Acta Marisiensis - Seria Medica 2020;66(1):9-14 DOI: 10.

2478/amma-2020-0007

REVIEW

Patient Positioning in Neurosurgery, Principles and

Complications
Adrian Balasa1*, Corina Ionela Hurghis2, Flaviu Tamas2, Rares Chinezu1,2
1. George Emil Palade University of Medicine, Pharmacy, Science, and Technology of Targu Mures, Romania
2. Neurosurgery Clinic, Emergency County Hospital, Targu Mures, Romania

Patient positioning is a crucial step in neurosurgical interventions This is the responsibility of both the neurosurgeon and the anesthesiologist.
Patient safety, surgeon’s comfort, choosing an optimal trajectory to the lesion, reducing brain tension by facilitating venous drainage, using
gravitation to maintain the lesion exposed and dynamic retraction represent general rules for correct positioning. All bony prominences must
be protected by silicone padding. The head can be positioned using a horseshoe headrest or three pin skull clamp, following the general
principles: avoiding elevating the head above heart more than 30 degrees, avoiding turning the head to one side more than 30 degrees and
maintaining 2 to 3 finger breaths between chin and sternum. Serious complications can occur if the patient is not properly positioned so this
is why great care must be paid during this step of the surgical act.

Keywords: positioning, complications, patient safety

Received 3 December 2019 / Accepted 13 February 2020

General principles Head positioning and fixation

Correctly positioning the patient is a crucial step in After securing the body, the head can be positioned. A gen-
neurosurgical procedures. This is the responsibility of both eral rule is to not elevate the head above the heart more
the neurosurgeon and the anesthesiologist. Patient safety than 30 degrees because this can lead to decreased cere-
is the most important factor, this is why when positioning bral perfusion pressure compromising cerebral blood flow.
the patient, blood pressure and pulse oximetry should be Every 2,5cm of head elevation above the heart decreases
monitored and clamping chest tubes is not allowed [1] and the mean arterial pressure by 2mmHg [2]. Another rule is
also we must take into consideration surgeons comfort, es- that the distance between the chin and sternum shouldn’t
pecially for long interventions. A correct position should be less than 2 to 3 finger breaths, because hyperflexion
provide the optimal trajectory to the lesion and whenever can lead to cervical cord ischemia. The head shouldn`t be
possible we must use positions that maintain the lesion turned more than 30 degrees to one side, especially when
exposed via gravity and facilitate dynamic retraction; the turning it towards the dominant jugular vein.
use of spatulas and retractors should be avoided if possible. The head can be fixed using a three pin skull clamp
Another key factor when positioning the patient is ensur- (Mayfield fixator) or using a horseshoe headrest. When fix-
ing that venous drainage is facilitated, this way avoiding ing the head with the tree pin skull clamp, the imaginary
brain tension. line between the pins has to be under the equatorial line
In this paper we aim to assess the most important prin- of the head; the pins must not interfere with the surgical
ciples and risk factors associated to each of the six basic field. Frontal sinuses, temporal squamous bone and venous
positions used in neurosurgical cranial interventions: su- sinuses must be avoided when inserting the pins. The risks
pine, lateral (“park bench”), prone (three-quarter prone) associated to pin skull clamp fixation are bleeding, eye/
and sitting positions. scalp laceration and air embolism which can be prevented
Patient positioning always starts by positioning the body by using antibiotic ointment on the pins prior to insertion.
first. All bony prominences must be protected by silicone El-Zenati et al. [3] reported one case of venous air embo-
padding and the body must be secured to the operating lism after removal of the Mayfield skull clamp to a 33 year
table with special padded belts. When using a lateral po- male. The horseshoe headrest is used in trans-sphenoidal
sition or “park bench” position, lateral supports must be surgical approaches or for short time interventions. Long
used, this way permitting lateral tilting of the table with interventions can lead to pressure alopecia when using a
the patient secured. horseshoe headrest [4].
The operating table must fulfill the following character- Our experience shows that the Mayfield skull clamp is
istics in order to properly position the patient: it has to be extremely versatile and use of the horseshoe headrest has
a table with at least 3 sections, it has to have sliding/tilting limited use.
function, and it has to have range variability between the
lowest and the highest position. Supine position
Supine position can be used for approaching the frontal,
* Correspondence to: Adrian Balasa
temporal and parietal lobes, anterior, middle and even
E-mail: [email protected]
10 Acta Marisiensis - Seria Medica 2020;66(1)

