C O N F L U E N C E : Saving the Brain Together

Prone Position in
Neurosurgery

EDUARDO A. BARRENECHEA II
Section of Neuroanesthesiology

DEPARTMENT OF ANESTHESIOLOGY & PAIN MEDICINE 4th Post Graduate COURSE

Disclosures

No conflict of interest

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DISCLAIMER

PRONE: flat prone

Defined as:
 face-down
 arms are extended and secured on armboards at a lower level than the chest
 arms are abducted less than 90 degrees with the elbows flexed and palms down to
maintain neutral alignment of the arms and wrists
 arms may also be tucked at the patient’s side
 head is in a neutral position without excessive flexion, extension, or rotation

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DISCLAIMER

Other Prone Positions

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Objectives
Indications Physiology &
To be able to define
the indications for
Anatomy
placing a patient for To be able to describe the
neurosurgery in the physiologic and anatomic
prone position implications of the prone position
in an anesthetized patient

Advantages Risks Management/Prevention

To be able to To be able to To be able to identify the common
enumerate the enumerate the risks complications associated with placing
advantages of placing associated with a patient in the prone position and
a patient in the prone placing a patient in the how to prevent or manage these said
position prone position complications
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Introduction

Prone versus Sitting?

Which one is easier?
Do we have other choices?

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Survey: Would you rather do prone or sit-up surgeries?
 I prefer prone, or if tumor has laterality,
place the patient on lateral or park bench

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position. I try to avoid sitting or beach chair.

Prone or park bench is easier. Sitting position

has more complications. My stress levels are
through the roof during sit-up ORs. Although
for surgeons, sitting has its advantages.

Maybe if with TEE, I’ll be a bit more

comfortable with sitting. But honestly,
putting a patient in sit-up position is always
an adventure.
Which procedures elicit the prone vs sitting
debate?

 Posterior fossa surgery

 Cervical spine surgery
 Deep brain stimulation

Himes BT, Mallory GW, Abcejo AS, Pasternak J, Atkinson JLD, Meyer FB, Marsh WR,
Link MJ, Clarke MJ, Perkins W, Van Gompel JJ. Contemporary analysis of the
9 intraoperative and perioperative complications of neurosurgical procedures performed in the
sitting position. J Neurosurg. 2017 Jul;127(1):182-188. doi: 10.3171/2016.5.JNS152328.
Epub 2016 Aug 5. PMID: 27494821.
Posterior Fossa Surgery: GOALS
In general…

 Facilitate surgical access

 Minimize nervous tissue trauma
 Maintain respiratory & cardiovascular stability

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GENERAL PRINCIPLES
 Echocardiography preop: Screen for PFO
 Maintain normovolemia
 Invasive monitoring: place transducer at the level of the skull base
 Minimize excessive neck flexion
 Pressure points: padded adequately

11 Annual Review October 23, 2023

The Art of War
by Sun Tzu

“If you know the enemy and know yourself, you

need not fear the result of a hundred battles. If you
know yourself but not the enemy, for every victory
gained you will also suffer a defeat. If you know
neither the enemy nor yourself, you will succumb
in every battle.”

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Background
 Sitting position: more popular in the 1970s and 1980s compared to today
 Sitting: preferable for posterior fossa lesions
 Prone position has presented itself as an alternative with less complications
 Presently: sitting has become en vogue again

Luostarinen T, Lindroos AC, Niiya T, Silvasti-Lundell M, Schramko A, Hernesniemi J,

Randell T, Niemi T. Prone Versus Sitting Position in Neurosurgery-Differences in Patients'
13 Hemodynamic Management. World Neurosurg. 2017 Jan;97:261-266. doi:
10.1016/j.wneu.2016.10.005. Epub 2016 Oct 12. PMID: 27744075.
Why do sit-up surgeries?
Advantages

 Improved venous drainage due to reduced thoracic outlet pressure

 Decreased intracranial pressure
 Improved visualization of the surgical field
 Reduced need for cerebellar retraction in posterior fossa cases
 Less Cranial Nerve damage

Himes BT, Mallory GW, Abcejo AS, Pasternak J, Atkinson JLD, Meyer FB, Marsh WR,
Link MJ, Clarke MJ, Perkins W, Van Gompel JJ. Contemporary analysis of the
14 intraoperative and perioperative complications of neurosurgical procedures performed in the
sitting position. J Neurosurg. 2017 Jul;127(1):182-188. doi: 10.3171/2016.5.JNS152328.
Epub 2016 Aug 5. PMID: 27494821.
Why do sit-up surgeries?
Retractorless Surgery

 Prolonged or forceful use of fixed retraction might injure tissues

 Retraction injury: happens to neural and vascular structures
 Devastating and unwanted complications or outcomes
• Increased ICP secondary to brain edema/contusion
• Ischemia
• Venous infarction
• Cranial nerve injuries

