CLINICAL ARTICLE

J Neurosurg 127:182–188, 2017

Contemporary analysis of the intraoperative and

perioperative complications of neurosurgical procedures
performed in the sitting position
Benjamin T. Himes, MD,1 Grant W. Mallory, MD,1 Arnoley S. Abcejo, MD,2 Jeffrey Pasternak, MD,2
John L. D. Atkinson, MD,1 Fredric B. Meyer, MD,1 W. Richard Marsh, MD,1 Michael J. Link, MD,1
Michelle J. Clarke, MD,1 William Perkins, MD,2 and Jamie J. Van Gompel, MD1
Departments of 1Neurologic Surgery and 2Anesthesiology, Mayo Clinic, Rochester, Minnesota

OBJECTIVE  Historically, performing neurosurgery with the patient in the sitting position offered advantages such as
improved visualization and gravity-assisted retraction. However, this position fell out of favor at many centers due to
the perceived risk of venous air embolism (VAE) and other position-related complications. Some neurosurgical centers
continue to perform sitting-position cases in select patients, often using modern monitoring techniques that may improve
procedural safety. Therefore, this paper reports the risks associated with neurosurgical procedures performed in the
sitting position in a modern series.
METHODS  The authors reviewed the anesthesia records for instances of clinically significant VAE and other complica-
tions for all neurosurgical procedures performed in the sitting position between January 1, 2000, and October 8, 2013. In
addition, a prospectively maintained morbidity and mortality log of these procedures was reviewed for instances of sub-
dural or intracerebral hemorrhage, tension pneumocephalus, and quadriplegia. Both overall and specific complication
rates were calculated in relation to the specific type of procedure.
RESULTS  In a series of 1792 procedures, the overall complication rate related to the sitting position was 1.45%, which
included clinically significant VAE, tension pneumocephalus, and subdural hemorrhage. The rate of any detected VAE
was 4.7%, but the rate of VAE requiring clinical intervention was 1.06%. The risk of clinically significant VAE was highest
in patients undergoing suboccipital craniotomy/craniectomy with a rate of 2.7% and an odds ratio (OR) of 2.8 relative to
deep brain stimulator cases (95% confidence interval [CI] 1.2–70, p = 0.04). Sitting cervical spine cases had a compara-
tively lower complication rate of 0.7% and an OR of 0.28 as compared with all cranial procedures (95% CI 0.12–0.67, p <
0.01). Sitting cervical cases were further subdivided into extradural and intradural procedures. The rate of complications
in intradural cases was significantly higher (OR 7.3, 95% CI 1.4–39, p = 0.02) than for extradural cases. The risk of VAE
in intradural spine procedures did not differ significantly from sitting suboccipital craniotomy/craniectomy cases (OR
0.69, 95% CI 0.09–5.4, p = 0.7). Two cases (0.1%) had to be aborted intraoperatively due to complications. There were
no instances of intraoperative deaths, although there was a single death within 30 days of surgery.
CONCLUSIONS  In this large, modern series of cases performed in the sitting position, the complication rate was low.
Suboccipital craniotomy/craniectomy was associated with the highest risk of complications. When appropriately used
with modern anesthesia techniques, the sitting position provides a safe means of surgical access.
https://thejns.org/doi/abs/10.3171/2016.5.JNS152328
KEY WORDS  sitting position; venous air embolism; posterior fossa surgery; surgical technique

U
se of the sitting position in neurosurgery has long
been a matter of some debate.32 Interest in its use
stems from a number of perceived advantages rela-
tive to other positions, particularly for procedures involv-
ing the posterior fossa and cervical spine. These advantages
include improved venous drainage due to reduced thoracic
outlet pressure, improved visualization of the surgical field,
and reduced need for cerebellar retraction in posterior fossa
cases.15,32 In some instances, specifically deep brain stimu-
lator (DBS) implantation, the use of the sitting position is
preferred to ensure appropriate access and patient comfort
as well as to minimize brain shift during the procedure.

ABBREVIATIONS  ACLS = advanced cardiovascular life support; CI = confidence interval; DBS = deep brain stimulator; OR = odds ratio; PFO = patent foramen ovale; TEE
= transesophageal echocardiography; VAE = venous air embolism.
SUBMITTED  October 6, 2015.  ACCEPTED  May 17, 2016.
INCLUDE WHEN CITING  Published online August 5, 2016; DOI: 10.3171/2016.5.JNS152328.

182 J Neurosurg  Volume 127 • July 2017 ©AANS, 2017

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These benefits must be weighed against perceived
complications inherent to the sitting position. Venous
air embolism (VAE), postoperative quadriplegia, tension
pneumocephalus, and subdural hematomas have been re-
ported.15,28,37 In much of the reported literature, these com-
plications occur at very low rates, but the results can be
devastating when they do occur. However, modern tech-
niques to prevent, monitor, diagnose, and rapidly treat
these complications can potentially improve outcome.14
This is supported by a number of recent series that have
demonstrated reduced rates of complications, particularly
VAE, relative to older studies.15,21,37 These results suggest
that rather than abandoning this procedure as has occurred
at many centers, modern techniques aimed at recognizing
VAE may mitigate complications associated with the sit-
ting position, improving its safety. In this paper we report
a modern series of 1792 procedures performed in the sit-
ting position from January 1, 2000, to October 8, 2013.