the posterior cranial fossa, lateral and third ventricles and lateral suboccipital craniotomy is performed in standard
also the cervical spine for anterior approaches. The head fashion. The dimensions of the craniotomy are reduced
shouldn`t be rotated more than 30 degrees to one side. compared to operating in prone or lateral position because
More rotation can be achieved by tilting the table or by there is less need for a large exposure. The dura is cut in
using a roll under the ipsilateral shoulder. There are three an “U” shape and reflected over the transverse sinus. Cis-
variants of the supine position (Figure 1). The horizontal terna magna is opened and brain relaxation is achieved by
position is not well tolerated by the conscious patient for removing CSF. Access to the quadrigeminal cistern is now
long periods of time so this is why it is not recommended. easily obtained and more CSF can be removed if needed.
The lawn-chair position is a more natural position that can The cerebellum falls and good access over the top of the
be well tolerated for long periods of time (Figure 2). The cerebellum or to the postero-lateral midbrain is achieved.
patient is positioned on the table with the head and thorax Using this position has the advantages of operating in sit-
slightly elevated and the hips and knees slightly flexed. A ting position but venous air embolism risk is reduced and
pillow must be placed under the knees and a silicone pad the discomfort for the neurosurgeon is minimal. It has its
must be placed under the heels. Bony prominences must limitations though, this position is not adequate for mid-
be padded and ulnar nerve protected. This position has the line lesions or for patients with a stiff neck.
advantage that the slight elevation of the head and legs im- Our experience has showed that supine position and
prove venous drainage of the brain and venous return. Also it’s minor adaptations, represented by placing a roll under
elevating the head and thorax improves ventilation in the one shoulder can be used to successfully operate a myriad
dependent zones of the lungs by displacing the abdominal of pathologies of anterior skull base, through unilateral or
organs away from the diaphragm [1]. Reverse Trendelen- bilateral frontal or subfrontal approaches and pathologies
burg position is basically a horizontal position with the located in the Sylvian fissure.
head slightly elevated.
Posterior fossa lesions can be operated through an adap- Lateral position and park bench position
tation of the supine position. Awad et al. [5] described the There are two variants of the lateral position: pure lateral
gravity dependent supine position used for infratentorial and park bench position. Pure lateral position it`s mainly
supracerebelar lateral approaches. The patient is positioned used for temporal area surgery, and park bench for poste-
supine with a lateral roll under the ipsilateral shoulder and rior fossa lesions.
the head is flexed and rotated to the contralateral side. A The patient is positioned with the side of the lesion up-
lazy “S” incision is made over the transverse sinus and a wards. When a pure lateral position (Figure 3) is needed,
the long axis of the head is parallel to the ground. In park
bench position (Figure 4), the head is rotated towards the
shoulder contralateral to the lesion, without exceeding 30
degrees of lateral rotation. The following steps for position-
ing are similar for both lateral and park bench positions: a
roll is placed under the contralateral upper chest, we must
avoid putting it directly under the axilla because the bra-
chial plexus and axillary vessels will be compressed; all bony
prominences must be protected; the depressed arm hangs
over the end of the table on an arm support or suspended
with a padded string; the ipsilateral hand is placed across
the thorax with the elbow in slight flexion; the ipsilateral
Fig. 1. Supine position variants: top-horizontal position; middle-
lawn-chair position; bottom reverse Trendelenburg position knee is positioned in extension and the depressed knee is
positioned in flexion; a pillow must be placed between the
knees; lateral supports are being placed in the sternal region
and in the interscapular region and afterwards the patient
is secured across the pelvic region with padded strings [4].
There have been described various complications fol-
lowing interventions with the patients positioned in lat-
eral or park bench, starting from pressure sores to upper
limb palsy to tongue swelling or delayed airway obstruc-
tion. Koizumi et al. [6] published a case report of a 43
year old man that has developed a massive tongue swelling
13 hours after undergoing a left suboccipital craniotomy
in park bench position. In this case it seems that the cause
of the massive tongue swelling was a malpositioned bite
Fig. 2. The Lawn-chair position block that compromised the circulation into the left side of
Acta Marisiensis - Seria Medica 2020;66(1) 11

the tongue during the intervention. The edema gradually

improved after administration of intravenous steroids and
no reintubation was needed. Yamaguchi et al. [7] reported
two cases operated in park bench position that developed
delayed airway obstruction postoperatively. They reviewed
related articles written in English literature and found
only five cases reported of delayed airway obstruction af-
ter craniotomy in lateral or park bench position, excluding
the two cases reported by them in their case report. They
concluded that excessive lateral flexion and rotation of the
head (that is easily achieved especially in underweighted
patients) kinks the internal jugular vein and therefore ve-
nous and lymphatic drainage from the head and neck is
altered for many hours during long interventions. After
the surgery is concluded, the soft tissue of the neck is rep-
erfused causing face and neck edema that leads to airway
obstruction few hours after surgery.
In our experience we have found that the lateral and
park bench position are very good for treating pathologies
located in the temporal, parietal or ponto-cerebellar fis-
sure. Despite being more difficult to set up and requiring
more time to do so, this time is well spent allowing for
comfortable lengthy procedures for both the surgeon and
the patient.