Nazim, W.M., Elborady, M.A. Retractorless brain surgery: technical considerations. Egypt J
Neurol Psychiatry Neurosurg 57, 98 (2021). https://doi.org/10.1186/s41983-021-00329-w
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Contraindications to Sitting Position
RELATIVE:
 Intracardiac septal defects
 Pulmonary arteriovenous malformations
 Severe hypovolemia
 Cachexia
 Severe hydrocephalus

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Using Gravity

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Physiologic implications of the Prone Position

 Cardiac
 Pulmonary

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Prone Position Physiology: Cardiovascular System

 Decreased cardiac index of around 24%

 Mostly due to decreased stroke volume (HR was unchanged)
 Increased intrathoracic pressure  decreased venous return and/or decreased LV compliance
 Mean arterial pressure (MAP) was maintained by increased systemic vascular resistance
(SVR)
 Pulmonary vascular resistance (PVR) was also increased
 Obstruction of IVC

H. Edgcombe, K. Carter, S. Yarrow, Anaesthesia in the prone position, BJA: British Journal
of Anaesthesia, Volume 100, Issue 2, February 2008, Pages 165–183,
19 https://doi.org/10.1093/bja/aem380
Prone Position Physiology: Pulmonary System

 Increase in functional residual capacity (FRC)

• FVC & FEV have minimal change
 Improved ventilation/perfusion (V/Q) matching
 Improvement in oxygenation

H. Edgcombe, K. Carter, S. Yarrow, Anaesthesia in the prone position, BJA: British Journal
of Anaesthesia, Volume 100, Issue 2, February 2008, Pages 165–183,
https://doi.org/10.1093/bja/aem380
Guideline for positioning the patient. (2017). AORN Journal, 105(4), P8-P10.
doi:10.1016/s0001-2092(17)30237-5
20
Prone Position Physiology: Pulmonary System

 Early studies: blood flow was diverted to dependent areas

 Human studies: lung perfusion was more uniformly distributed in the prone
position compared to supine
 Gravity has a minor role in regional lung perfusion
 PRONE: blood flow may be relatively uniform as gravitational forces are
opposing the regional differences in PVR
Glenny RW LW, Albert RK, Robertson HT. Gravity is a minor determinant of pulmonary
blood flow distribution, J Appl Physiol, 1991, vol. 71 (pg. 620-9)

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Anatomic implications of the Prone Position

 Ventral abdominal wall must be free (need to elevate the trunk)

 Head and lower extremities are below the level of the heart
• Pooling of venous blood in dependent regions
 Pressure on contact points
• Elbows, pelvis, face
 Peripheral nerve injuries secondary to over stretching/over rotation
 Securing belts should not be too tight

H. Edgcombe, K. Carter, S. Yarrow, Anaesthesia in the prone position, BJA: British Journal
of Anaesthesia, Volume 100, Issue 2, February 2008, Pages 165–183,
22 https://doi.org/10.1093/bja/aem380
“
ADVANTAGE
S
Advantages

 Less risk of Venous air embolism (VAE) (1.6% - 50% risk in Sitting)
 Less episodes of hypotension
 Less volume loading(?)
 Less decrease in cardiac function
 Easier to perform ACLS/PALS in cases of arrest

Luostarinen T, Lindroos AC, Niiya T, Silvasti-Lundell M, Schramko A, Hernesniemi J,

Randell T, Niemi T. Prone Versus Sitting Position in Neurosurgery-Differences in Patients'
24 Hemodynamic Management. World Neurosurg. 2017 Jan;97:261-266. doi:
10.1016/j.wneu.2016.10.005. Epub 2016 Oct 12. PMID: 27744075.
Venous Air Embolism

 Less risk compared to sitting

 HOWEVER: head is still usually elevated above the heart to decrease venou
bleeding
 So VAE risk is NOT eliminated

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“
COMPLICATIO
NS
Disadvantages

 Higher incidence of increased ICP

 Head being lower than heart
 Increased intra-abdominal pressure
 Venous congestion
 More pressure points
 Thorax/Abdomen
 Arms
 Face
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 Genitals
Disadvantages

 Airway pressures
 Higher compared to sitting
 Thoracic expansion may be impaired
 Limited access to the face
 For monitoring cranial nerves during stimulation
 For reintubation

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Disadvantages

 Surgical Exposure:
 Access to superior posterior fossa structures and ease of head
manipulation is not as favorable

