Recommendations for Avoiding Position-Related Complications During Lumbar Surgery

Commentary by Michael F. Shriver, BS and Nasir A. Quraishi, FRCS

Excessive pressure applied to ventral or lateral structures during lumbar spine surgery may cause a number of position-related complications. New findings from a systematic review and meta-analysis suggest ways to avoid potentially severe complications associated with intraoperative positioning.

New findings suggest ways to avoid potentially severe complications associated with intraoperative positioning.“The intention of our study was to identify reported complications following various intraoperative positions for lumbar spine surgery,” said Michael F. Shriver, BS, Case Western Reserve University School of Medicine, Cleveland, Ohio. “Positioning during lumbar spine surgery and its associated complications, derived from excessive pressure applied to ventral or lateral structures, are typically analyzed from an institutional perspective. While these complications are often transient, some may be permanent and result in serious disability during the postoperative period. These complications are currently only characterized by case reports and small cohorts within the literature.

“Our review attempted to investigate these complications and provide evidence-based recommendations for their avoidance,” Mr. Shriver explained. “It is important that surgeons remain vigilant of intraoperative positioning to properly avoid injurious pressure upon susceptible structures,” Mr. Shriver said.

Thirty-Four Studies Met the Inclusion Criteria
“Thirty-four total studies met our inclusion criteria, with 23 reporting the use of the prone position, and an additional 7 studies utilizing the knee-chest positioning,” Mr. Shriver explained. “Knee-elbow, lateral decubitus and supine positioning were used by a single study each.”

Vision Loss Was the Most Common Complication
“Across all the included studies, vision loss was the most commonly reported complication following prone and knee-chest positioning for lumbar spine surgery,” Dr. Shriver said. “In addition, there were a number of other complications associated with excessive pressure during the surgical procedure, highlighting the variety of potential complications,” Mr. Shriver said.

Furthermore, a direct relationship between increased operation time and the number of reported position complications for prone positioning was found. This relationship did not exist for the knee-chest position.

Dr. Shriver and colleagues highlighted evidenced-based recommendations for avoiding complications resulting from positioning during lumbar surgery (Table).

Commentary From the Field
“This is certainly an interesting review, and clearly much work has gone into this paper,” commented Nasir A. Quraishi, FRCS, who is Head of Service, Consultant Spine Surgeon & Honorary Clinical Associate Professor at the Centre for Spine Studies & Surgery, Queens Medical Centre, in Nottingham, UK.

Dr. Quraishi noted that, given the lack of available literature on this topic, most of the studies included in this review were case reports (27 out of 34 studies). “Nevertheless, the authors have done a good job of summarizing the relevant findings,” he said.

“Visual loss was the most commonly reported complication, with a reported incidence of 3 per 10,000 for spinal fusion procedures. In the United Kingdom, there is a changing legal opinion of what needs to be disclosed to patients, and the disclosure of complications such as visual loss, becomes even more pertinent in the subgroup of high-risk patients,” Dr. Quraishi explained.^1,2

“This paper clearly highlights the need for future studies comparing the various spinal positions and postoperative complications,” Dr. Quraishi concluded.