Methods
Study Population
Institutional Review Board approval was obtained
prior to data collection. Patients undergoing DBS elec-
trode placement, suboccipital craniotomy/craniectomy,
and procedures involving the posterior cervical spine in
the sitting position between January 1, 2000, and October
8, 2013, were included. Patients undergoing percutaneous
procedures or refusing consent for research were exclud-
ed. Morbidity and mortality logs, operative reports, and
electronic medical records were reviewed for instances
of detected VAE, clinically significant VAE (defined as
those cases requiring anesthetic intervention), subdural
hematoma, tension pneumocephalus, and postoperative
quadriplegia. The morbidity and mortality log represents
a prospectively maintained database of immediate and
near-term postoperative complications (within 30 days
of the procedure) as recorded by providers in the Depart-
ment of Neurological Surgery. Preoperatively, there were
no predetermined criteria as to what cases were to be per-
formed in the sitting position. Surgeon preference was the
deciding factor, with consultation with the anesthesiolo-
gist at the time of surgery.
Postoperative hemorrhages, including subdural hema-
tomas, were part of the analysis if listed as an immediate
or short-term complication in the morbidity and mortality
log during the acute hospital period. Cases of tension pneu-
mocephalus were included if intervention was required in
the form of twist-drill evacuation. The overall incidence of
complications as well as individual complication rates was
analyzed. Further subset analysis was performed accord-
ing to procedure type.
Data Collection
Cases of VAE were identified based on specific docu-
mentation in the anesthesia record. This was performed via
a database query of the included cases for the terms “VAE,”
“venous air embolism,” “air embolism,” “air emb-,” “air
he-,” “air se-,” “air id-,” and “air bu-.” The results of the
query were manually reviewed to ensure the accuracy of
the included cases. The diagnosis of VAE was made in-
Contemporary complications in the sitting position
traoperatively. This diagnosis was made at the discretion
of the documenting physician based on clinical findings
and intraoperative fluctuations in the patient’s vital signs.
Cases of VAE were not diagnosed retrospectively. Cases
of VAE were retrospectively classified as mild (requiring
no intervention), moderate (a significant drop in end-tidal
CO2 or hemodynamic instability requiring support with va-
sopressors), or severe (moderate criteria with the addition
of emergency repositioning or use of Advanced Cardiovas-
cular Life Support [ACLS] resuscitation). A case of VAE
was deemed clinically significant if it was classified in the
moderate or severe categories.
Intraoperative Monitoring
Intraoperative monitoring to aid in the diagnosis of VAE
was case-dependent. Sitting cranial cases typically includ-
ed precordial Doppler ultrasonography, transesophageal
echocardiography (TEE), and placement of a central line
for central venous pressure monitoring. Anesthesia was
maintained with isoflurane, with or without nitrous oxide
or desflurane and short-acting narcotics. Cervical spine
cases used similar monitoring and anesthesia to cranial
cases but without central venous pressure monitoring. DBS
cases were monitored with precordial Doppler ultrasonog-
raphy only. DBS cases typically proceeded under moni-
tored sedation with dexmedetomidine; in cases in which
general anesthesia was required, maintenance proceeded
with isoflurane or sevoflurane with or without nitrous ox-
ide. The typical intraoperative positioning of a patient,
as well as the intraoperative monitoring configuration, is
presented in Fig. 1. A retrospective review of the intraop-
erative anesthesia record was undertaken to assess the in-
cidence of VAE based on precordial Doppler monitoring,
changes in end-expired CO2, and changes in hemodynamic
stability. Preoperative risk assessment, such as with bubble
echocardiography, was not routinely undertaken.
Statistical Analysis
Statistical analysis was performed using Microsoft Ex-
cel and MedCalc online to calculate the odds ratio (OR),
95% confidence interval (CI), and statistical significance
of complications during a given type of procedure. Cases
were broadly divided into sitting suboccipital craniotomy/
craniectomy, DBS, or cervical spine procedures. Compli-
cations in sitting suboccipital cases were compared with
those in DBS procedures. Cervical spine procedures were
further categorized as either intradural or extradural, and
the risk of VAE was compared between these two groups.
Results
Demographics
A total of 1792 procedures were identified during the time
interval of the study. The overall series consisted of 41% fe-
male patients with a median age of 54 years (range 3–92
years). Further demographic data can be found in Table 1.
Events
The overall complication rate related to the procedure
was 1.45% (26/1792 procedures). The incidence rates of
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B. T. Himes et al.
