{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,7,15]],"date-time":"2026-07-15T12:17:49Z","timestamp":1784117869313,"version":"3.55.0"},"reference-count":96,"publisher":"Journal of Neurosurgery Publishing Group (JNSPG)","issue":"4","content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["FOC"],"published-print":{"date-parts":[[2015,10]]},"abstract":"\n OBJECT<\/jats:title>\n There are a variety of surgical positions that provide optimal exposure of the dorsal lumbar spine. These include the prone, kneeling, knee-chest, knee-elbow, and lateral decubitus positions. All are positions that facilitate exposure of the spine. Each position, however, is associated with an array of unique complications that result from excessive pressure applied to the torso or extremities. The authors reviewed clinical studies reporting complications that arose from positioning of the patient during dorsal exposures of the lumbar spine.<\/jats:p>\n <\/jats:sec>\n \n METHODS<\/jats:title>\n MEDLINE, Scopus, and Web of Science database searches were performed to find clinical studies reporting complications associated with positioning during lumbar spine surgery. For articles meeting inclusion criteria, the following information was obtained: publication year, study design, sample size, age, operative time, type of surgery, surgical position, frame or table type, complications associated with positioning, time to first observed complication, long-term outcomes, and evidence-based recommendations for complication avoidance.<\/jats:p>\n <\/jats:sec>\n \n RESULTS<\/jats:title>\n Of 3898 articles retrieved from MEDLINE, Scopus, and Web of Science, 34 met inclusion criteria. Twenty-four studies reported complications associated with use of the prone position, and 7 studies investigated complications after knee-chest positioning. Complications associated with the knee-elbow, lateral decubitus, and supine positions were each reported by a single study. Vision loss was the most commonly reported complication for both prone and knee-chest positioning. Several other complications were reported, including conjunctival swelling, Ischemic orbital compartment syndrome, nerve palsies, thromboembolic complications, pressure sores, lower extremity compartment syndrome, and shoulder dislocation, highlighting the assortment of possible complications following different surgical positions. For prone-position studies, there was a relationship between increased operation time and position complications. Only 3 prone-position studies reported complications following procedures of less than 120 minutes, 7 studies reported complications following mean operative times of 121\u2013240 minutes, and 9 additional studies reported complications following mean operative times greater than 240 minutes. This relationship was not observed for knee-chest and other surgical positions.<\/jats:p>\n <\/jats:sec>\n \n CONCLUSIONS<\/jats:title>\n This work presents a systematic review of positioning-related complications following prone, knee-chest, and other positions used for lumbar spine surgery. Numerous evidence-based recommendations for avoidance of these potentially severe complications associated with intraoperative positioning are discussed. This investigation may serve as a framework to educate the surgical team and decrease rates of intraoperative positioning complications.<\/jats:p>\n <\/jats:sec>","DOI":"10.3171\/2015.7.focus15268","type":"journal-article","created":{"date-parts":[[2015,10,1]],"date-time":"2015-10-01T03:41:45Z","timestamp":1443670905000},"page":"E16","source":"Crossref","is-referenced-by-count":55,"title":["Lumbar spine surgery positioning complications: a systematic review"],"prefix":"10.3171","volume":"39","author":[{"given":"Michael F.","family":"Shriver","sequence":"first","affiliation":[{"name":"Case Western Reserve University School of Medicine;"},{"name":"Center for Spine Health, and"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Valerie","family":"Zeer","sequence":"additional","affiliation":[{"name":"Case Western Reserve University School of Medicine;"},{"name":"Center for Spine Health, and"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Vincent J.","family":"Alentado","sequence":"additional","affiliation":[{"name":"Case Western Reserve University School of Medicine;"},{"name":"Center for Spine Health, and"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Thomas E.","family":"Mroz","sequence":"additional","affiliation":[{"name":"Center for Spine Health, and"},{"name":"Department of