Lateral Decubitus Position in
Spinal Surgery - Current Concepts
Dr. P. Gopinath
Asst Professor in Orthopaedics
Medical College Calicut
E-Mail: drpgopinath@yahoo.com
Addresses for Correspondence
Dr. P. Gopinath
Asst Professor in Orthopaedics
Medical College Calicut,
Kerala, India.
Phone: +91 495 2390014
E-Mail: drpgopinath@yahoo.com
JJ.Orthopaedics 2005;2(5)e1
Introduction:
Spinal surgeries were
traditionally under taken in the prone position for a long time.
But some authors used operate the spine in lateral position. The
prone position has the many anesthetic surgical disadvantages
difficult ventilation compression of he endotracheal tube and
the presence of many pressure points. Eye ball compression has
been documented to result in vagal stimulation cardiac arrest
and even blindness. A catastrophic complication like cardiac
arrest during surgery is likely to fatal since resuscitation is
often not possible in this position. Abdominal pressure is
likely to result in profuse epidural bleeding and difficult
ventilation. Lateral position during spinal surgeries has the no
disadvantage as mentioned above but surgeon has to have adequate
training to operate the spine in lateral position. The purpose
of this review article is to under stand the current concept
regarding the ideal position to operate the spine with a review
of author’s own experience.
Review:
Fourney DR et al(1) concluded from their
study that they have performed done simultaneous anterior and
posterior approach with the patients in the lateral decubitus
position. They further stated that the simultaneous
anterior-posterior approach is a safe and feasible alternative
for the exposure tumors of the thoracic and lumbar spine that
involve both the anterior and posterior columns. Advantages of
the approach include direct visualization of adjacent
neurovascular structures, the ability to achieve complete
resection of lesions involving all three columns simultaneously
(optimizing hemostasis), and the ability to perform excellent
dorsal and ventral stabilization in one operative session.
Dagher C et al (2) inferred that Lumbar
microdiscectomy surgery is already performed under spinal
anesthesia (SA) in many institution. Following light sedation,
SA is performed with the patient in the left lateral decubitus
position, one to two levels above the herniated disc level.
Isobaric 0.5% bupivacaine 3-3.5 ml was injected intrathecally
followed by wound infiltration with 15 ml of bupivacaine with
1/200 000 epinephrine prior to surgical incision.
Cybulski GR et al(3) used a modified lateral
decubitus position with the scapula falling away from the side
of exposure was used for T1-5 segment lesions, and a prone
position was used for the (T-6)-(T-12) segment. Adequate
decompression of the spinal canal was achieved in all cases. All
patients who were ambulating preoperatively maintained
ambulatory ability, and pain and/or further neurological
improvement as well occurred in 75%.
Baulot E et al (4) performed thoracoscopy
in the lateral decubitus position. The patient was prepared in
the standard manner for a full thoracotomy. Surgical instruments
that are needed for conversion to an open procedure must be in
the operative room in the same position. Ventilation was stopped
to the ipsilateral lung.