FIG. 1. Illustrative setup for sitting procedure. The patient is placed in a
Mayfield pinion, the table is maximally flexed (A and B), and the patient
secured to a Mayfield cross bar adapter (C). An antebrachial peripheral-
ly inserted central catheter is also placed prior to positioning (D). Figure
is available in color online only.
clinically significant (moderate or severe) VAE, tension
pneumocephalus, and subdural or remote hemorrhage
were 1.06%, 0.11%, and 0.28%, respectively, inclusive of
all procedures. There were no intraoperative deaths; how-
ever, 1 patient died within 30 days of the procedure.
Procedure-Specific Data
Among sitting suboccipital procedures (450 cases), the
rates of clinically significant VAE, tension pneumocepha-
lus, and hemorrhage (1 subdural and 1 remote) were 2.7%,
0.2%, and 0.4%, respectively, with an overall complication
rate of 3.3% (Table 2). In 332 DBS cases, there was a 0.3%
incidence of clinically significant VAE and a 0.9% inci-
dence of subdural hemorrhage, with no cases of tension
pneumocephalus. Within the 1010 included cervical spine
cases, there was a 0.7% incidence of clinically significant
VAE and 0.1% rate of tension pneumocephalus, with no
instances of significant postoperative hemorrhage. When
separated into intradural and extradural cervical spine
cases, the rates of clinically significant VAE were 1.8%
TABLE 1. Demographic data
Procedure No. of Cases Women (%)
Overall 1792 736 (41)
Cervical 1010 354 (35)
DBS 332 125 (38)
Suboccipital 450 257 (57)
184 J Neurosurg  Volume 127 • July 2017
and 0.5%, respectively (Table 3). The lone case of tension
pneumocephalus noted in a sitting cervical procedure oc-
curred in an intradural case. No neurological deficits were
directly attributable to patient positioning in any of the in-
cluded cases. Sitting cervical procedures were overall as-
sociated with fewer complications than cranial procedures
(OR 0.28, 95% CI 0.12–0.67, p = 0.0042).
The occurrence of clinically significant VAE (OR 9.07,
95% CI 1.17–70.09, p = 0.035) was more strongly associ-
ated with suboccipital procedures as compared with DBS
implantation, but overall complication rates were compa-
rable (OR 2.83, 95% CI 0.93–8.6, p = 0.67; Table 2). There
was no significant difference in the risk of hemorrhage
or tension pneumocephalus between the two groups (p =
0.435 and p = 0.626, respectively), although there were no
incidences of tension pneumocephalus occurring in DBS
cases in this series.
In cervical spine cases, intradural procedures (n = 54)
were more strongly associated with mild (clinically insig-
nificant) VAE compared with extradural cervical spine
cases (n = 956; OR 6.87, 95% CI 2.38–19.38, p = 0.0004;
Table 4). However, when limited to clinically significant
VAE (moderate or severe), there was no significant dif-
ference (OR 3.59, 95% CI 0.41–31.27, p = 0.247; Table 3).
Intradural cases were also associated with a significantly
higher risk of tension pneumocephalus relative to extradu-
ral procedures (OR 53.64, 95% CI 2.16–1332.35, p = 0.015;
Table 3). When compared with sitting suboccipital cranial
procedures, there was not a statistically significant differ-
ence in the risk of clinically significant VAE in intradural
cervical procedures (p = 0.723; Table 3). There was no in-
cidence of clinically significant postoperative hemorrhage
in either group.
No deaths resulted from any of the observed complica-
tions; the single death within 30 days of the procedure was
unrelated to the procedure performed. Two procedures
(2/1792) were aborted due to intraoperative VAE.
Cases of VAE were subdivided into mild, moderate, and
severe categories, based on changes in end-expired CO2
or hemodynamic instability requiring intervention. Mild
cases required no intervention; moderate cases involved a
significant decrease in end-expired CO2 requiring use of
vasopressor support; and severe cases required emergency
repositioning or ACLS resuscitation. Mild cases of VAE
were significantly associated with suboccipital cranioto-
my/craniectomy relative to DBS procedures (p = 0.001,
Table 4). Similarly, mild cases of VAE were also signifi-
cantly more frequent in intradural cervical spine cases (5
of 54) as compared with extradural procedures (14 of 956;
p = 0.0004, Table 4). There was not a significant associa-
tion between moderate or severe VAE in comparing either
Age in Yrs (range)
Median Males Females
54 (3–92) 56 (3–92) 51 (7–92)
54 (17–92) 55 (17–92) 51 (23–92)
62 (9–84) 62 (9–84) 64 (9–83)
45 (3–83) 47 (3–81) 43 (7–83)
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 Contemporary complications in the sitting position

TABLE 2. Overall and specific complication rates for sitting TABLE 3. Risk of complications in intradural cervical procedures
suboccipital craniotomies and DBS cases* compared with extradural cervical cases and sitting suboccipital
craniotomy/craniectomy cases
Complications p
Cranial Cases (%) OR 95% CI Value Complications p
Cervical Spine Cases (%) OR 95% CI Value
Overall 24 (3.1) 2.83 0.93–8.6 0.067
 Suboccipital 15 (3.3) Overall 7 (0.7) 7.32 1.39–38.61 0.019
 DBS 4 (1.2)  Intradural 2 (3.7)
Moderate/severe VAE 9.07 1.17–70.09 0.035  Extradural 5 (0.5)
 Suboccipital 12 (2.7) Moderate/severe VAE 3.59 0.41–31.27 0.247
 DBS 1 (0.3)  Intradural 1 (1.8)
Tension pneumo- 2.22 0.09–54.65 0.626  Extradural 5 (0.5)
cephalus Tension pneumo- 53.64 2.16–1332.35 0.015
  Suboccipital 1 (0.2) cephalus
  DBS 0 (0)   Intradural 1 (1.8)
Hemorrhage 0.49 0.08–2.95 0.435   Extradural 0 (0)
 Suboccipital 2 (0.4) Risk of moderate/ 0.69 0.09–5.40 0.723
 DBS 3 (0.9) severe VAE
  Intradural 1 (1.8)
*  Odds ratios are presented comparing suboccipital craniotomy/craniectomy
to DBS for each complication and overall, along with a 95% CI and associated   Suboccipital 12 (2.7)
p values.