Neurological Surgery, Cleveland Clinic, Cleveland, Ohio"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Edward C.","family":"Benzel","sequence":"additional","affiliation":[{"name":"Center for Spine Health, and"},{"name":"Department of Neurological Surgery, Cleveland Clinic, Cleveland, Ohio"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Michael P.","family":"Steinmetz","sequence":"additional","affiliation":[{"name":"Center for Spine Health, and"},{"name":"Department of Neurological Surgery, Cleveland Clinic, Cleveland, Ohio"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1754","reference":[{"key":"b1-focus15268","series-title":"J Bone Joint Surg Br","first-page":"279","article-title":"Problems associated with the use of the knee-chest position for operations on lumbar intervertebral discs","volume":"55","author":"Alexander","year":"1973"},{"key":"b2-focus15268","series-title":"J Clin Anesth","first-page":"471","article-title":"Unusual presentation and complication of the prone position for spinal surgery","volume":"15","author":"Ali","year":"2003"},{"key":"b3-focus15268","series-title":"Br J Anaesth","first-page":"452","article-title":"The prone position for the surgical patient: a historical review of the principles and hazards","volume":"67","author":"Anderton","year":"1991"},{"key":"b4-focus15268","series-title":"Spine Surgery: Techniques, Complication Avoidance, and Management","author":"Benzel","year":"2012"},{"key":"b5-focus15268","series-title":"Eur Spine J","first-page":"426","article-title":"Fatal pulmonary fat embolism after dorsal spinal fusion","volume":"7","author":"Brandt","year":"1998"},{"key":"b6-focus15268","series-title":"Korean J Anesthesiol","first-page":"365","article-title":"Tongue bite in a patient with tracheostomy after prone position\u2014a case report","volume":"60","author":"Chae","year":"2011"},{"key":"b7-focus15268","series-title":"Eye (Lond)","first-page":"367","article-title":"Severe bilateral posterior ischemic optic neuropathy as a complication of spinal surgery","volume":"19","author":"Chalam","year":"2005"},{"key":"b8-focus15268","series-title":"Spine (Phila Pa 1976)","first-page":"1299","article-title":"The incidence of vision loss due to perioperative ischemic optic neuropathy associated with spine surgery: the Johns Hopkins Hospital Experience","volume":"30","author":"Chang","year":"2005"},{"key":"b9-focus15268","series-title":"J Korean Neurosurg Soc","first-page":"392","article-title":"Prone position-related meralgia paresthetica after lumbar spinal surgery: a case report and review of the literature","volume":"44","author":"Cho","year":"2008"},{"key":"b10-focus15268","series-title":"Rev Bras Anestesiol","first-page":"273","article-title":"Optic nerve ischemia after spine surgery: case report","volume":"56","author":"Corso","year":"2006"},{"issue":"Suppl 4","key":"b11-focus15268","series-title":"Eur Spine J","first-page":"S554","article-title":"Anterior thigh compartment syndrome after prone positioning for lumbosacral fixation","volume":"21","author":"Dahab","year":"2012"},{"key":"b12-focus15268","series-title":"Spine (Phila Pa 1976)","first-page":"1388","article-title":"Effect of prone positioning systems on hemodynamic and cardiac function during lumbar spine surgery: an echocardiographic study","volume":"31","author":"Dharmavaram","year":"2006"},{"key":"b13-focus15268","series-title":"Can J Anaesth","first-page":"63","article-title":"Ischaemic optic neuropathy after spinal fusion","volume":"45","author":"Dilger","year":"1998"},{"key":"b14-focus15268","series-title":"Spine (Phila Pa 1976)","first-page":"897","article-title":"The knee-elbow position in lumbar disc surgery: a review of complications","volume":"8","author":"Eie","year":"1983"},{"key":"b15-focus15268","series-title":"Asian Spine J","first-page":"287","article-title":"Cortical blindness following spinal surgery: very rare cause of perioperative vision loss","volume":"6","author":"Goni","year":"2012"},{"key":"b16-focus15268","series-title":"Neuroradiology","first-page":"227","article-title":"Positional occlusion of the vertebral artery: a rare cause of embolic stroke","volume":"23","author":"Grossmann","year":"1982"},{"key":"b17-focus15268","series-title":"AMA Arch Opthalmol","first-page":"819","article-title":"Unilateral blindness occurring during anesthesia for neurosurgical operations","volume":"52","author":"Hollenhorst","year":"1954"},{"key":"b18-focus15268","series-title":"J Neurosurg Anesthesiol","first-page":"1","article-title":"Effect of head position on postoperative chemosis after prone spinal surgery","volume":"19","author":"Jeon","year":"2007"},{"key":"b19-focus15268","series-title":"Arch Ophthalmol","first-page":"925","article-title":"Ischemic optic neuropathy after lumbar spine surgery","volume":"112","author":"Katz","year":"1994"},{"key":"b20-focus15268","series-title":"Am J Ophthalmol","first-page":"889","article-title":"Blindness and rectus muscle damage following spinal surgery","volume":"138","author":"Kumar","year":"2004"},{"key":"b21-focus15268","series-title":"Spine (Phila Pa 1976)","first-page":"1932","article-title":"Quadriplegia after lumbar disc surgery. 