Sukegawa I et al (5)reported
two cases of the rhabdomyolysis of the erector spine muscles
occurring after nephrectomy in lateral flexed decubitus
position. A 39-year-old man (170-cm, 85-kg) underwent right
nephrectomy for a right renal tumor. The patient was placed in a
left flexed lateral decubitus position with a roll placed under
the dependent iliac crest and upper half of the body was rotated
backward for 6 h. . Direct, prolonged pressure on the
paravertebral muscle was the etiology of rhabdomyolysis in their
cases. Although their cases were not severe and the
complications were not induced, it must be kept in mind that
excessive pressure in a limited area can damage the muscle
during prolonged surgery
Wawro et al(6)concluded from their study
that the correction of posttraumatic kyphosis in the
thoracolumbar region almost always requires a combined anterior
and posterior approach because of the particular anatomic
situation and the pathomorphologic changes. We suggest that the
patient be placed in a right lateral decubitus position. This
allows dual access to the spine by a posterior midline approach
and a retroperitoneal thoracolumbar approach, so that
simultaneous anterior and posterior manipulation, correction and
stabilization of the spine are possible with no need to turn the
patient intraoperatively
Gonzalez Della Valle A et
al(7)inferred from their study that the lateral decubitus
position can cause dependent shoulder discomfort or result in
traction on the brachial plexus. They measured pressure beneath
the dependent shoulder and lateral angulation of the cervical
spine in patients positioned in the lateral decubitus position
for total hip replacement under epidural anesthesia. Inflatable
pillows (Shoulder-Float) beneath the chest wall and head reduced
pressure beneath the dependent shoulder from 66 to 12 mm Hg (P <
0.001) and lateral angulation of the cervical spine from 14
degrees to 4 degrees (P < 0.001). In a randomized crossover
study of a further 15 patients, the use of inflatable pillows
resulted in significantly less pressure beneath the dependent
shoulder and chest wall than either a gel-pad or a 1000-mL
lactated Ringer's bag. Inflatable pillows placed beneath the
chest wall and head in the lateral decubitus position provided
lower pressure beneath the dependent shoulder than other support
devices and facilitated alignment of the cervical spine. When
patients lie on their side, this results in pressure beneath the
shoulder and tilting of the head and neck to one side. These
problems were effectively corrected with an inflatable pillow
(Shoulder-Float).
Sato K etal(8)concluded that
hypotension after positioning is sometimes seen especially in
patients with cervical spinal lesion operated on under prone
position. Patients with spinal lesion and those with brain
lesion are compared in the frequency of hypotension after
positioning to prone. Sixty-one cases operated on with prone
position were studied. Ages ranged from 40 to 82 (mean 61) years
and ASA grade was 1 or 2 in each case. Cervical laminoplasty
(group C) or craniotomy (group B) are performed in 40 and 21
patients, respectively. Ephedrine was administrated when the
systolic blood pressure decreased under 80 mmHg and the
frequency of ephedrine use was compared. There were no
differences in age and sex distribution between group C and B.
The induction doses of propofol and fentanyl in group B were
larger than those of group C, but ephedrine use in group C was
more frequent than in group B. In T2-weighted image of the
cervical cord, high signal intensity areas were depicted in
cases with hypotension. The sympathetic flow descends in the
medial part in the lateral funiculus. Damage of this pathway
would cause autonomic dysfunction in patients with cervical
spinal lesion and strict monitoring is necessary during
positioning to prone
Papin P et al (9)inferred that
thoracoscopic release and fusion of the discs space followed in
the same time by a posterior instrumentation and fusion is a
good option. Six cases were done in the prone position, two in
the lateral decubitus with shorter surgical time.
Chang SH et al(10) studied the
incidence of perioperative ischemic optic neuropathy (POION) in
spine surgery at our institution. . POION is a rare but
potentially devastating and untreatable complication of spine
surgery, particularly that performed with the patient in the
prone position. Anemia, hypotension, long duration of surgery,
and significant intraoperative hydration may all be risk factors
for this condition. All patients undergoing spine surgery should
be informed about the low but definite risk of this condition,
and every attempt should be made during surgery to maintain
stable hemoglobin and mean arterial pressure and to avoid
overhydration.
Sucato DJ et al(11) concluded
that the results and complications of patients undergoing a
thoracoscopic anterior release and fusion comparing those
performed prone with those in the lateral position. A
thoracoscopic anterior spinal release and fusion in the prone
position appears to achieve the same results as when performed
in the lateral position for pediatric spinal deformity.
The authors own(12,13,14) experience is to
perform operations like anterior instrumentation, posterior
instrumentation, disectomy, anterior and posterior scoliosis
correction , spondylolisthsis reduction in the lateral position
with definite advantage to patient, anaethesiologist ,surgeon
and other OT personnel with the best possible out come
Conclusion:
Traditionally spine
surgeries were under taken in prone position which could be knee
chest, kneeling, jack knife position etc. This additional
gadgets like frames bolsters etc. This position has been has
been accepted out of familiarity, training and experience. The
problems faced by the surgeons including bleeding from excessive
abdominal pressure resulting in epidural venous engorgement.
Other disadvantages including static position during surgery and
alteration position is almost impossible ,combined anterior and
posterior exposure not possible, maneuvering equipments like
C-Arm image intensifier and operating microscope is diificult
and strain on the surgeon.