extradural with intradural cervical cases or suboccipital
craniotomy/craniectomy with DBS cranial cases (Table 4).
Discussion
Despite the potential advantages of the sitting position,
hesitancy regarding its implementation persists among
some neurosurgeons and anesthesiologists, precluding its
widespread use. This negative stigma is partially due to in-
creased risk of VAE, but also due to other rare and severe
complications that have been attributed to sitting proce-
dures. Our institution has an extensive history of perform-
ing neurosurgical procedures in the sitting position.3,7,11 To
better ascertain the true nature of these risks, we reviewed
a large modern series (n = 1792, from January 1, 2000,
until October 8, 2013) of various neurosurgical procedures
performed in the sitting position. The overall incidence
of complications attributable to the sitting position was
1.45%. The overall incidence of VAE requiring intraoper-
ative treatment was 1.1%. The incidence of VAE increased
to 4.7% when all cases of VAE were included; however,
these additional occurrences responded to minimal field
interventions such as waxing bone edges, cauterizing ves-
sels, or copious irrigation. No deaths resulted from any
of the observed complications, and only 2 procedures
(2/1794) were aborted due to intraoperative VAE.
Venous Air Embolism
The reported incidence of VAE during sitting neurosur-
gical procedures is extremely variable in the literature and
largely depends on the way that VAE was defined, as well
as the patient population. The methods used to detect VAE
have also evolved over time.8,25 In our series, we empha-
sized clinically significant VAE, meaning a VAE resulting
in hemodynamic or respiratory compromise, or alteration
of the course of the case. Recently, Ganslandt and col-
leagues (2013) reviewed more than 600 suboccipital and
cervical spine procedures and evaluated the incidence of
VAE as defined by a decrease in end-expired CO2 of more
than 4 mm Hg, characteristic sounds on Doppler ultraso-
nography, or any sign of air on TEE. The overall incidence
in their series was 19%. However, the incidence of VAE
causing hemodynamic or respiratory compromise was
3.3%, and only 1 in 200 cases had to be terminated due
to VAE.15 Using a similar definition, Leslie et al. (2006)
found an overall incidence of 9%, also in a mixture of cer-
vical and suboccipital cases.24 In contrast, Papadopoulos et
al. (1994) prospectively reviewed 22 posterior fossa cases
and 40 cervical spine cases, defining VAE solely by using
TEE, and reported an incidence of 76% and 25%, respec-
tively.31 However, the incidence of VAE detected in this
manner is not known for other surgical positions.
Perhaps the most comprehensive study using variable
definitions of VAE is that conducted by Feigl et al., who
reviewed 200 consecutive semisitting neurosurgical cases
in 2014. Using a graded scale, they found the incidence to
be 42.3% if a definition of the presence of air bubbles on
TEE was used, compared with 3.8% if a decrease in end-
expired CO2 of more than 3 mm Hg was used and 1.9% if
clinically significant changes (drop in mean arterial pres-
sure > 20% or increase in heart rate > 40%) were used.
No VAEs resulted in hemodynamic instability requiring
resuscitation.13 While series that use the most stringent of
definitions for VAE reveal that air passes into systemic
circulation with no small frequency, it is worthy of note
that comparably few VAEs involve adverse consequenc-
es. A review of 430 posterior fossa cases by Bithal et al.
showed that 37% of VAEs (defined as a sustained decrease
in end-tidal CO2 by > 0.7 kPa) in adults and 33% in chil-
dren resulted in hypotension, and only in one instance was
it necessary to abort a procedure.2 Furthermore, VAE is
a risk of any procedure in which the head is above the
heart, and there is scant literature to determine what the
exact incidence of VAE is in these cases. As reverse Tren-

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B. T. Himes et al.