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An unusual complication of anterior lumbar interbody fusion","volume":"19","author":"Papastefanou","year":"1994"},{"key":"b32-focus15268","series-title":"Case Rep Neurol Med","first-page":"792168","article-title":"Symptomatic pneumocephalus associated with lumbar dural tear and reverse Trendelenburg positioning: a case report and review of the literature","volume":"2013","author":"Pirris","year":"2013"},{"issue":"Suppl 4","key":"b33-focus15268","series-title":"Eur Spine J","first-page":"S495","article-title":"Transient bilateral postoperative visual loss in spinal surgery","volume":"21","author":"Quraishi","year":"2012"},{"key":"b34-focus15268","series-title":"J Neuroophthalmol","first-page":"327","article-title":"Dilated superior ophthalmic veins and posterior ischemic optic neuropathy after prolonged spine surgery","volume":"28","author":"Reddy","year":"2008"},{"key":"b35-focus15268","series-title":"Spine (Phila Pa 1976)","first-page":"853","article-title":"Deep vein thrombosis after major reconstructive spinal surgery","volume":"21","author":"Rokito","year":"1996"},{"key":"b36-focus15268","series-title":"Anesth Analg","first-page":"1185","article-title":"Visual loss in a prone-positioned spine surgery patient with the head on a foam headrest and goggles covering the eyes: an old complication with a new mechanism","volume":"104","author":"Roth","year":"2007"},{"issue":"Suppl 2","key":"b37-focus15268","series-title":"Eur Spine J","first-page":"S180","article-title":"Bilateral gluteal compartment syndrome and severe rhabdomyolysis after lumbar spine surgery","volume":"20","author":"Rudolph","year":"2011"},{"key":"b38-focus15268","series-title":"Anesth Analg","first-page":"1534","article-title":"The prevalence of perioperative visual loss in the United States: a 10-year study from 1996 to 2005 of spinal, orthopedic, cardiac, and general surgery","volume":"109","author":"Shen","year":"2009"},{"issue":"4","key":"b39-focus15268","series-title":"Neurosurg Focus","first-page":"E16","article-title":"Abdominal complications following posterior spinal fusion in patients with previous abdominal surgeries","volume":"31","author":"Shih","year":"2011"},{"key":"b40-focus15268","series-title":"Spine J","first-page":"e7","article-title":"Bilateral acute angle-closure glaucoma as a complication of facedown spine surgery","volume":"10","author":"Singer","year":"2010"},{"key":"b41-focus15268","series-title":"Anesth Analg","first-page":"318","article-title":"Axillary artery compression and the prone position","volume":"65","author":"Skeehan","year":"1986"},{"key":"b42-focus15268","series-title":"Nippon Ganka Kiyo","first-page":"239","article-title":"A case of central retinal artery occlusion diagnosed after general anesthesia for a spinal operation","volume":"52","author":"Suzuki","year":"2001"},{"key":"b43-focus15268","series-title":"Anesth Analg","first-page":"1417","article-title":"The frequency of perioperative vision loss","volume":"93","author":"Warner","year":"2001"},{"issue":"8 Suppl","key":"b44-focus15268","series-title":"Spine (Phila Pa 1976)","first-page":"S254","article-title":"Incidence of deep vein thrombosis in major adult spinal surgery","volume":"17","author":"West","year":"1992"},{"key":"b45-focus15268","series-title":"Anesth Analg","first-page":"1018","article-title":"Postoperative ischemic optic neuropathy","volume":"80","author":"Williams","year":"1995"},{"key":"b46-focus15268","series-title":"J Neurol Sci Turk","first-page":"422","article-title":"Visual loss after lumbar discectomy due to cortical infarction: Case report","volume":"30","author":"Yilmaz","year":"2013"},{"key":"b47-focus15268","series-title":"Spine (Phila Pa 1976)","first-page":"E569","article-title":"Ischemic orbital compartment syndrome after posterior spinal surgery","volume":"33","author":"Yu","year":"2008"},{"key":"b48-focus15268","series-title":"Eur