Problems Associated With the Use of the Knee-Chest Position for Operations on Lumbar Intervertebral Discs

Alexander, John P.

doi:10.1302/0301-620x.55b2.279

Cited by 6 publications

(5 citation statements)

References 12 publications

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“…Twentyfour studies performed surgery in the prone position (Table 1), and 7 studies investigated complications following lumbar spine surgery in the knee-chest position (Table 2). 1,2,[5][6][7][9][10][11]13,15,18,19,[21][22][23][24][25][26]28,29,[32][33][34]36,37,39,40,42,[46][47][48] Complications related to the knee-elbow, lateral decubitus, and supine positions were each reported by a single study (Table 3). 14,30,31 prone-position studies Vision loss was the most commonly reported complication, with 11 case reports describing postoperative-onset vision loss.…”

Section: Study Characteristicsmentioning

confidence: 99%

“…Acute renal failure, rhabdomyolysis, insecure endotracheal intu- bation, and quadriplegia were only reported among studies using the knee-chest position. 1,28,21,37 Furthermore, vision loss was only reported by 3 studies (Table 4). 21,33,36 There was no correlation found between increased operative time and the number of studies reporting complications, but this may have been due to the limited number of studies reporting complications related to this operative approach.…”

Section: Knee-chest Studiesmentioning

confidence: 99%

“…29 Most studies do not correlate intraoperative posi-tioning with rates of thrombosis, but proper distribution of weight and avoidance of acute joint flexion may contribute to reduced DVT and PE incidence. 1,24,29 Minami et al 24 further postulated that particular neck positions during lumbar spine surgery in the prone position might result in venous kinking. The patient in their case report was placed in a slightly flexed-neck position which, in combination with the presence of a central venous catheter in the internal jugular vein, potentially contributed to venous stasis and thrombosis.…”

Section: Thromboembolic Complicationsmentioning

confidence: 99%

“…4,12 Use of pillows and careful positioning of the abdomen and extremities diminish these pressure points as well. 1,2,5,29 The risk and consequences of developing pressure sores is important. This review highlights the need for future studies comparing the relative risk of pressure sores following the use of various tables and frames.…”

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Lumbar spine surgery positioning complications: a systematic review

Shriver

Zeer

Alentado

et al. 2015

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OBJECT There are a variety of surgical positions that provide optimal exposure of the dorsal lumbar spine. These include the prone, kneeling, knee-chest, knee-elbow, and lateral decubitus positions. All are positions that facilitate exposure of the spine. Each position, however, is associated with an array of unique complications that result from excessive pressure applied to the torso or extremities. The authors reviewed clinical studies reporting complications that arose from positioning of the patient during dorsal exposures of the lumbar spine. METHODS MEDLINE, Scopus, and Web of Science database searches were performed to find clinical studies reporting complications associated with positioning during lumbar spine surgery. For articles meeting inclusion criteria, the following information was obtained: publication year, study design, sample size, age, operative time, type of surgery, surgical position, frame or table type, complications associated with positioning, time to first observed complication, long-term outcomes, and evidence-based recommendations for complication avoidance. RESULTS Of 3898 articles retrieved from MEDLINE, Scopus, and Web of Science, 34 met inclusion criteria. Twenty-four studies reported complications associated with use of the prone position, and 7 studies investigated complications after knee-chest positioning. Complications associated with the knee-elbow, lateral decubitus, and supine positions were each reported by a single study. Vision loss was the most commonly reported complication for both prone and knee-chest positioning. Several other complications were reported, including conjunctival swelling, Ischemic orbital compartment syndrome, nerve palsies, thromboembolic complications, pressure sores, lower extremity compartment syndrome, and shoulder dislocation, highlighting the assortment of possible complications following different surgical positions. For prone-position studies, there was a relationship between increased operation time and position complications. Only 3 prone-position studies reported complications following procedures of less than 120 minutes, 7 studies reported complications following mean operative times of 121–240 minutes, and 9 additional studies reported complications following mean operative times greater than 240 minutes. This relationship was not observed for knee-chest and other surgical positions. CONCLUSIONS This work presents a systematic review of positioning-related complications following prone, knee-chest, and other positions used for lumbar spine surgery. Numerous evidence-based recommendations for avoidance of these potentially severe complications associated with intraoperative positioning are discussed. This investigation may serve as a framework to educate the surgical team and decrease rates of intraoperative positioning complications.