TABLE 4. Severity of VAE stratified by procedure type*
Severity of
VAE Suboccipital DBS OR 95% CI
Mild 38 8 3.74 1.72–8.12
Moderate 9 1 6.75 0.85–53.58
Severe 3 0 5.2 0.28–101.04
*  Cases were stratified as mild, moderate, or severe based on the following criteria: mild = diagnosis of VAE without clinical significance or need for pharmacological,
anesthetic, or surgical intervention; moderate = diagnosis of VAE with significant drop in end-tidal CO2 or requiring pressor support; severe = moderate criteria in addi-
tion to emergency repositioning or requiring ACLS resuscitation.
delenburg positioning is very commonly employed to re-
duce brain swelling, VAE has been reported in horizontal
neurosurgical cases, although the incidence is higher with
sitting procedures.12
Interestingly, the incidence of VAE appears to differ
with the type of procedure as well. We found that cranial
cases, both suboccipital craniotomies (2.7%) and intradural
cervical spine cases (1.8%), had higher incidences of clini-
cally significant VAE compared with DBS cases (0.3%)
and extradural cervical cases (0.5%). While the reasons for
these findings are not entirely clear, they have also been
borne out in other series.12,15 In a meta-analysis of more
than 4000 cases, Fathi et al. found a nearly 3-fold increase
in the incidence of VAE during posterior fossa procedures
compared with cervical cases.12 The incidence in 467 DBS
cases was 1.3% as reported by Chang et al.6 Additionally,
the type of suboccipital craniotomy may also play a role,
as Yonekawa and colleagues reported higher rates with lat-
eral approaches (21% vs 8%).43 The incidence rate may also
vary with operative time, as 1 study that reviewed the util-
ity of image guidance with lateral suboccipital craniotomy
found lower incidences of VAE (8% vs 19%) and faster op-
erative times (21 vs 39 minutes) in cases that used image
guidance compared with cases in which this technology
was not used.16 However, it should be noted that cases us-
ing image guidance had lower rates of venous sinus injury
that may also account for this difference. The difference in
risks may in part be explained by lower degrees of inva-
siveness given that craniotomies/craniectomies have great-
er risk than DBS procedures. Cerebrospinal fluid egress
also likely plays a role as the cervical cases in this series
were mostly decompressive laminectomies and forami-
notomies, with a smaller representation of intradural pro-
cedures in which a higher, but not statistically significant,
rate of clinically significant VAE was observed.
Pneumocephalus
Pneumocephalus is a common occurrence with any
cranial procedure, and is a gravity-dependent phenom-
enon. Thus, it is not surprising that the reported incidence
of pneumocephalus after sitting procedures is higher than
procedures performed in the horizontal position.40 Howev-
er, tension pneumocephalus, a potential expanding volume
of air that results in an increase in intracranial pressure, is
rare and is not necessarily unique to sitting neurosurgical
cases.20,33,39 Di Lorenzo conducted a prospective study of
30 cases and found a 100% occurrence of pneumocepha-
lus, although no patient suffered tension pneumocephalus
or any neurological symptom as the result of intracranial
186 J Neurosurg  Volume 127 • July 2017
Cervical
p Value Intradural Extradural OR 95% CI p Value
0.001 5 14 6.87 2.38–19.83 0.0004
0.071 1 5 3.59 0.41–31.27 0.247
0.276 0 0 — — —
air.10 A larger study conducted by Standefar et al. of 488
cases found that only 8 patients (1.6%) developed symp-
tomatic pneumocephalus, none of whom required twist-
drill bur hole and aspiration through a subdural catheter
to relieve pressure.37
Subdural and Remote Hemorrhages
The development of subdural hemorrhage was exceed-
ingly rare in the present series. No subdural hematomas
occurred after cervical cases, and 5 patients developed a
subdural hematoma after a cranial case (3 DBS cases and
2 posterior fossa cases). Standefar et al. also reported a low
subdural hematoma rate (0.6% after all cases and 1.3%
after posterior fossa cases) following sitting procedures.37
Presumably, the cause for subdural hematomas is related
to mechanical displacement of the brain resulting in tear-
ing of bridging veins. While this appears to be a logical
explanation, it does not fully explain the findings of re-
mote intraparenchymal or epidural hemorrhages that have
been observed after sitting procedures.4,22,30 Furthermore,
it is debatable as to whether the sitting position truly leads
to an increase in these complications, as these complica-
tions are observed in more conventional positions as well.