The disadvantages to
anaesthesiologists include the universal need for GA and
catastrophic complications like cardio respiratory is almost
impossible to manage.
The other OT personnel are
at disadvantage because combined ant and posterior approach
needs frequent change of position. The disadvantage to the
patients include increased stress in small areas, cervical spine
injury during position and high risk for elderly and obese
patients. Many current articles support position of the patient
in the lateral position with no disadvantages mentioned above.
The patient can be positioned for combined anterior and
posterior approach of the spine in lateral position. There is
no bleeding, because there is less pressure occurring in the
anterior abdominal wall and reduced venous engorgement.
Anaesthetic risk is reduced in lateral position. Patient can be
positioned into Kyphosis and Lordosis by just altering the hip
and knee positions.
The authors own experience
supports lateral decubitus position in all types of spinal
surgeries with great advantage to the surgeon, anaesthesiologist,
assistant, other OT personals and the patient.
References:
- Fourney DR, Abi-Said D, Rhines LD, Walsh GL, Lang FF,
McCutcheon IE, Gokaslan ZL. Simultaneous anterior-posterior
approach to the thoracic and lumbar spine for the radical
resection of tumors followed by reconstruction and
stabilization, J Neurosurg. 2001 Apr;94(2 Suppl):232-44.
- Dagher C, Naccache N, Narchi P,
Hage P, Antakly MC. Regional
anesthesia for lumbar microdiscectomy: J Med Liban. 2002
Sep-Dec;50(5-6):206-10.
- Cybulski GR,
Stone JL,
Opesanmi O. Spinal cord
decompression via a modified costotransversectomy approach
combined with posterior instrumentation for management of
metastatic neoplasms of the thoracic spine. : Surg Neurol.
1991 Apr;35(4):280-5
- Baulot E,
Trouilloud P,
Ragois P,
Giroux EA,
Grammont PM. Anterior spinal
fusion by thoracoscopy. A non-traumatic technique: Rev Chir
Orthop Reparatrice Appar Mot. 1997;83(3):203-9.
-
Sukegawa I,
Miyabe M,
Fujii T,
Hoshi T,
Takahashi S,
Toyooka H Rhabdomyolysis
after nephrectomy in the lateral flexed decubitus position:
Masui. 2003 Aug;52(8):882-5.
-
Wawro W,
Boos N,
Aebi M. Technique of surgical
correction of post-traumatic kyphosis Unfallchirurg. 1992
Jan;95(1):41-6.
-
Gonzalez Della Valle A,
Salonia-Ruzo P,
Peterson MG,
Salvati EA,
Sharrock NE.
Inflatable pillows as axillary support devices during surgery
performed in the lateral decubitus position under epidural
anesthesia. Anesth Analg. 2001 Nov;93(5):1338-43
-
Sato K,
Kato M Hypotension after
turning to the prone position Masui. 2003 Jan;52(1):46-8.
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Papin P,
Arlet V,
Marchesi D,
Laberge JM,
Aebi M Treatment of scoliosis
in the adolescent by anterior release and vertebral
arthrodesis under thoracoscopy. Preliminary results Rev Chir
Orthop Reparatrice Appar Mot. 1998 May;84(3):231-8.
-
Chang SH,
Miller NR. The incidence of
vision loss due to perioperative ischemic optic neuropathy
associated with spine surgery: the Johns Hopkins Hospital
Experience. Spine. 2005 Jun 1;30(11):1299-302
-
Sucato DJ,
Elerson E A comparison
between the prone and lateral position for performing a
thoracoscopic anterior release and fusion for pediatric spinal
deformity. Spine. 2003 Sep 15;28(18):2176-80.
- Dr.P.Gopinathan et al : Lumbar Segmental Instability
Treated by Expandable Spinal Spacer in PLIF, J.Orthopaedics
2004; 1(3)e4
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Dr.P.Gopinathan et al: Jacking up the
spine – A better way of treating lumbar spine instability, J.
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- Dr.P.Gopinathan et al lateral position the gold
standard position in spinal surgeries JCOA: Vol3, No.2 page
34- 39
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