Prone position
Prone position is being used for posterior fossa lesions,
fourth and third ventricle lesions or pineal region lesions.
It can also be used for posterior approaches to the cervical,
Fig. 3. The pure lateral position thoracic and lumbar spine. The patient is intubated in su-
pine position and afterwards it is rolled in prone position
on the operating table. Two rolls should be placed under
the upper part of the thorax and pelvis for releasing pres-
sure on the abdomen. When performing spine surgery a
Wilson frame can be used. A roll is placed under the shins
and the knees are flexed by elevating the leg segment of the
operating table. When performing cranial or upper cervi-
cal spine surgery the arms are positioned adducted along
the patient and when performing thoracic or lumbar spine
surgery, the arms are abducted and placed on arm boards,
and the elbows are flexed; care must be exercised not to
hyperextend the arms because brachial plexus injury can
occur. A padded belt is placed under the fesier region to
secure the patient in case afterwards the table is elevated in
reverse Trendelenburg position [4].
The reverse Trendelenburg position, also known as Con-
corde position is mainly used for posterior fossa interven-
tions or posterior approaches of the cervical spine. The
head is then immobilized in a Mayfield head fixator and
flexed, being aware to leave at least two finger breaths be-
tween the chin and sternum. A horseshoe head rest can be
used for thoracic and lumbar spine interventions. Fixating
the head after positioning the table in reverse Trendelen-
burg position prevents strain on the cervical spine. This
position causes hemodynamic instability because the car-
Fig. 4. The park bench position diac index and left ventricular ejection fraction decreases,
12 Acta Marisiensis - Seria Medica 2020;66(1)

in contrast, oxygenation seems to improve because of the

improved matching of ventilation-perfusion [1].
Kwee et al. [8] published a review of intraoperative and
postoperative complications related to prone positioning.
They analyzed 53 papers in English language literature and
found 13 complications following prone position surgi-
cal interventions. The following complications were de-
scribed: oropharyngeal swelling, nerve palsies (lateral fem-
oral cutaneous nerve), postoperative vision loss, pressure
sores, venous air embolism, increased intraabdominal pres-
sure, increased bleeding, hepatic dysfunction, abdominal
compartment syndrome, limb compartment syndrome,
thrombosis and stroke, cardiovascular compromise and
endotracheal tube dislodgement. The worst complication
that can incur with the patient in prone position is cardiac
arrest. A good measure of dealing with cardiac arrest is at-
taching the defibrillation pads before surgery. According to
Nanjangud et al.[9] if a patient is diagnosed with cardiac
arrest, cardio-pulmonary resuscitation must start as soon
as possible with the patient in prone position, without
wasting time turning the patient supine. Cardiac massage
consists of manually compressing the middle portion of
the thoracic spine. It seems that the systolic blood pressure
generated when resuscitating a patient in prone position is
higher than in supine position [10].
In our experience prone position is a very good position
Fig. 5. The three quarter prone position
to do surgery in the occipital lobe, posterior fossa, cranio-
cervical junction tumors and whole spine.
In our experience the three quarter prone position can
Three quarter prone position be a good alternative to park bench in parieto-occipital of
This is a position mainly used for posterior fossa lesions lateral posterior fossa tumors.
or for lesions in the parieto-occipital region. When using
this position, the operative site is downwards. Three quar- Sitting position
ter prone position (Figure 5) is best suited for occipital The sitting position (Figure 6) is less used nowadays be-
transtentorial approaches, as described in the year 1988 by cause of the increased complication ratio related to it. It is
Ausman et al.[11] He described the use of this position for mainly used for posterior fossa lesions that are approached
pineal region tumors and concluded that the risk of air em- through the infratentorial supracerebelar approach, suboc-
bolism is reduced compared with the sitting position and cipital transtentorial approach, retrosigmoid approach or
that because the operative site is down, there is less need for approaches to the superior cervical spine. Also patients that
using brain retractors. need implantation of deep brain stimulators are positioned
The patient is intubated in supine position and after- this way because brain shift is minimized in comparison to
wards it is rotated on the operating table. A roll is placed other positions [12].
under the contralateral hemithorax, elevating it approxi- The patient is intubated supine and afterwards the op-
matively 15 degrees of the horizontal plane. A small roll erating table is flexed, elevating the thorax and body of the
is placed in the ipsilateral axilla. The contralateral arm is patient in sitting position. The hips are also positioned in
placed along the body and the ipsilateral hand is posi- slight flexion and the knees should be also slightly flexed.
tioned behind the body. The superior leg is flexed and the A crossbar that attaches to the first segment of the table
inferior leg is extended. A pillow must be placed between is positioned anterior to the patient. The head is fixed in
the knees. The head is then fixed in the Mayfield device the Mayfield head holder that is attached to the crossbar.
that is attached to the operating table. Usually the nose is The head is flexed until the tentorium is as parallel as pos-
positioned perpendicular to the ground (but the head can sible to the ground but hyperflexion of the head should be
be rotated as much as 45 degrees) and the neck is slight- avoided [4].
ly flexed. The body is secured with padded strings to the Sitting position has the advantage that the cerebellar
operating table. This position offers good comfort for the structures are gravity-retracted, leaving a good operating
surgeon [4]. corridor to the pineal gland or the superior cerebellar area.
Acta Marisiensis - Seria Medica 2020;66(1) 13

