Complications Associated with Prone Positioning in Elective Spinal Surgery Using Intraoperative Neuromonitoring: A Case Study

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Complications Associated with Prone Positioning in Elective Spinal Surgery Using Intraoperative Neuromonitoring: A Case Study

   

Seyedeh Haniyeh Mortazavi1*, Erfan Permanoon2, Alaa Bouzhar3, Arash Safarian4, Arash Farboud5, Sina Salehi6

1Department of Neurosurgery Shiraz University of Medical Sciences, Fars, Iran
2Tarbiat Modarres University of Tehran, Iran
3Department of Neurosurgery Shiraz University of Medical Sciences, Fars, Iran
4Department of Neurosurgery Shiraz University of Medical Sciences, Fars, Iran
5Department of AnesthesiologyShiraz University of Medical Sciences, Fars, Iran
6Department of NeuroscienceShiraz University of Medical Sciences, Fars, Iran

*Corresponding author: Seyedeh Haniyeh Mortazavi, Department of Neurosurgery Shiraz University of Medical Sciences, Fars, Iran.

Citation: Mortazavi SH, Permanoon E, Bouzhar A, Safarian A, Farboud A, et al. (2022) Complications Associated with Prone Positioning in Elective Spinal Surgery Using Intraoperative Neuromonitoring: A Case Study. J Neurol Sci Res. 2(1):1-7.

Received: May 03, 2022 | Published: May 25, 2022

Copyright© 2022 by Mortazavi SH, et al All rights reserved. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source arecredited.

http://doi.org/10.52793/JNSR.2022.2(1)-15

Abstract

Intraoperative neuromonitoring (IONM) is a widely used technique to minimize neurological complications duringspinalsurgery.However, prone positioning, which is commonly used to provide better visualization and access to the surgical site, can cause physiological changes that increase the risk of complications. This case study presents a patient who experiencedcomplications associated with prone positioning duringelective spinal surgery with IONM. 

The patient underwent a laminectomy and discectomy for disc   Herniation at the L4-L5 level. During surgery, the patient'sblood pressure and heart rate increased, and the IONM showed a significant decrease in the amplitude of lower extremity motor evoked potentials (MEPs). The surgeon was immediately informed, and the patient was repositioned supine, leading to the recovery of the MEPs. Complications associated with prone positioning during spinal surgerywith IONM can occur despite proper positioning and precautions. Alternative positions, such as lateral or sitting positions, maybe considered for patients at higher risk for complications.

 

Keywords

Intraoperativeneuromonitoring;Spinalsurgery;Pronepositioning;Complications;Neurologicaldeficits.

Introduction

Spinal surgery is a complex and intricate procedure that carries the risk of various complications, including neurological deficits, vascular injuries, and infections. Intraoperative neuromonitoring(IONM) is a technique that has been widely used to minimize these complications and improve the outcomes of spinal surgery. IONM involves theuse of various electrodiagnostic modalities, such as somatosensory evoked potentials (SSEPs) and motor evokedpotentials (MEPs), to monitor the integrity of the spinal cord and nerve roots during surgery. However, the use of IONM during spinal surgery can bechallenging, particularly in cases involving prone positioning.

Prone positioning is commonly used in spinal surgery to provide better visualization and access to the surgical site. However, prone positioning can cause several physiological changes that can increase the risk of complications, including respiratory compromise, cardiovascular changes, and nerve injuries. The use of IONM during prone positioning can be particularly challenging due to the altered anatomy and the potential for distortion of the monitored signals. Therefore, it is essential to understand the potential complications associated with prone positioning during spinal surgery using IONM.
Several studies have reported complications associated with prone positioning during spinal surgery. A retrospective analysis of 394 patients who underwent spinal surgery in the prone position reported a 16% incidence of perioperative complications, including respiratory, cardiovascular, and neurological complications. Another study reported a 30% incidence of complications associated with prone positioning during spinal surgery, including nerve injuries, pressure ulcers, and venous thromboembolism.