Although Brisman et al. found that 87% of remote hemor-
rhages occurred in the sitting procedures in his review of
the literature, a large series by Kalfas and Little that re-
viewed nearly 5000 supratentorial and infratentorial cases
did not find an increased risk with the sitting position.4,22
Other Neurological and Rare Complications
Although no neurological complications were directly
attributable to the sitting position in our series, a variety
of neurological complications have been described as a re-
sult of its use.19,23,27,29,38,41 Sciatic nerve palsies have been
described with the use of the sitting position.23,41 Other
cranial nerve palsies have also been described such as
delayed lateral rectus palsies and anosmia.34,38 These re-
ported complications range from minor complications
such as peripheral and cranial nerve palsies to devastat-
ing complications such as cervical quadriplegia. Periph-
eral nerve palsies that have been described due to the sit-
ting position include sciatic nerve injury.34,35,38 One of the
most feared complications is cervical quadriplegia due
to cord stretch.42 Both cord infarction and quadriparesis
have been described.19,27,29 While such complications are
likely exceedingly rare, they do emphasize the necessity
for meticulous positioning and support the use of monitor-
ing (motor and somatosensory evoked potentials) for pre-
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vention. Other rare complications that have been reported
after sitting procedures include acute parotitis, pyriformis
syndrome, and tension pneumoventricle.1,5,18 We did not
observe these complications in this series, and our series
likely represents a more modern approach to these cases
compared with the prior report. Additionally, consequenc-
es of VAE such as paradoxical emboli in the presence of
patent foramen ovale (PFO) or due to right-to-left intra-
pulmonary shunting and fatal coagulopathy have been de-
scribed.12,17,26,36 Due to the risk of paradoxical emboli, the
presence of PFO is considered a contraindication to the
sitting position by some, and efforts have been undertaken
to identify patients undergoing sitting procedures where
there may be a PFO.9 However, in a series of 200 patients
undergoing semisitting procedures, 52 of whom had a
PFO, no instances of paradoxical emboli were reported by
Feigl et al. using modern protocols for VAE detection.13
Limitations of the Study
The present series has value in its large sample size
and derivation from a prospectively collected morbidity
and mortality database. However, because the database is
maintained by neurosurgical staff, attention to anesthetic
complications (such as delayed extubation or macroglos-
sia) would likely not be captured in this cohort. Thus, the
overall complication rate may well be higher if all anesthet-
ic-related complications are considered. Additionally, our
definition of VAE makes it difficult to compare incidences
among other institutions or other series that may use more
stringent definitions. We did endeavor to separately review
the intraoperative anesthesia data to assess the incidence of
VAE from a different perspective to address these issues.
The lack of any set criteria in the selection of patients to
undergo surgery in the sitting position may also present a
confounding variable. Similarly, the variability of methods
used to detect VAE (such as the use of TEE in suboccipital
cases but not in DBS) may lead to some ascertainment bias
in the detection of mild VAE. However, this variation is un-
likely to obscure the detection of moderate or severe cases
of VAE as these cases involved some evidence of hemo-
dynamic instability requiring intervention. Lastly, the het-
erogeneity of procedures (cervical, suboccipital, and DBS
cases) may also preclude direct comparisons to other prior
series that did not include these specific types of procedures.
We used data from a neurosurgical morbidity and mortality
database, and events that may have occurred at a later time
(past the first 30 days postoperatively) were unlikely to be
captured. Future study assessing the risk factors for compli-
cations among different procedure types would be of value
to better understand which subset of patients is truly at risk
to further mitigate the risk of these complications.
Conclusions
In this large, modern series of cases performed in the
sitting position, the overall rate of complications was quite
low. No neurological deficits were observed directly as a
result of positioning (i.e., quadriplegia). While the risk of
VAE has been shown to be higher in sitting procedures,
the overall risk of clinically significant VAE in this study
was small at 1.1%. The risk of clinically significant VAE
Contemporary complications in the sitting position
is higher in suboccipital cases relative to DBS procedures.
While a higher rate of clinically significant VAE was ob-
served in intradural cervical cases relative to extradural
ones, it did not reach statistical significance. There was,
however, a significantly higher rate of mild VAE in intra-
dural cases. When appropriately used, the sitting position
provides a safe means of surgical access.
Acknowledgments
We would like to acknowledge Dr. Guiseppe Lanzino and Dr.
Kendall Lee, who contributed cases to this series and aided in the
preparation of this paper.
