Anterior Tibial Compartment Syndrome as a Positioning Complication of the Prone-Sitting Position for Lumbar Surgery

Complications associated with prone positioning in elective spinal surgery

“…Ophthalmological complications ION [14] Obesity, male sex, Wilson frame use, longer anesthetic duration, greater estimated blood loss, increased ratio of crystalloid to colloid Posterior ION [13] Blood loss greater than 4 L, persistent relative hypotension Anterior ION [16] Atherosclerosis, diabetes Central retinal artery occlusion [5,13] External compression of the eye Cortical blindness [13] Profound hypotension, prolonged hypoxia, cardiac arrest, thromboembolism Neurologic complications Acute cervical myelopathy [20] Cervical spondylosis, neck extension, paralytic anesthesia Brachial plexopathy [21] Extension, external rotation, and abduction of the arm, ipsilateral rotation and lateral flexion of neck, shoulder braces Ulnar nerve palsy [30] Obesity, inadequate elbow padding Myocutaneous complications Compartment syndrome [34][35][36] Padding directly over the compartment, obesity Pressure ulcers [37,38] Procedure duration, advanced age, obesity, steroid administration Femoral head avascular necrosis [42] Pressure over the groin, hypotension ION: Ischemic optic neuropathy.…”

“…The brachial plexus innervates all upper limb musculature (except for the trapezius and levator scapulae) and supplies sensation to the upper limb with the exception of the axillary, superior shoulder, and dorsal scapular innervated regions. The plexus is fixed at the cervical vertebrae and the axillary fascia [21] , increasing the [14] Reverse trendelenburg positioning, colloid administration by anesthesia, limit prolonged intraoperative hypotension Posterior ION [13] Limit prolonged intraoperative hypotension Anterior ION [16] None Central retinal artery occlusion [5,13] Avoid compression of the globe Cortical blindness [13] Limit prolonged intraoperative hypotension Neurologic complications Acute cervical myelopathy [20] Thorough history and preoperative imaging, careful neck positioning during patient transfers and surgical procedure Brachial plexopathy [21] Careful anatomic positioning of the arm, limiting extension and external rotation of shoulder Ulnar nerve palsy [30] Avoid compression and pressure at the elbow, maintain arm position during procedure (avoid arm falling off of arm board) Myocutaneous complications Compartment syndrome [34][35][36] Avoid pressure on anterior thigh and leg, avoid extremely long surgical procedures. Extra care with obese patients Pressure ulcers [37,38] Pad bony prominences.…”

“…Compartment syndrome after spine surgery is rare, although anterior thigh and anterior tibial compartment syndromes have both been reported [34][35][36] . The diagnosis of postoperative compartment syndrome is often delayed or missed because the symptoms are similar to other postoperative conditions including nerve root injury, persistent nerve root compression, traction neuropraxia, or peripheral nerve palsy.…”

“…He also developed rhabdomyolosis and acute kidney injury [35] . Geisler et al [36] reported two cases of anterior tibial compartment syndrome after lower lumbar surgery performed in the pronesitting position on an Andrews frame. Both patients complained of shin pain, foot drop, and decreased sensation between the first and second toes.…”

“…Both patients complained of shin pain, foot drop, and decreased sensation between the first and second toes. After intracompartmental pressures were found to be significantly elevated, both underwent urgent fasciotomy [36] . Pressure ulcers can also occur as a result of prone positioning, though investigation has shown that the prone position results in lower pressure on bony prominences than the supine or lateral positions [37] .…”