Perfecting Spine Surgery Positioning

Neurosurgery-Spine Patient Safety Orthopedics

By: Jared Bilski | Managing Editor

Published: 9/22/2022

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Proper assessments, refresher training and plenty of padding are ingredients for success.


Grant Shifflett, MD, has a simple way to sum up the importance of positioning patients correctly for spine surgery. “Proper positioning is as important as the surgical procedure itself,” he says. Dr. Shifflett, an orthopedic surgeon at DISC Sports and Spine Center in Marina del Ray, Calif., isn’t being hyperbolic. Spine patients who aren’t properly positioned and monitored carefully during surgery are vulnerable to a host of disastrous complications, from pressure and nerve injuries to vision loss.

The very notion of operating on the spine makes many patients uneasy, which isn’t an unfounded fear. “Bad things can happen even if you do everything right,” says Alex Vaccaro, MD, PhD, MBA, president of Rothman Orthopaedic Institute in Philadelphia. Of course, adverse events are far less likely to occur when your perioperative team does everything it should positioning-wise. “When it comes to proper patient positioning, surgical teams must have a sound mechanical strategy in place to expose the surgical site and to protect vulnerable pressure points and vascular structures,” says Dr. Vaccaro.

Different protocols, same team

Proper positioning depends on multiple disciplines coming together and working seamlessly as a single unit to ensure everything runs smoothly. “Each discipline has its own protocols, but ultimately you need everybody — the surgeon, anesthesiologist and the nurses — working together and refreshing upon all the appropriate principles,” says Dr. Vaccaro.

If your facility is among the many that use intraoperative neuromonitoring to prevent nerve injuries, monitoring technicians become a key part of the team as well. When this monitoring technology is used, there must be an open line of communication between the surgeons and the monitoring technicians. “You need to listen to the techs because patients are often repositioned based on what those techs see,” says Dr. Shifflett. “They get feedback and say, ‘We’re losing the hand,’ and we know to reposition the patient to prevent an injury.”

Positioning education and training should involve periodic in-services on everything from the ins and outs of spine tables to checklists that ensure critical steps aren’t missed throughout the procedure. For his part, Dr. Vaccaro runs an annual demonstration for his facility’s surgeons on spine table usage.

While a formal how-to demonstration on surgical tables may seem like overkill to busy administrators, the benefits of this refresher training cannot be overstated. After all, the latest spine tables are complex pieces of equipment, some of which are hinged mid-table and offer surgeons the capability to achieve precise and ideal flexion and extension. “Surgeons and staff must be familiar with using these state-of-the-art tables to prevent positioning injuries,” says Dr. Vaccaro. “They must be comfortable performing maneuvers such as safely turning the patient from the supine position to the prone position, and that takes practice.”

Regardless of how often your team practices patient positioning, there are certain universal components of the process you need to address.

• Thorough assessments. One of the most common positioning mistakes Dr. Shifflett sees with outpatient spine surgery is a failure to assess the patient properly in the preoperative phase. “The pre-op assessment is so important, and you need to have an accurate health history because if you don’t know about the patient’s bad shoulder or stiff neck ahead of time, the routine positioning precautions you take may not be enough to prevent harm,” he explains.

EYE ON THE EYES Vision loss is the most drastic complication stemming from improper positioning, but corneal abrasions and other irritations are also causes for concern.

Dr. Shifflett says that if a patient mentions anything about a physical issue, even a problem seemingly unrelated to the surgery they’re undergoing, the entire OR team needs to be made aware of it. One of the most effective ways to prevent a patient from glossing over something that could be of critical importance during the history is to avoid making the process appear rushed and to listen actively and empathetically to all the patient’s responses.

• Regular positioning checks. Providers are often exceedingly careful when they initially position the patient for a spine procedure. Throughout the case, however, the patient may shift or get jostled enough to put them in a precarious situation. And when surgeons are laser-focused on the surgery at hand, things can get missed. That’s why it’s so important for everyone in the OR to routinely take a step back to check that the patient is still where they should be — even if it means peeking under the drapes. Dr. Shifflett says it’s common for his staff to double-check on something mid-case. “During the procedure, you’ll often hear our team saying things like, ‘Can you look under the drapes?’” he says. “Or X-ray techs will call out, ‘Hey, can you check that arm again?’”

Proper positioning can be as simple as putting yourself in the patient’s shoes. “Sometimes I’ll take a step back, look at the patient and ask myself, ‘Does this look comfortable?’ If the answer is no, then I’ll adjust the patient,” says Dr. Shifflett.

Dr. Vaccaro agrees on the importance of monitoring the patient’s positioning throughout surgery. “A complete visual inspection of the eyes, axilla, elbows, knees and abdomen is a simple but effective way to make sure the patient is positioned correctly for surgery,” he says.

• Focus on high-risk areas. Vision loss is a risk associated with spine procedures — a complication that Dr. Vaccaro says every surgeon fears. Providers should closely monitor intraoperative eye pressure and watch for swelling throughout the procedure — especially during longer cases. However, with the threat of vision loss looming as a complication, Dr. Vaccaro urges his team of surgeons to remember one simple but seldom employed tactic that is always at their disposal: “I always remind them that it’s OK to stop the operation.”

While vision loss is understandably a huge concern, it’s not the only eye-related risk associated with spine surgery. “You also worry about corneal abrasions when the eyelids aren’t covered or are moist,” says Dr. Shifflett. “You worry about irritation.” The brachial plexus is another area you need to pay extra attention to during spine procedures. “If the patient is on their stomach, make sure the arms aren’t extended more than 90 degrees,” says Dr. Vaccaro. When men are in this position, the genital region is vulnerable to pressure injuries and ulceration, and catheter movement can lead to urethra injuries, adds Dr. Shifflett.

• Padding and positioning. There are plenty of positioning aids available, but your options are even more expansive than the padding marketed specifically for surgery, and many providers get creative when it comes to padding. For instance, Dr. Shifflett will purchase an entire egg crate mattress, tear off pieces at a time and use them to pad vulnerable areas. “The pieces are easy to tear off and place around the patient,” says Dr. Shifflett. “The versatility of the stuff is incredible.” Whatever you use for positioning, don’t forget to add a bite block to the mix, says Dr. Shifflett. “You need to use a bite block when the patient’s jaw is clenched,” he says. “I heard a horror story from a fellow about a patient who bit off part of their tongue because a bite block wasn’t in place.” 

Overcautious is OK
Many providers tend to be a bit over the top when it comes to patient positioning but, given the stakes, that’s understandable. Dr. Shifflett would happily accept being called overly cautious if it means a safer outcome for his patients. At the end of day, he believes his role in the positioning process is vital. “Surgeons are the captain of the ship,” he says. “We have to take ownership in the care of our patients because the responsibility for the outcomes — good and bad — lies with us.” OSM

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