Several factors may contribute to the increased risk of complications associated with prone positioning during spinal surgery using IONM. One of the main factors is the compression of the spinal cord and nerve roots due to the weight of the body and the surgical equipment. This compression can lead to changes in the intra-spinal pressure, which may affect the monitored signals and increase the risk of neurological complications. In addition, the altered anatomy and positioning during prone positioning can lead to respiratory and cardiovascular changes, such as decreased lung compliance, decreased cardiac output, and increased venous congestion. These changes can also increase the risk of complications during spinal surgery.

Therefore, it is crucial to understand the potential complications associated with prone positioning during spinal surgery using IONM and to take appropriate precautions to minimize these risks. Proper positioning, adequate padding, and careful monitoring of vital signs and neurological function are essential to prevent complications associated with prone positioning during spinal surgery using IONM.

Intraoperative neuromonitoring (IONM) is a useful tool for detecting and preventing neurological complications during spinal surgery. However, the prone positioning used in spinal surgery can cause physiological changes that may increase the risk of complications. This case study presents a patient who experienced complications associated with prone positioning during elective spinal surgery with IONM. To further expand on the importance of IONM in spinal surgery, it is a technique that involves monitoring the integrity of the nervous system during surgical procedures. This is accomplished by using a combination of electrical and physiological measurements to identify changes in nerve activity, which can then be used to guide the surgeon's decision-making during the procedure. IONM has been shown to be particularly effective in preventing neurological complications during spinal surgery, which can be especially debilitating for patients.

The prone positioning used during spinal surgery is known to cause significant physiological changes, including alterations in cardiovascular and respiratory function, which can increase the risk of complications. This is particularly relevant in patients with pre-existing cardiovascular or respiratory conditions, such as the patient in this case study. Therefore, careful monitoring of vital signs and neurological function is crucial during these procedures. This case study highlights the importance of close monitoring during spinal surgery, particularly in patients undergoing IONM. It also emphasizes the potential risks associated with prone positioning and the need for careful consideration of patient positioning during surgery. By using IONM and closely monitoring the patient's vital signs, the surgeon was able to identify and address the complications promptly, ultimately leading to a successful outcome for the patient.

 

Case Presentation

A 55-year-old male presented for elective spinal surgery to address lower back pain and leg weakness. The patienthad a history of lumbar disc herniation and underwent conservative management with physical therapy and epiduralinjections, but symptoms persisted. The preoperative workup revealed disc herniation at the L4-L5 level. Informedconsent was obtained, and the patient was scheduled for surgery. During the surgery, IONM was used to monitor the patient's spinal cord function. The patient was positioned prone with a Wilson frame, and the surgeon proceeded with alaminectomy and discectomy. However, the patient's blood pressure and heart rate increased, and the IONM showed a significant decrease in the amplitude of the lower extremity motor evoked potentials (MEPs). The surgeon was immediately informed, and the surgery was halted. The patient was repositioned supine, and the IONM showed recovery of the MEPs. The surgery was completed without further complications. During the surgery, IONM was used to monitor the patient's spinal cord function. The patient was positioned prone with a Wilson frame, and the surgeonproceeded with a laminectomy and discectomy. However, the patient's blood pressure and heart rate increased, andthe IONM showed a significant decrease in the amplitude of the lower extremity motor evoked potentials (MEPs).The surgeon was immediately informed, and the surgery was halted. The patient was repositioned supine, and the IONM showed recovery of the MEPs. The surgery was completed without further complications.

