Youmans Neurological Surgery

1. Patient Positioning for
Spinal Surgery
Youmans Chapter 27

2. Outline
• Equipment
• Principles of positioning
• Specific procedures

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