Copyright ©The Author(s) 2015. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Orthop. Apr 18, 2015; 6(3): 351-359
Published online Apr 18, 2015. doi: 10.5312/wjo.v6.i3.351
Complications associated with prone positioning in elective spinal surgery
J Mason DePasse, Mark A Palumbo, Maahir Haque, Craig P Eberson, Alan H Daniels
J Mason DePasse, Mark A Palumbo, Maahir Haque, Craig P Eberson, Alan H Daniels, Department of Orthopaedics, Warren Alpert Medical School of Brown University, Providence, RI 02903, United States
Author contributions: All authors contributed to this manuscript.
Conflict-of-interest: J Mason DePasse has received educational materials from Stryker. Mark A Palumbo has received fees as a consultant for Stryker and research funding from Globus Medical. Maahir Haque has no disclosures. Craig P Eberson has received fees for serving as a speaker for Stryker and as a consultant for Orthofix, Inc. Craig P Eberson has also received intellectual property royalties from Global Medical. Alan H Daniels has received education materials from Stryker, and he has also received fees as a consultant for Osseus. None of these disclosures are relevant to this review.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See:
Correspondence to: J Mason DePasse, MD, Department of Orthopaedics, Warren Alpert Medical School of Brown University, 593 Eddy Street, Providence, RI 02903, United States.
Telephone: +1-401-4444030 Fax: +1-401-4446182
Received: January 23, 2015
Peer-review started: January 24, 2015
First decision: February 7, 2015
Revised: February 12, 2015
Accepted: March 5, 2015
Article in press: March 9, 2015
Published online: April 18, 2015

Complications associated with prone surgical positioning during elective spine surgery have the potential to cause serious patient morbidity. Although many of these complications remain uncommon, the range of possible morbidities is wide and includes multiple organ systems. Perioperative visual loss (POVL) is a well described, but uncommon complication that may occur due to ischemia to the optic nerve, retina, or cerebral cortex. Closed-angle glaucoma and amaurosis have been reported as additional etiologies for vision loss following spinal surgery. Peripheral nerve injuries, such as those caused by prolonged traction to the brachial plexus, are more commonly encountered postoperative events. Myocutaneous complications including pressure ulcers and compartment syndrome may also occur after prone positioning, albeit rarely. Other uncommon positioning complications such as tongue swelling resulting in airway compromise, femoral artery ischemia, and avascular necrosis of the femoral head have also been reported. Many of these are well-understood and largely avoidable through thoughtful attention to detail. Other complications, such as POVL, remain incompletely understood and thus more difficult to predict or prevent. Here, the current literature on the complications of prone positioning for spine surgery is reviewed to increase awareness of the spectrum of potential complications and to inform spine surgeons of strategies to minimize the risk of prone patient morbidity.

Keywords: Spine, Patient positioning, Prone position, Complications, Prevention and control

Core tip: This review addresses the complications of prone positioning for spine surgery, which is an important and relatively underrepresented topic in the literature. Here, we address the wide range of complications by system, covering the most common complications, current understanding of pathophysiology, and strategies for prevention. Individual cases of very rare complications are also addressed. This article provides increased awareness and understanding of the risks of prone positioning, which is important for patient morbidity.