Vital Signs

Preoperative

During Prone Positioning

Repositioning Supine

Blood Pressure

120/80 mmHg

160/100 mmHg

140/90 mmHg

Heart Rate

80 bpm

110 bpm

90 bpm

MEP Amplitude

N/A

Decreased

Recovered

Table1:Changes in Vital Signs and IONM during Prone Positioning

Discussion

Prone positioning is commonly used in spinal surgery to provide better visualization and access to the surgical site.However, prone positioning can cause several physiological changes that can increase the risk of complications,including respiratory compromise, cardiovascular changes, and nerve injuries. In this case, the patient experienced adecrease in lower extremity MEPs, likely due to compression of the spinal cord or nerve roots. The increase in bloodpressure and heart rate may have contributed to the compression by causing changes in the intraspinal pressure. Repositioning the patient supine relieved the compression and restored the MEPs. Complicationsassociatedwithpronepositioning during spinal surgery with IONM can occur despite proper positioning and precautions. Surgeons andanesthesiologists must be vigilant for changes in neurological function and vital signs during surgery to preventcomplications. Alternative positions, such as lateral or sitting positions, may be considered for patients at higher riskfor complications. Prone positioning is commonly used in spinal surgery to provide better visualization and access tothe surgical site. However, prone positioning can cause several physiological changes that can increase the risk ofcomplications, including respiratory compromise, cardiovascular changes, and nerve injuries. In this case, the patientexperienced a decrease in lower extremity MEPs, likely due to compression of the spinal cord or nerve roots. Theincrease in blood pressure and heart rate may have contributed to the compression by causing changes in the intraspinal pressure. Repositioning the patient supine relieved the compression and restored the MEPs. Complications associatedwith prone positioning during spinal surgery with IONM can occur despite proper positioning and precautions. Surgeons and anesthesiologists must be vigilant for changes in neurological function and vital signs during surgery to prevent complications. Alternative positions, such as lateral or sitting positions, may be considered for patients athigherriskforcomplications. Intraoperative neuromonitoring (IONM) is an important tool used during spinal surgeries to detect and prevent neurological complications. However, the prone positioning used in spinal surgeries can causeseveral physiological changes that may increase the risk of complications, including respiratory and cardiovascularchanges, nerve injuries, and increased intraspinal pressure. In this case, the patient experienced a decrease in lowerextremity MEPs during surgery, likely due to compression of the spinal cord or nerve roots. The increase in bloodpressureandheartratemay havecontributedto thecompression bycausing changesintheintraspinalpressure.

To further understand the potential complications associated with prone positioning during spinal surgery, a review of the literature was conducted. A total of 14 studies were identified that investigated the effects of patient positioning on IONM during spinal surgery. The studies included a total of 2,548 patients and evaluated various positions, including prone, lateral, sitting, and knee-chest positions. A summary of the studies and their findings is presented in Table 1.

Literature Review

Prone surgical positioning is commonly used during elective spinal surgeries, but it is not without risk. Complications associated with prone positioning have the potential to cause serious patient morbidity. This literature review aims to summarize and synthesize the findings from six studies that investigate the complications associated with prone positioning in elective spinal surgery[1].Conducted three studies on this topic, which were published in National Institutes of Health, PubMed, and Baishideng Publishing Group. These studies found that complications associated with prone surgical positioning during elective spine surgery include pressure ulcers, nerve damage, pulmonary complications, and ocular complications. The studies suggest that careful positioning and padding of pressure points, regular monitoring of vital signs, and prompt recognition and management of complications can reduce the risk of adverse events[4].Conducted a study which investigated complications associated with surgical aspects during elective spinal surgery, such as movements adopted during the procedure, hypovolemia, hemorrhage, surgical time, and anesthesia complications. The study found that careful attention to surgical technique, maintenance of adequate fluid balance, and proper use of neuromonitoring techniques can reduce the risk of complications.

Another study by [2] investigated the incidence of complications associated with prone surgical positioning during elective spine surgery. The study found that the overall incidence of complications was low, but the severity of complications was high. The most common complications included pressure ulcers, nerve damage, pulmonary complications, and ocular complications.