Spine J","first-page":"171","article-title":"Amaurosis after spine surgery: survey of the literature and discussion of one case","volume":"20","author":"Zimmerer","year":"2011"},{"key":"b1-focus15268","series-title":"J Bone Joint Surg Br","first-page":"279","article-title":"Problems associated with the use of the knee-chest position for operations on lumbar intervertebral discs","volume":"55","author":"Alexander","year":"1973"},{"key":"b2-focus15268","series-title":"J Clin Anesth","first-page":"471","article-title":"Unusual presentation and complication of the prone position for spinal surgery","volume":"15","author":"Ali","year":"2003"},{"key":"b3-focus15268","series-title":"Br J Anaesth","first-page":"452","article-title":"The prone position for the surgical patient: a historical review of the principles and hazards","volume":"67","author":"Anderton","year":"1991"},{"key":"b4-focus15268","series-title":"Spine Surgery: Techniques, Complication Avoidance, and Management","author":"Benzel","year":"2012"},{"key":"b5-focus15268","series-title":"Eur Spine J","first-page":"426","article-title":"Fatal pulmonary fat embolism after dorsal spinal fusion","volume":"7","author":"Brandt","year":"1998"},{"key":"b6-focus15268","series-title":"Korean J Anesthesiol","first-page":"365","article-title":"Tongue bite in a patient with tracheostomy after prone position\u2014a case report","volume":"60","author":"Chae","year":"2011"},{"key":"b7-focus15268","series-title":"Eye (Lond)","first-page":"367","article-title":"Severe bilateral posterior ischemic optic neuropathy as a complication of spinal surgery","volume":"19","author":"Chalam","year":"2005"},{"key":"b8-focus15268","series-title":"Spine (Phila Pa 1976)","first-page":"1299","article-title":"The incidence of vision loss due to perioperative ischemic optic neuropathy associated with spine surgery: the Johns Hopkins Hospital Experience","volume":"30","author":"Chang","year":"2005"},{"key":"b9-focus15268","series-title":"J Korean Neurosurg Soc","first-page":"392","article-title":"Prone position-related meralgia paresthetica after lumbar spinal surgery: a case report and review of the literature","volume":"44","author":"Cho","year":"2008"},{"key":"b10-focus15268","series-title":"Rev Bras Anestesiol","first-page":"273","article-title":"Optic nerve ischemia after spine surgery: case report","volume":"56","author":"Corso","year":"2006"},{"issue":"Suppl 4","key":"b11-focus15268","series-title":"Eur Spine J","first-page":"S554","article-title":"Anterior thigh compartment syndrome after prone positioning for lumbosacral fixation","volume":"21","author":"Dahab","year":"2012"},{"key":"b12-focus15268","series-title":"Spine (Phila Pa 1976)","first-page":"1388","article-title":"Effect of prone positioning systems on hemodynamic and cardiac function during lumbar spine surgery: an echocardiographic study","volume":"31","author":"Dharmavaram","year":"2006"},{"key":"b13-focus15268","series-title":"Can J Anaesth","first-page":"63","article-title":"Ischaemic optic neuropathy after spinal fusion","volume":"45","author":"Dilger","year":"1998"},{"key":"b14-focus15268","series-title":"Spine (Phila Pa 1976)","first-page":"897","article-title":"The knee-elbow position in lumbar disc surgery: a review of complications","volume":"8","author":"Eie","year":"1983"},{"key":"b15-focus15268","series-title":"Asian Spine J","first-page":"287","article-title":"Cortical blindness following spinal surgery: very rare cause of perioperative vision loss","volume":"6","author":"Goni","year":"2012"},{"key":"b16-focus15268","series-title":"Neuroradiology","first-page":"227","article-title":"Positional occlusion of the vertebral artery: a rare cause of embolic stroke","volume":"23","author":"Grossmann","year":"1982"},{"key":"b17-focus15268","series-title":"AMA Arch Opthalmol","first-page":"819","article-title":"Unilateral blindness occurring during anesthesia for neurosurgical operations","volume":"52","author":"Hollenhorst","year":"1954"},{"key":"b18-focus15268","series-title":"J Neurosurg Anesthesiol","first-page":"1","article-title":"Effect of head position on postoperative chemosis after prone spinal surgery","volume":"19","author":"Jeon","year":"2007"},{"key":"b19-focus15268","series-title":"Arch Ophthalmol","first-page":"925","article-title":"Ischemic optic neuropathy after lumbar spine surgery","volume":"112","author":"Katz","year":"1994"},{"key":"b20-focus15268","series-title":"Am J Ophthalmol","first-page":"889","article-title":"Blindness and rectus muscle damage following