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Risks

 Injuries to the Central Nervous System

 Peripheral Nerve Injuries
 Pressure Injuries
 Ophthalmic Injury

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CNS Injuries

 Rare but catastrophic

 Underlying mechanism:
 Arterial or venous occlusion – common carotid arteries (most common)
 Air entrainment/Pneumocephalus
 Cervical spine injury – due to excessive neck flexion
 Or undiagnosed space-occupying lesions – spinal arachnoid cysts,
metastases, etc (affects CSF flow dynamics)
H. Edgcombe, K. Carter, S. Yarrow, Anaesthesia in the prone position, BJA: British Journal
of Anaesthesia, Volume 100, Issue 2, February 2008, Pages 165–183,
31 https://doi.org/10.1093/bja/aem380
Considerations When Proning
 Use chest supports that extend from the clavicle to the iliac crest
 Ensure the breast, abdomen, and genitals are free from pressure
 Pad the patient’s knees
 Elevate the patient’s toes off the bed with padding under the shins
 Use a face positioner when the patient’s head is in midline
 Prevent direct pressure on the patient’s eyes
 Ensure a gurney is always readily accessible to reposition the patient from the
prone position to the supine position if cardiopulmonary resuscitation becomes
necessary
H. Edgcombe, K. Carter, S. Yarrow, Anaesthesia in the prone position, BJA: British Journal
of Anaesthesia, Volume 100, Issue 2, February 2008, Pages 165–183,
32 https://doi.org/10.1093/bja/aem380
Prone Cushioning

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Considerations When Proning

As with all surgical positions, ALL surgical staff should be

aware of risks to the patient in the prone position
Patient’s face: should be monitored
Pressure kept off of the patient’s eyes, cheeks, and ears
At a minimum, four people should be available when turning
a patient prone (both the cart and OR table should be locked)

Guideline for positioning the patient. (2017). AORN Journal, 105(4), P8-P10.
doi:10.1016/s0001-2092(17)30237-5
34
 “
MANAGEMENT
OF COMMON
C O M P L I C AT I O N S I N
THE PRONE POSITION
Management/Prevention
DVT Prophylaxis
Extremities are below the heart = pooling of venous blood
Compression stockings
Post-operative Visual Loss
Place head higher than or level with the heart
Maintain intravascular volume
Reduce intra-abdominal pressure
Limit duration of OR to less than 6 hours (or staged sx)
Guideline for positioning the patient. (2017). AORN Journal, 105(4), P8-P10.
doi:10.1016/s0001-2092(17)30237-5
36
Management/Prevention
Pressure points
Eyelids should be closed & protected
Lubrication? Debatable
Eyes and ears: free from pressure
3-pin head holder can be used
Corneal edema
Elevate head above the heart
NOT related to ischemic optic neuropathy
Guideline for positioning the patient. (2017). AORN Journal, 105(4), P8-P10.
doi:10.1016/s0001-2092(17)30237-5
37
Management/Prevention
Neck pain
Keep head in the neutral position and in sagittal plane
when prone
Brachial Plexus injuries
Ensure neck is not turned excessively
Padding to elbows and shoulders
Screen for thoracic outlet obstruction
Guideline for positioning the patient. (2017). AORN Journal, 105(4), P8-P10.
doi:10.1016/s0001-2092(17)30237-5
38
Management/Prevention
Venous Air Embolism
Central venous catheter (forearm/antecubital
fossa/subclavian)
Insertion and removal should be while px is flat

Guideline for positioning the patient. (2017). AORN Journal, 105(4), P8-P10.
doi:10.1016/s0001-2092(17)30237-5
39
“
Clinical Case
Case Vignette

 65 year old female

 Chief complaint: gait imbalance
 3 month history of nausea and vomiting with associated with gait
imbalance
 MRI revealed an extra-axial soft tissue mass measuring 2.7 x 1.5 x
1.9cm in the mid inferior cerebellar region indenting inferior
cerebellum & dorsal medulla
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Case Vignette

 100 kg, BMI 44.5

 No other comorbidities
 GCS 15
 (+) Romberg Test (sways to the right)

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Imaging

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Guide Questions

1) How would you prepare patients before positioning?

A) sit-up B) prone
2) Anesthesia maintenance between sit-up and prone? Is there a
difference?
3) What are possible complications intraoperatively for both
positions and management?
4) Post operatively is there a difference in the outcome in terms of
positioning?
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Conclusion

Sitting position is almost as safe as prone position

Both positions have their respective risks
Both options may be effectively employed at surgeon’s discretion
Choice should be based on the surgical team’s institutional familiarity,
experience and mastery of a specific position

Himes, B. T., Abcejo, A. S., Kerezoudis, P., Bhargav, A. G., Trelstad-Andrist, K., Maloney,
P. R., Atkinson, J. L. D., Meyer, F. B., Marsh, W. R., & Bydon, M. (2020). Outcomes in
single-level posterior cervical spine surgeries performed in the sitting and prone
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positions. Journal of Neurosurgery: Spine SPI, 33(5), 667-673.
https://doi.org/10.3171/2020.4.SPINE191323
 It’s not about the car, it’s the driver.

The only thing that matters is who’s behind the wheel.

Fast & Furious

Thank you!

Questions?
barre05@yahoo.com
Department of Anesthesiology & Pain Medicine
Cardinal Santos Medical Center