References
  1. Berker M, Sahin A, Aypar U, Ozgen T: Acute parotitis fol-
lowing sitting position neurosurgical procedures: review of
five cases. J Neurosurg Anesthesiol 16:29–31, 2004
  2. Bithal PK, Pandia MP, Dash HH, Chouhan RS, Mohanty B,
Padhy N: Comparative incidence of venous air embolism
and associated hypotension in adults and children operated
for neurosurgery in the sitting position. Eur J Anaesthesiol
21:517–522, 2004
  3. Black S, Ockert DB, Oliver WC Jr, Cucchiara RF: Outcome
following posterior fossa craniectomy in patients in the sit-
ting or horizontal positions. Anesthesiology 69:49–56, 1988
  4. Brisman MH, Bederson JB, Sen CN, Germano IM, Moore F,
Post KD: Intracerebral hemorrhage occurring remote from
the craniotomy site. Neurosurgery 39:1114–1122, 1996
  5. Brown JA, Braun MA, Namey TC: Pyriformis syndrome in a
10-year-old boy as a complication of operation with the pa-
tient in the sitting position. Neurosurgery 23:117–119, 1988
  6. Chang EF, Cheng JS, Richardson RM, Lee C, Starr PA, Lar-
son PS: Incidence and management of venous air embolisms
during awake deep brain stimulation surgery in a large clini-
cal series. Stereotact Funct Neurosurg 89:76–82, 2011
  7. Cucchiara RF, Bowers B: Air embolism in children undergo-
ing suboccipital craniotomy. Anesthesiology 57:338–339,
1982
  8. Cucchiara RF, Nugent M, Seward JB, Messick JM: Air em-
bolism in upright neurosurgical patients: detection and local-
ization by two-dimensional transesophageal echocardiogra-
phy. Anesthesiology 60:353–355, 1984
  9. Cucchiara RF, Seward JB, Nishimura RA, Nugent M, Faust
RJ: Identification of patent foramen ovale during sitting posi-
tion craniotomy by transesophageal echocardiography with
positive airway pressure. Anesthesiology 63:107–109, 1985
10. Di Lorenzo N, Caruso R, Floris R, Guerrisi V, Bozzao L,
Fortuna A: Pneumocephalus and tension pneumocephalus
after posterior fossa surgery in the sitting position: a prospec-
tive study. Acta Neurochir (Wien) 83:112–115, 1986
11. Duke DA, Lynch JJ, Harner SG, Faust RJ, Ebersold MJ: Ve-
nous air embolism in sitting and supine patients undergoing
vestibular schwannoma resection. Neurosurgery 42:1282–
1287, 1998
12. Fathi AR, Eshtehardi P, Meier B: Patent foramen ovale and
neurosurgery in sitting position: a systematic review. Br J
Anaesth 102:588–596, 2009
13. Feigl GC, Decker K, Wurms M, Krischek B, Ritz R, Unertl
K, et al: Neurosurgical procedures in the semisitting position:
evaluation of the risk of paradoxical venous air embolism
in patients with a patent foramen ovale. World Neurosurg
81:159–164, 2014
14. Gale T, Leslie K: Anaesthesia for neurosurgery in the sitting
position. J Clin Neurosci 11:693–696, 2004
15. Ganslandt O, Merkel A, Schmitt H, Tzabazis A, Buchfelder
M, Eyupoglu I, et al: The sitting position in neurosurgery:
J Neurosurg  Volume 127 • July 2017 187
Unauthenticated | Downloaded 09/05/20 03:42 PM UTC
B. T. Himes et al.
indications, complications and results. A single institution
experience of 600 cases. Acta Neurochir (Wien) 155:1887–
1893, 2013
16. Gharabaghi A, Rosahl SK, Feigl GC, Safavi-Abbasi S,
Mirzayan JM, Heckl S, et al: Image-guided lateral suboccipi-
tal approach: part 2-impact on complication rates and opera-
tion times. Neurosurgery 62 (3 Suppl 1):24–29, 2008
17. Girard F, Ruel M, McKenty S, Boudreault D, Chouinard P,
Todorov A, et al: Incidences of venous air embolism and
patent foramen ovale among patients undergoing selective
peripheral denervation in the sitting position. Neurosurgery
53:316–320, 2003
18. Gonçalves MB, Nunes CF, Melo JO Jr, Guimarães RD,
Klescoski J Jr, Landeiro JA: Tension pneumoventricle after
resection of a fourth ventricle choroid plexus papilloma: An
unusual postoperative complication. Surg Neurol Int 3:116,
2012
19. Haisa T, Kondo T: Midcervical flexion myelopathy after pos-
terior fossa surgery in the sitting position: case report. Neu-
rosurgery 38:819–822, 1996
20. Hernández-Palazo NJ, Nuño de la Rosa-Carrillo V, Martinez-
Lage JF, López-Hernández F, Pérez-Espejo MA: [Tension
pneumocephalus after intracranial surgery in the supine posi-
tion.] Neurocirugia (Astur) 15:596–599, 2004 (Span)
21. Hooper AK, Okun MS, Foote KD, Haq IU, Fernandez HH,
Hegland D, et al: Venous air embolism in deep brain stimula-
tion. Stereotact Funct Neurosurg 87:25–30, 2009
22. Kalfas IH, Little JR: Postoperative hemorrhage: a survey of
4992 intracranial procedures. Neurosurgery 23:343–347,
1988
23. Konovalov AN, Lubnin AI, Shimanskiĭ VN, Kolycheva MV,
Ogurtsova AA, Grigorian AA: [Positional damage of the
sciatic nerve during neurosurgical intervention into the pos-
terior cranial fossa in the sitting position.] Anesteziol Reani-
matol 3:58–60, 2009 (Russian)
24. Leslie K, Hui R, Kaye AH: Venous air embolism and the
