and compartment syndrome may also occur after prone positioning, albeit rarely. Other uncommon positioning complications such as tongue swelling resulting in airway compromise, femoral artery ischemia, and avascular necrosis of the femoral head have also been reported. Many of these are well-understood and largely avoidable through thoughtful attention to detail. Other complications, such as POVL, remain incompletely understood and thus more difficult to predict or prevent. Here, the current literature on the complications of prone positioning for spine surgery is reviewed to increase awareness of the spectrum of potential complications and to inform spine surgeons of strategies to minimize the risk of prone patient morbidity.
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Verlaan JJ, Kuperus JS, Slooff WB, Hennipman A, Oner FC. Complications, secondary interventions and long term morbidity after en bloc sacrectomy. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2014; 24:2209-19. [DOI: 10.1007/s00586-014-3729-5] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/21/2014] [Revised: 12/15/2014] [Accepted: 12/16/2014] [Indexed: 10/24/2022]
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Bonnaig N, Dailey S, Archdeacon M. Proper Patient Positioning and Complication Prevention in Orthopaedic Surgery. J Bone Joint Surg Am 2014; 96:1135-1140. [PMID: 24990979 DOI: 10.2106/jbjs.m.01267] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
➤ The consequences of improper intraoperative positioning can be profound: it not only may cause substantial morbidity but also may be a major area of litigation, particularly when peripheral nerve injury occurs.➤ The ulnar nerve is most likely to be injured secondary to improper positioning. The elbow should be flexed ≤90° and the forearm placed in a neutral or slightly supinated position intraoperatively to minimize pressure in the cubital tunnel.➤ Pressure-related complications, such as pressure ulcers and alopecia, are best avoided by the use of adequate padding. Cushions on the operating-room table and armrest should be emphasized under osseous prominences.➤ Positioning the head in a non-neutral alignment or arm abduction of ≥90° may result in injury to the brachial plexus.➤ The hemilithotomy position increases intracompartmental pressure in the leg on the uninjured side. The risk of well-leg compartment syndrome can be minimized by avoiding this position if possible.
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Affiliation(s)
| | - Steven Dailey
- UC Health Department of Orthopaedic Surgery, University of Cincinnati College of Medicine, 231 Albert Sabin Way, ML 0212, Cincinnati, OH 45267-0212. E-mail address for S. Dailey:
| | - Michael Archdeacon
- UC Health Department of Orthopaedic Surgery, University of Cincinnati College of Medicine, 231 Albert Sabin Way, ML 0212, Cincinnati, OH 45267-0212. E-mail address for S. Dailey:
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Abstract
OBJECTIVES The objective of the authors was to provide an up-to-date review about the epidemiology, diagnosis, and surgical management of the malignant primary sacral tumors. METHODS A PubMed search was conducted using a combination of the following items: (('Spinal Neoplasms'[Mesh]) AND 'Sacrum'[Mesh]) NOT ('Metastasis' OR 'Metastases' OR 'Benign'). The literature review and the author's own surgical experiences were used to assess the current treatment strategies of the malignant sacral tumors. RESULTS Twenty case series were identified, which studies discuss in detail the surgical strategies, the postoperative complications, the functional and oncologic outcome, and the recurrence-free and disease-specific survival of this rare patient category. DISCUSSION Sacral tumors are rare pathologies. Their management generates a complex medical problem, as they usually are diagnosed in advanced stages with extended dimensions involving the sacral nerves and surrounding organs. The evaluation and complex treatment of these rare tumors require a multidisciplinary approach, optimally at institutions with comprehensive care and experience. Although conventional oncologic therapeutic methods should be used as neoadjuvant or adjuvant therapies in certain histological types, en bloc resection with wide surgical margins is essential for long-term local oncologic control. This is often technically difficult to achieve, as just a few centers in the world perform sacral tumor surgeries on a regular basis, and have enough wide experience. Therefore international cooperation and organization of multicenter tumor registries are essential to develop evidence based treatment protocols.
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Kwee MM, Ho YH, Rozen WM. Complications of prolonged prone positioning during reconstructive surgery. Microsurgery 2012; 32:588-9. [DOI: 10.1002/micr.22029] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2012] [Accepted: 04/19/2012] [Indexed: 11/11/2022]
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