027 Patient posioning for spine surgery

Youmans Neurological Surgery

1. Patient Positioning for
Spinal Surgery
Youmans Chapter 27

2. Outline
•Equipment
•Principles of positioning
•Specificprocedures

3. Equipment

4. Tables

5. Tables
•Operations in the supine position
–anterior cervical procedures
–anterior lumbar fusions in the distal lumbar spine
(L3-S1)
•A lateral approach for thoracic, thoracolumbar,
and lumbar procedure
•Thoracoabdominal and retroperitoneal flank
approaches, it is often helpful to place the level
of pathology at the table break and flex the
patient laterally.

6. Jackson spinal table
•Radiolucent
•Greater length of
height
•Full 360 clearance
•Use of multiple pad

7. Head Holders
•Cutouts for the eyes and endotracheal tube are
the main safety features
•Other
–Bean bag : lateral position for thoracotomy or
retroperitoneum flank approach
–Armrests
–Foam pad
–Disposable heating blanket

8. Principles of positioning
•Surgical access : allow the surgeon to achieve
the surgeon objective
•Patient safety and Protection
–Neuropathies and prevention
–Soft tissue injuries
–Head Positioning
–Visual loss and Its prevention
–Air embolism
•Spinal alignment
•Surgeon Ergonomics

9. Neuropathies and prevention
•Ulnar neuropathy : most common
postoperative neuropathies
•it is thought to be related to intraneural capillary
ischemia resulting from nerve overstretch or
compression, perhaps exacerbated by
prolonged intraoperative hypotension
•Time of onset of ulnar nerve symptom : after
surgery to 3 day postoperative
•Duration : day to year
•Risk factor : diabete, old age, male gender

10. Neuropathies and prevention
•Superficial condyle
groove
•Elbow flexion>110
•External
compression

11. Neuropathies and prevention
•Supine position : direct
pressure on ulnar n. at
the elbow is significantly
higher if both arm are
pronated than if they are
neutral position and
supinate

12. Neuropathies and prevention
•Brachial plexus neuropathy : shoulder pain,
scapular winging, and shoulder weakness
•Incidence during posterior spinal surgery : 3.6-
15 %
•Duration : persistent at late 1-3 yrs
•Upper trunk in supine position
•Lower trunk in prone position
•Pt congenital anomaly : cervical rib, shoulder
contracture

13. Neuropathies and prevention
•Somatosensory evoked potential (SSEP)
monitoring as a way to detect impending nerve
injury
•Lower extremity neuropathies : common
peroneal n. injury(superficial location as it
transverse the head of fibula)

14. Neuropathies and prevention
•Peroneal neuropathy : complete plegia of
dorsiflexion and eversion without significant pain
complain
•L5 radiculopathy : dermatomal pain, sensory
deficit, weakness of dorsiflexion, toe extension,
and foot inversion

15. Soft tissue injuries
•Prolong pressure leads to local ischemia, tissue
necrosis
•Not bear significant structure
•No EKG leads, IV line connector on supporting
pad
•Lateral or prone position : abdomen should be
free as possible  decrease intra-abdominal
pressure, decrease pressure in the valveless
epidural venous plexus (reduce epidural
bleeding)

16. Head Positioning
•Neutral positioning for cervical region
•Lateral and supine : soft support (doughbut-
shape foam or gel pad or pillow)
•Rigid head holding
•May-field system
•Traction

17. Visual loss and Its prevention
•POVL : post operative visual loss
•Most common cause : ischemic optic
neuropathy from compromised blood
flow(increase venous pressure and interstitial
edema), unilateral more than bilateral, prone
position
•May be attribute to central renal artery occlusion
•Associated with prolong anesthetic
operation(>6hr), significant blood loss(>1 lit)

18. Air embolism
•Sitting position,Cervical osteotomies
•Operative field above the heart  air may be entrained
into open  uncoaulated venous channel  air
embolism
•Precordial Doppler probe for diagnose an air embolism
•Long venous line used in attempt to aspirate air
•If air embolism is suspected during surgery : the field
should be flooded with sterile irrigation and position
change to bring the head close to the level of heart

19. Spinal alignment
•For procedure with no arthrodesis is performed :
lumbar microdiskectomy or cervical foraminotomy :
optimized to facilitate safe, thorough neural
decompression

20. Spinal alignment
•Occipitocervical alignment
–improper positioning can lead to ovely extending
and inability of patient to see their body
–excessive flexion or retraction can make
swallowing difficult
–coronal or axial will require
patient to compensate for head tilt
or rotation to maintain level,
forward gaze

21. Spinal alignment
•Lumbar decompressive : lumbar flexion
create
•This position would not be used if an
arthrodesis were also to be performed
•Hipextension enhances lumbar
lordosis, thereby resulting in
optimal spinal alignment for
instrumented arthrodesis

22. Surgeon ergonomic
•Optomize the working environment for surgeon
•Operative field heigt should be comfortable for
surgeon
•Horizontal plane as possible
•Lower cervical or cervicothoracic : reverse
trendelenberg
•Operating microscope

23. Specific procedure
•Anterior cervical
•Posterior occipitocervical, cervical,
cervicothoracic
•Posterior Thoracolumbar Arthrodesis
•Anterolateral, Retropleural Thoracic, Lateral
lumbar
•Anterior lumbar
•Intraoperative Repositioning

24. Anterior cervical
•Maintain gentle cervical extension(lordosis), maintain
head and cervical spine are neutrally aligned in the axial
plane
•Hypoextension: kyphosis
•Hyperextension : cervical spinal stenosis, neurological
risk intraoperative
•Small padded roll is placed underneath the patient and
extended transversely to about the T2 level,
•Foam doughnut is placed under the occiput
•Paper tape extending from one side to the other and
adherent to the forehead is adequate to maintain neutral
alignment

25. Posterior occipitocervical,
cervical, cervicothoracic
•First, unobstructed anteroposterior and lateral
radiographs or fluoroscopy can be obtained
•Second, the tabletop can be set up in a
moderate reverse Trendelenburg position
without raising the head unit
•Third, the modular pads can accommodate a
wide variety of body types.
•Finally, the dual-vector traction is easily set up
and manipulated.

26. Posterior Thoracolumbar Arthrodesis
•Position to maintain or enhance lumbar lordosis
•All contact point,particulary the knees, are
padded carefully
•It is also important to flex the knees and to
ensure that the feet are in a relaxed,neutral
position and not in forced plantar flexion

27. Anterolateral, lateral lumbar
Retropleural Thoracic,
•Lateral positioning follow the same principle as
for the common anterior and posterior approach
•Soft tissue or pheripheral n. injury secondary to
focal pressure
•Dependent axilla : soft roll to prevent excessive
shoulder abduction
•Dependent arm : externally rotate, elbox flex 90,
upper part gently flex, pillow
•Dependent leg : flex hip, flex knee

28. Anterior lumbar
•The arm may be abductes to allow access for
anesthesiologist
•Heel support

29. Intraoperative repositioning
•Supine to prone, prone to supine
•Two standard electric operating table