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Section: Study Characteristicsmentioning

confidence: 99%

Section: Knee-chest Studiesmentioning

confidence: 99%

Section: Thromboembolic Complicationsmentioning

confidence: 99%

mentioning

confidence: 99%

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Lumbar spine surgery positioning complications: a systematic review

Shriver

Zeer

Alentado

et al. 2015

FOC

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“…However, undesirable effects of the knee-chest position have been reported, such as persistent postoperative pain in the hip and the quadriceps area,5 deep vein thrombosis,' bilateral calf-muscle ischaemia with rhabdomyolysis and acute renal failure' due to the prolonged flexion of the lower limbs and systemic hypotension when the legs are straightened at the end of surgery. 6 The knee-chest position is not a physiological position. It could theoretically produce a significant decrease in CBF, especially in old arteriosclerotic patients,8 since the head is slightly downwards (fig 1).…”

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confidence: 99%

Effect of the knee-chest position on cerebral blood flow in patients undergoing lumbar spinal surgery.

Pittet

Ramadan

Morel

et al. 1989

Journal of Neurology, Neurosurgery & Psychiatry

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sumMARY The cerebral haemodynamic effect of the knee-chest position was evaluated in 15 anaesthetised patients undergoing elective lumbar disc surgery and divided into a control group (n = 8) where cerebral blood flow (CBF) was measured twice in the supine position and an experimental group (n = 7) where the first CBF was measured in the supine position and the second in the knee-chest position. CBF was measured by a modified intravenous "'xenon washout technique.Mean global CBF did not change in control group (56-1, SD 9-2 versus 52 8, SD 108 units) and was not significantly modified by the knee-chest posture, 51-8, SD 8-8 units versus 53-9, SD 7-4 units in the supine position. The results indicate that mean global CBF in the knee-chest position is not different from CBF in the supine position in healthy patients.The knee-chest position for lumbar intervertebral disc surgery has many advantages: excellent exposure of interlaminar spaces, avoidance of epidural venous engorgement with decreased blood loss, easy administration of intermittent positive pressure ventilation and decreased risk of injury to major prevertebral vessels and organs even in obese patients."' However, undesirable effects of the knee-chest position have been reported, such as persistent postoperative pain in the hip and the quadriceps area,5 deep vein thrombosis,' bilateral calf-muscle ischaemia with rhabdomyolysis and acute renal failure' due to the prolonged flexion of the lower limbs and systemic hypotension when the legs are straightened at the end of surgery.6The knee-chest position is not a physiological position. It could theoretically produce a significant decrease in CBF, especially in old arteriosclerotic patients,8 since the head is slightly downwards (fig 1). Furthermore in our practice, we have occasionally observed oedema and venous stasis of the face at the end ofsurgery. If similar stasis occurred in the cerebral veins, it could also increase intracranial pressure and possibly decrease CBF.The present study was designed to compare the effect of the knee-chest with the supine position on CBF in patients undergoing elective lumbar disc surgery. Methods PatientsAfter informed consent and institutional approval, sixteen patients scheduled for elective lumbar intervertebral disc surgery participated in the study. The patients were randomly divided into a control (n = 8) and an experimental group (n = 7). Patients more than 62 years old, or with cardiovascular, pulmonary, or neurological diseases, or under medication other than minor analgesics, were excluded from the study. Moreover, the patients enrolled in the study were immediately excluded from the investigation if they had cardiac arrhythmias or a decrease ofmore than 30% ofmean systemic arterial pressure (MAP) after induction of anaesthesia despite a rapid infusion of 500 ml of crystalloids. ProcedureThe effects of knee-chest position on cerebral haemo-

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Lower limb compartment syndrome following lumbar discectomy in the knee-chest position

1990

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We report on two cases of compartment syndrome following lumbar discectomy in the knee-chest position. This complication has only been described once since 1953. Seven cases of compartment syndrome following other surgical procedures were found in the literature. Any increases in tissue pressure of a muscle compartment exceeding 35-40 mmHg over a longer period of time can result in this complication for example, too tight cast, space-occupying intrafascial bleeding, or postischemic swelling. The diagnosis is purely clinical and is based on the typical combination of extremely painful edema with rapid onset of sensory loss and subsequent motor deficits. The muscle necrosis leads to myoglobinaemia and myoglobinuria, recognizable by brown urine. The therapy consists of urgent fasciotomy of swollen compartments without skin suture. The prognosis is highly dependent on the time of the surgical decompression: within 6 hours serious deficits are avoidable; after 24 hours irreversible necrosis of muscle occurs. It seems that the possibility of a compartment syndrome is a specific, but a rare risk of a prolonged knee-chest position.

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Problems Associated With the Use of the Knee-Chest Position for Operations on Lumbar Intervertebral Discs

Cited by 6 publications

References 12 publications

Lumbar spine surgery positioning complications: a systematic review

Lumbar spine surgery positioning complications: a systematic review

Effect of the knee-chest position on cerebral blood flow in patients undergoing lumbar spinal surgery.

Lower limb compartment syndrome following lumbar discectomy in the knee-chest position

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