spinal surgery","volume":"138","author":"Kumar","year":"2004"},{"key":"b21-focus15268","series-title":"Spine (Phila Pa 1976)","first-page":"1932","article-title":"Quadriplegia after lumbar disc surgery. A case report","volume":"21","author":"Langmayr","year":"1996"},{"key":"b22-focus15268","series-title":"Spine (Phila Pa 1976)","first-page":"941","article-title":"Effect of patient position and hypotensive anesthesia on inferior vena caval pressure","volume":"23","author":"Lee","year":"1998"},{"key":"b23-focus15268","series-title":"Ophthalmology","first-page":"105","article-title":"Ischemic orbital compartment syndrome as a complication of spinal surgery in the prone position","volume":"113","author":"Leibovitch","year":"2006"},{"key":"b24-focus15268","series-title":"J Anesth","first-page":"464","article-title":"Case report: central venous catheterization via internal jugular vein with associated formation of perioperative venous thrombosis during surgery in the prone position","volume":"26","author":"Minami","year":"2012"},{"key":"b25-focus15268","series-title":"South Med J","first-page":"528","article-title":"Acute bowel ischemia following spinal surgery","volume":"99","author":"Mofredj","year":"2006"},{"key":"b26-focus15268","series-title":"J Med Sci","first-page":"44","article-title":"Effects of head position on postoperative conjunctival swelling after prone spinal surgery","volume":"8","author":"Mohammadi","year":"2008"},{"key":"b27-focus15268","series-title":"BMJ","first-page":"b2535","article-title":"Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement","volume":"339","author":"Moher","year":"2009"},{"key":"b28-focus15268","series-title":"Rev Mex Anestesiol","first-page":"215","article-title":"Lower extremities acute compartment syndrome in lumbar column surgery in genupectoral position; clinical case","volume":"31","author":"Moriano-B\u00e9jar","year":"2008"},{"key":"b29-focus15268","series-title":"Eur Spine J","first-page":"1548","article-title":"Incidence of thromboembolic complications in lumbar spinal surgery in 1,111 patients","volume":"18","author":"Nicol","year":"2009"},{"key":"b30-focus15268","series-title":"Spine (Phila Pa 1976)","first-page":"E650","article-title":"Prior abdominal surgery is associated with an increased risk of postoperative complications after anterior lumbar interbody fusion","volume":"39","author":"Osler","year":"2014"},{"key":"b31-focus15268","series-title":"Spine (Phila Pa 1976)","first-page":"2842","article-title":"Femoral nerve palsy. An unusual complication of anterior lumbar interbody fusion","volume":"19","author":"Papastefanou","year":"1994"},{"key":"b32-focus15268","series-title":"Case Rep Neurol Med","first-page":"792168","article-title":"Symptomatic pneumocephalus associated with lumbar dural tear and reverse Trendelenburg positioning: a case report and review of the literature","volume":"2013","author":"Pirris","year":"2013"},{"issue":"Suppl 4","key":"b33-focus15268","series-title":"Eur Spine J","first-page":"S495","article-title":"Transient bilateral postoperative visual loss in spinal surgery","volume":"21","author":"Quraishi","year":"2012"},{"key":"b34-focus15268","series-title":"J Neuroophthalmol","first-page":"327","article-title":"Dilated superior ophthalmic veins and posterior ischemic optic neuropathy after prolonged spine surgery","volume":"28","author":"Reddy","year":"2008"},{"key":"b35-focus15268","series-title":"Spine (Phila Pa 1976)","first-page":"853","article-title":"Deep vein thrombosis after major reconstructive spinal surgery","volume":"21","author":"Rokito","year":"1996"},{"key":"b36-focus15268","series-title":"Anesth Analg","first-page":"1185","article-title":"Visual loss in a prone-positioned spine surgery patient with the head on a foam headrest and goggles covering the eyes: an old complication with a new mechanism","volume":"104","author":"Roth","year":"2007"},{"issue":"Suppl 2","key":"b37-focus15268","series-title":"Eur Spine J","first-page":"S180","article-title":"Bilateral gluteal compartment syndrome and severe rhabdomyolysis after lumbar spine surgery","volume":"20","author":"Rudolph","year":"2011"},{"key":"b38-focus15268","series-title":"Anesth Analg","first-page":"1534","article-title":"The prevalence of perioperative visual loss in the United States: a 10-year study from 1996 to 2005 of spinal, orthopedic, cardiac, and general surgery","volume":"109","author":"Shen","year":"2009"},{"issue":"4","key":"b39-focus15268","series-title":"Neurosurg 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