Safety: The Finer Points of Spine Surgery Positioning

Tables, tools and tactics that keep vulnerable patients safe.

There’s a reason surgeons who perform outpatient spine surgery will say proper positioning is as important as the procedure itself. Improper positioning increases the risk of several complications such as pressure injuries, nerve damage and vision loss, and can also reduce surgical field visibility.

Whole process

Joel Beckett, MD, a board-certified neurological spine surgeon at DISC Sports & Spine Center in Marina del Ray, Calif., believes the complex nature of spine surgery itself requires a special type of vigilance from the entire team — especially the surgeon — from start to finish when positioning the patient.

“The attending surgeon really takes responsibility,” says Dr. Beckett. “It’s relatively easy to get the patient prepared, but my approach to positioning in spine surgery is really to be there for the whole process. There’s a lot of nuances to how a patient is positioned in the OR, not only to protect their pressure points from nerve injury or pressure sores, but also to make sure that the patient is positioned appropriately for the spinal surgery that’s being performed.”

Therein lies the challenge, because positioning-related issues occur regularly in spine surgery. In fact, improperly aligned fusions are not rare at all, according to J. Alex Sielatycki, MD, an orthopedic spine surgeon at UCHealth Yampa Valley Medical Center in Steamboat Springs, Colo. It actually happens quite frequently, due to reasons beyond positioning or equipment.

“For a patient with a lot of abdominal obesity, it can be very challenging to get their spine in the proper position for reconstructive surgery,” says Dr. Sielatycki. “Even if you do have all the proper tools and everything is in place, you can still have a bad outcome.”

Adverse events are far less likely to occur when your perioperative team does everything it should when positioning patients.

Fusions, for instance, can be particularly challenging. If a patient isn’t positioned properly, particularly in the lumbar spine, they have too flat of a posture, leading to a flat fusion, which can limit their outcomes, says Dr. Sielatycki.

“When you’re doing a reconstruction, fusion or disc replacement, the positioning is part of the case, and making sure that the segment you’re working on is positioned in such a way that you’ll get the best outcome,” he says.

Prone, lateral and supine

The three most common positions in which a patient will be placed for spine surgery are prone, lateral or supine position. Modifications to the surgical table and cushioning are needed for each of these positions.

Instead of your average OR surgical table, a table specifically designed for spine surgeries allows surgical staff to position the patient more properly.

As Outpatient Surgery Magazine previously reported, most spine tables used today are based on the Jackson table design because it can be adapted to every type of operation a spine surgeon performs.

For lumbar decompression surgeries, Dr. Sielatycki will place the patient on a Wilson frame on top of a regular table or a Jackson table, depending on the model of the Wilson frame. Other frames and table adjustments have been developed to provide further flexibility in the OR.

For Dr. Sielatycki, “a Jackson table is the most versatile, because you can use the pads and the leg boards to move those around and optimize your patient’s position and their spine position before you start the surgery.” Tables modeled off the Jackson design have become more advanced. Some allow spine surgeons to break, rotate or change the table to allow the spine to change position during surgery. There are even head holders that are robotically or machine controlled.

These new adaptations from vendors are facilitating improvements in the ability to perform more complex spinal surgeries.

“If someone has scoliosis, kyphosis or severe spinal malalignment, OR tables may not actually fit them well, and so adaptations to those tables need to be made to accommodate severe spinal curvatures,” says Dr. Beckett. “When you’re talking about these large deformities or reconstructive spinal surgeries, you’re absolutely dealing with situations where the patient’s anatomy, spine, trauma, scoliosis or deformity may not allow them to safely fit even the more standardized spinal positioning tables, which are already very specific, as opposed to regular operating room tables for the spine itself.”

Cost considerations

For Dr. Sielatycki, the right table can play a vital role in positioning spine patients correctly — and can ultimately increase the liklihood of a successful outcome.

“Frankly, most lumbar reconstructive surgeries are much easier to do with [a Jackson table], and you can position much more appropriately. I think that does improve patient outcomes,” he says. “It improves the surgical workflow, and it improves the patient’s alignment at the time of their reconstruction. I’ve had the challenge before of having to use a regular OR table for a lumbar reconstruction where the Jackson was not available, and it can be tricky to get them in the right position. You have to use rolled blankets and shoulder bolsters and a lot of various tools to try and get their back in the right position.”

There is also no shortage of positioning aids that exist to better customize the optimal placement of the patient’s body. Over the last five to 10 years, there has been rapid growth in this area, according to Dr. Beckett.

“Aids like custom-made pillows, wedges and body positioning holders exist to better adapt to patient and surgeon needs,” he says. “However, these customized tools can be expensive.”

Without the innovation of customized positioning aides, Dr. Beckett says cost-conscious facilities often come up with creative, arts-and-crafts-like solutions of their own. “You’re rolling up towels and taping them together, making pillows out of nothing, and taping the patient to the bed in certain ways,” he says.

It is ultimately a value proposition for surgery centers whether they choose to invest in modern positioning aids or save money by making their own, which could ultimately cost time in the OR.

Cost is the biggest hurdle that exists to the widespread adoption of tools like customized pillows and positioning aids. A surgery center’s chosen approach must make sense for OR efficiency. Whether there is a significant difference in outcomes and efficiency between customized aids compared with an improvised approach is unclear. Existing data are largely industry-reported, according to Dr. Beckett.

Future innovations

The future of spine surgery positioning leaves plenty of opportunity for further innovation, including the integration of computer learning and human intelligence, where AI monitors nerve signals during surgery or quickly assesses an intraoperative X-ray to check positioning angles.

Cutting-edge technology will continue to play an evolving and critical role in improving positioning capability and customizations. Whether these innovations are cost-effective for a surgery center remains to be seen. OSM