veins by the mechanical displacement of the cerebellum;

nevertheless tension pneumocephalus and subdural hema-
tomas are complications that can appear in every cranial
procedure. Cervical quadriplegia is a devastating complica-
tion that is specific to sitting position and can be prevented
by relieving the strain on the cervical spine by properly
sustaining the patient`s body, without leaving it hang by
the patient`s head which is firmly placed in the Mayfield
head holder; this situation, combined with position related
hypotension can lead to cervical spine ischemia leading to
quadriparesis or quadriplegia. Sciatic nerve injury is an-
other complication that can appear.
Sitting position is a relative contraindication to patients
that are diagnosed with patent foramen ovale because of
the risk of paradoxical air embolism. Echocardiography is
the screening method recommended to every patient that
is a candidate for a neurosurgical intervention in sitting
position [12, 13].
Despite being proved as safe we have used the sitting po-
sition just a limited number of cases, mainly for infraten-
torial-supracerebellar approaches. We fell that the prone
position allows for similar results in other lesions of the
posterior fossa whilst allowing the operating surgeon more
Fig. 6. The sitting position comfort and avoiding the intraoperative complications de-
scribed by placing the patient in sitting position.
Another advantage to sitting position is that the CSF and
venous drainage improve, decreasing the cerebral pres- Conclusion
sure. The reason why this position is less used nowadays We can conclude that serious complications for the patient
has to do with the increased risk of venous air embolism can occur if it is not properly positioned so this is why
and hemodynamic instability. Dilmen et al. [13] published great care must be paid during this step of the surgical act.
a retrospective study in the year 2011 of 692 cases (601 Also the surgeon`s comfort is a very important aspect that
adults and 92 children) operated in sitting position and has to be taken into consideration when positioning the
concluded that venous air embolism, diagnosed using patient.
capnography, has an occurrence of 26.3% in children and
20.4% in adults and that position induced hypotension
occurs more frequently in adult population (37,6%) com- Authors' contributions
pared to pediatric population (18,6%). They also conclud- AB (Conceptualization; Project administration; Supervi-
ed that patients suffering of chronic obstructive pulmonary sion; Validation; Visualization)
disease tolerate with great difficulty venous air embolism CIH (Data curation; Investigation; Methodology; Re-
and recommend not using the sitting position in these pa- sources; Writing – review & editing)
tients. FT (Data curation; Formal analysis; Investigation; Meth-
Himes et al. [12] published a study of 1792 patients op- odology; Resources; Visualization; Writing – review & ed-
erated in sitting positions and reported a overall complica- iting)
tion rate of 1,45%. The incidence of venous air embolism RC (Data curation; Formal analysis; Methodology; Project
was 4,7%. Similarly with other studies, the incidence of ve- administration; Supervision; Visualization)
nous air embolism seems to be the highest in cranial suboc-
cipital interventions and intradural cervical spine interven- Conflicts of interests
tions compared with cervical extradural interventions that The authors of this paper state that they have no conflict of
had much lower incidence of venous air embolism. The interests to disclosure.
reason why this is happening is not clear. Another com-
plication that can appear is tension pneumocephalus that References
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