sitting position: a case series. J Clin Neurosci 13:419–422,
2006
25. Michenfelder JD, Miller RH, Gronert GA: Evaluation of an
ultrasonic device (Doppler) for the diagnosis of venous air
embolism. Anesthesiology 36:164–167, 1972
26. Moningi S, Kulkarni D, Bhattacharjee S: Coagulopathy fol-
lowing venous air embolism: a disastrous consequence -a
case report-. Korean J Anesthesiol 65:349–352, 2013
27. Morandi X, Riffaud L, Amlashi SF, Brassier G: Extensive
spinal cord infarction after posterior fossa surgery in the sit-
ting position: case report. Neurosurgery 54:1512–1516, 2004
28. Mostafa RM, Mejadi A: Quadriplegia after interscalene
block for shoulder surgery in sitting position. Br J Anaesth
111:846–847, 2013
29. Nitta H, Yamashita J, Nomura M, Igarashi N: Cervical spinal
cord infarction after surgery for a pineal region choriocar-
cinoma in the sitting position: case report. Neurosurgery
40:1082–1086, 1997
30. Pandey P, Madhugiri VS, Sattur MG, Devi B I: Remote su-
pratentorial extradural hematoma following posterior fossa
surgery. Childs Nerv Syst 24:851–854, 2008
31. Papadopoulos G, Kuhly P, Brock M, Rudolph KH, Link J,
Eyrich K: Venous and paradoxical air embolism in the sitting
position. A prospective study with transoesophageal echocar-
diography. Acta Neurochir (Wien) 126:140–143, 1994
32. Porter JM, Pidgeon C, Cunningham AJ: The sitting position
in neurosurgery: a critical appraisal. Br J Anaesth 82:117–
128, 1999
33. Prabhakar H, Bithal PK, Garg A: Tension pneumocephalus
after craniotomy in supine position. J Neurosurg Anesthe-
siol 15:278–281, 2003
34. Ramsbacher J, Brock M, Kombos T: Permanent postoperative
188 J Neurosurg  Volume 127 • July 2017
anosmia: a hitherto undescribed complication following sur-
gery of the posterior cranial fossa in the sitting position. Acta
Neurochir (Wien) 139:482–483, 1997
35. Ramsbacher J, Vesper J, Brock M: Permanent postoperative
anosmia: a serious complication of neurovascular decom-
pression in the sitting position. Acta Neurochir (Wien)
142:1259–1261, 2000
36. Schlundt J, Tzanova I, Werner C: A case of intrapulmonary
transmission of air while transitioning a patient from a sitting
to a supine position after venous air embolism during a crani-
otomy. Can J Anaesth 59:478–482, 2012
37. Standefer M, Bay JW, Trusso R: The sitting position in neu-
rosurgery: a retrospective analysis of 488 cases. Neurosur-
gery 14:649–658, 1984
38. Stevens QE, Colen CB, Ham SD, Kattner KA, Sood S: De-
layed lateral rectus palsy following resection of a pineal cyst
in sitting position: direct or indirect compressive phenom-
enon? J Child Neurol 22:1411–1414, 2007
39. Suri A, Mahapatra AK, Singh VP: Posterior fossa tension
pneumocephalus. Childs Nerv Syst 16:196–199, 2000
40. Toung TJ, McPherson RW, Ahn H, Donham RT, Alano J,
Long D: Pneumocephalus: effects of patient position on the
incidence and location of aerocele after posterior fossa and
upper cervical cord surgery. Anesth Analg 65:65–70, 1986
41. Wang JC, Wong TT, Chen HH, Chang PY, Yang TF: Bi-
lateral sciatic neuropathy as a complication of craniotomy
performed in the sitting position: localization of nerve injury
by using magnetic resonance imaging. Childs Nerv Syst
28:159–163, 2012
42. Wilder BL: Hypothesis: the etiology of midcervical quad-
riplegia after operation with the patient in the sitting position.
Neurosurgery 11:530–531, 1982
43. Yonekawa Y: [Operative neurosurgery: personal view and
historical backgrounds (8) suboccipital craniotomy-sitting
position-linear incision.] No Shinkei Geka 39:789–809, 2011
(Jpn)
Disclosures
The authors report no conflict of interest concerning the materi-
als or methods used in this study or the findings specified in this
paper.
Author Contributions
Conception and design: Van Gompel, Himes, Mallory, Abcejo.
Acquisition of data: Himes, Mallory, Abcejo, Pasternak, Atkin-
son, Meyer, Marsh, Link, Clarke. Analysis and interpretation of
data: Himes, Mallory, Abcejo. Drafting the article: Van Gompel,
Himes, Mallory, Abcejo, Pasternak. Critically revising the article:
Van Gompel, Himes, Mallory, Abcejo, Pasternak, Atkinson,
Meyer, Clarke, Perkins. Reviewed submitted version of manu-
script: Van Gompel, Himes, Mallory, Abcejo, Pasternak, Atkin-
son, Meyer, Marsh, Clarke, Perkins. Approved the final version of
the manuscript on behalf of all authors: Van Gompel. Statistical
analysis: Himes, Mallory.
Supplemental Information
Previous Presentations
Portions of this work were presented as a platform presentation
at the 2014 AANS Annual Scientific Meeting in San Francisco,
California, April 7, 2014.
Correspondence
Jamie J. Van Gompel, Department of Neurosurgery, Mayo Clinic,
200 First St. SW, Rochester, MN 55905. email: vangompel.
jamie@mayo.edu.
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