Positioning patients for spine surgery: Avoiding uncommon position-related complications

Abstract

Positioning patients for spine surgery is pivotal for optimal operating conditions and operative-site exposure. During spine surgery, patients are placed in positions that are not physiologic and may lead to complications. Perioperative peripheral nerve injury (PPNI) and postoperative visual loss (POVL) are rare complications related to patient positioning during spine surgery that result in significant patient disability and functional loss. PPNI is usually due to stretch or compression of the peripheral nerve. PPNI may present as a brachial plexus injury or as an isolated injury of single nerve, most commonly the ulnar nerve. Understanding the etiology, mechanism and pattern of injury with each type of nerve injury is important for the prevention of PPNI. Intraoperative neuromonitoring has been used to detect peripheral nerve conduction abnormalities indicating peripheral nerve stress under general anesthesia and to guide modification of the upper extremity position to prevent PPNI. POVL usually results in permanent visual loss. Most cases are associated with prolonged spine procedures in the prone position under general anesthesia. The most common causes of POVL after spine surgery are ischemic optic neuropathy and central retinal artery occlusion. Posterior ischemic optic neuropathy is the most common cause of POVL after spine surgery. It is important for spine surgeons to be aware of POVL and to participate in safe, collaborative perioperative care of spine patients. Proper education of perioperative staff, combined with clear communication and collaboration while positioning patients in the operating room is the best and safest approach. The prevention of uncommon complications of spine surgery depends primarily on identifying high-risk patients, proper positioning and optimal intraoperative management of physiological parameters. Modification of risk factors extrinsic to the patient may help reduce the incidence of PPNI and POVL. It is important for spine surgeons to be aware of PPNI and POVL to participate in safe, collaborative perioperative care of spine patients. Proper education of perioperative staff, combined with clear communication and collaboration while positioning patients in the operating room is the best and safest approach. The prevention of uncommon complications of spine surgery depends primarily on identifying high-risk patients, proper positioning and optimal intraoperative management of physiological parameters.Kamel I, Barnette R. Positioning patients for spine surgery: Avoiding uncommon position-related complications. World J Orthop

Visual loss after spine surgery: Case report

“…Based on a report from the American Anesthesiologist Society, postoperative visual loss was found in 83 patients of the 93 reported, and had strong correlation to spine surgery. Multiple risk factors were described [5][6][7][8][9][10] (Table 3).…”

An update on the prone position: Continuing Professional Development

“…Parmi les autres lésions liées à la pression fréquemment rapportées, citons celles aux organes externes tels que les seins et les organes génitaux externes, mais il peut également y avoir des lésions aux organes viscéraux, comme par exemple l'apparition d'une pancréatite aiguë ou d'une insuffisance hépatique aiguë. 36 Malheureusement, la plupart des complications liées à la position ventrale apparaissent dans la littérature sous forme de cas isolés ou de petites séries de cas; l'incidence exacte de ces lésions et complications liées à la pression est donc difficile à déterminer. En effet, la nature sporadique des incidents rapportés nous laisse soupçonner que bon nombre d'autres lésions surviennent mais ne le sont pas.…”

“…Other commonly reported pressure-related injuries include those to external organs such as the breasts and external genitalia but can also include visceral organ damage such as acute pancreatitis or acute liver failure. 36 Unfortunately, the majority of prone position-related complications appear in the literature as case reports or small case series, so the exact incidence of pressure-related injuries and complications is largely unknown. Indeed the sporadic nature of the reported incidents makes one suspect that many more injuries occur but go un-reported.…”

Contemporaneous Evaluation of Intraoperative Ulnar and Median Nerve Somatosensory Evoked Potentials for Patient Positioning: A Review of Four Cases

“…However, there has been no clear establishment for what nerves to analyze for upper extremity positional injuries, and the mechanism of injury is not well understood (Kamel and Barnette 2014). Current techniques describe the use of ulnar nerve SSEP monitoring as the primary modality when evaluating for upper extremity positional injury during spinal procedures (Chung et al 2009;La Neve and Zitney, 2014;Schwartz et al 2006).…”