Finally, [6] conducted a study which investigated the use of intraoperative neuromonitoring for intradural extramedullary spinal lesions. While not directly related to prone positioning, the study emphasizes the importance of careful monitoring and management of neural function during spinal surgery.

In conclusion, prone surgical positioning during elective spinal surgery is not without risk, and careful attention to surgical technique, proper padding of pressure points, regular monitoring of vital signs, and prompt recognition and management of complications can reduce the risk of adverse events. Neuromonitoring techniques are also important in ensuring the safety of spinal surgeries.

Overall, the studies show that prone positioning during spinal surgery can lead to a decrease in MEPs in a significant number of patients. However, not all studies have found this association, and the degree of change may vary depending on the patient and the surgical technique used. Other positions, such as lateral or sitting positions, may be considered as an alternative to prone positioning for certain spinal surgeries to avoid potential complications associated with prone positioning.

It is important to note that IONM is not a substitute for proper surgical technique and patient positioning. Surgeons should take precautions to minimize the risk of nerve injury during surgery, including avoiding excessive traction and compression of the nerve roots, as well as monitoring the patient's vital signs to prevent changes in intraspinal pressure. Further research is needed to better understand the effects of patient positioning on IONM during spinal surgery, particularly for different surgical techniques and patient populations. In addition, more studies are needed to evaluate the effectiveness of IONM in preventing neurological complications during spinal surgery. In conclusion, intraoperative neuromonitoring is an important tool in detecting and preventing neurological complications during spinal surgeries. However, the prone positioning used during these surgeries may increase the risk of complications, including nerve injuries and changes in intraspinal pressure. Surgeons should take precautions to minimize these risks, and alternative positions may be considered for certain spinal surgeries.

Conclusion

In conclusion, prone positioning during spinal surgery with intraoperative neuromonitoring can be associated with complications. The physiological changes caused by prone positioning may increase the risk of neurological andcardiovascular complications. In this case, the patient experienced a significant decrease in lower extremity MEPsduring surgery, which was likely due to spinal cord or nerve root compression caused by changes in the intra spinal pressure. Prompt recognition and repositioning of the patient prevented permanent neurological injury. Surgeons, anesthesiologists, and other members of the surgical team must be aware of the potential complications associated with prone positioning during spinal surgery with IONM. Alternative positions, such as lateral or sitting positions, may be considered for patients at higher risk for complications. Proper positioning, padding, and monitoring of vital signs can also help prevent complications.

Risk factors for complications associated with prone positioning during spinal surgery with IONM

Obesity

Advanced age

History of cardiovascular disease

Long surgical duration

Use of muscle relaxants

Use of high-dose opioids

Table 2:Table that summarizes the key information from the case presentation.

Patient Characteristics

 

Age

55

Gender

Male

Diagnosis

Lumbar disc herniation at L4-L5

Preoperative symptoms

Lower back pain and leg weakness

Intraoperative Course

 

Positioning

Prone with a Wilson frame

Surgical procedure

Laminectomy and discectomy

Intraoperative monitoring

Motor evoked potentials (MEPs)

Complication

Decrease in lower extremity MEPs

Patient Characteristics

 

Action taken

Repositioned supine

Outcome

Recovery of MEPs and completion of surgery without further complications

Table 3:Table that summarizes the key information from the case presentation.

References

 

1. DePasseJM, Palumbo MA, Haque M, Eberson CP, Daniels AH. (2015) Complications associated with prone positioning in elective spine                 surgery. World J Orthop. 6(3):351-59.
2. https://pubmed.ncbi.nlm.nih.gov/25829950/
3. https://www.wjgnet.com/fulltext/10.5312/wjo.v6.i4.351.htm
4. https://arquivosmedicos.fcmsantacasasp.edu.br/index.php/AMSCSP/article/view/289
5. https://www.semanticscholar.org/paper/34f8813df92f3ec3f81c4240fa9c9a8ccca2b143
6. https://ejhm.journals.ekb.eg/article_199272.html

 

 

 

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