Patient Positioning Complications Related to Neurosurgical Procedures A

Patient Positioning Complications Related to Neurosurgical Procedures: A Systematic Review Thomas Frank, Yoshua Esquenazi and Arthur L Day Vivian L. Smith Department of Neurosurgery University of Texas Medical School at Houston, USA

Introduction v Although rare, complications related to patient positioning during neurosurgical procedures may occur. v Long procedures are common in neurosurgery and require knowledge of potential patient positioning complications. v Acknowledging these complications, often presenting postoperatively, enables early recognition and prompt treatment.

Methods v We performed a “Pubmed” literature search for English studies that reported a complication related to positioning in a neurosurgical procedure. Results are numbers of studies reporting complications were analyzed. v Search criteria: (Neurosurgery OR neurological surgery OR craniotomy OR spine surgery OR spinal surgery OR anesthesia) AND (complication OR problem) AND (position) AND (“variable”). v “Variable” referred to “(head or neck) ‘rotation’, ‘flexion’, ‘hyperflexion’, ‘hyperextension’, or ‘lateral flexion’”, body positions such as “supine”, “lawnchair”, “trendelenburg”, “lateral”, “park-bench”, “prone”, “sitting”, and various equipment.

Results Overview Number of studies reporting complications for each position Prone Head/Neck Position (n=117) 36% 6% Equipment 6% Lateral 8% Supine 10% Sitting 34% v Complications were subject to confounding and publication bias, and some reported cases most likely were omitted by not fitting the search criteria. v Although complications were rare, each position had a characteristic complication and a few very rare outcomes. A complication can be related to multiple positions.

Head/Neck Positions and Complications Position Complication Head/Neck Rotation • 1 Parotitis • 1 SSEP changes Head/Neck Flexion • • • Head/Neck Hyperflexion • 2 Quadriplegia Head/Neck Lateral Flexion • 1 SSEP changes 2 Macroglossia 1 Parotitis 1 Bilateral recurrent laryngeal nerve paralysis 1 SSEP changes 1 Spinal cord infarction

Supine Positions and Complications Position Complication Supine • • Trendelenburg • 1 Severe hypotension • 1 Cerebral herniation 5 Venous air embolism (VAE) 2 Tension pneumocephalus 2 Remote cerebellar hemorrhage (RCH) 1 Cerebral herniation 1 Retinal artery occlusion 1 Bilateral recurrent laryngeal nerve paralysis 1 Blindness

Lateral Positions and Complications Position Complication Lateral • • • Park Bench • 1 Pneumocephalus • 1 Long thoracic nerve injury • 1 Macroglossia 2 Perioperative ischemic optic neuropathy (PION) 2 Tension pneumocephalus 1 Discitis 1 Long thoracic nerve paralysis 1 Rhabdomyolysis 1 Parotitis

Prone Positions and Complications Position Complication Prone Kneeling • • • • 10 visual loss (bilateral & unilateral) 4 (PION) 3 Paraplegeia 2 Retinal artery occlusion 2 ischemic orbital compartment syndrome 2 Acute glaucoma 2 Meralgia paresthetica 2 Macroglossia 1 Anterior thigh compartment syndrome 1 Avascular necrosis of femoral head 1 Thoracic outlet syndrome 1 Coronary vasospasm 1 Hepatic infarction • 1 Anterior thigh compartment syndrome • • • • 1 Rhabdomyolysis 1 Quadraplegia 1 Atlanto axial dislocation 1 Intracerebral hemorrhage 1 RCH 1 Thrombo emoblic event 1 subconjuctival hemorrhage 1 shoulder dislocation 1 Lost monitored potentials 1 Bilateral occipital lobe infarct 1 Bifrontal epidural hematoma 1 Prolonghed hypotension 1 Acute mesenteric ischemia 1 Brachial plexopathy

Sitting Positions and Equipment Complications Position Complication Sitting • • • 9 Venous air embolism (VAE) 9 Tension pneumocephalus 3 Macroglossia 3 Quadr. Iplegia 3 SSEP changes 2 Sciatic neuropathy • • • Headrest • 2 Blindness Wilson Frame • 1 Visual Loss Jackson Table • Relton-Hall Frame • 1 Central cord syndrome 1 Supratentorial hematoma 1 Parotitis • • • 2 Tension pnuemoventricle • 2 Spinal cord infarction • 2 Supratentorial • hemorrhage 1 Lateral rectus palsy 1 Anosmia 1 Pyriformis syndrome • 1 Acute glaucoma • 1 Atlanto axial dislocation 1 Rhabdomyolysis • 1 Abducens nerve palsy 1 Brachial plexopathy • 1 Meralgia paresthetica

Conclusions v Neurosurgery patient positioning complications are rare, but surgeons should appreciate their possibilities in order to recognize and treat them swiftly. v Most of these complications can be prevented and permanent manifestations avoided if treated immediately. v The surgeon should appreciate the intricacies of various positions and be involved in the positioning of patients at the start of surgery.