The Prone Position During Surgery and its Complications: A Systematic Review and Evidence-Based Guidelines

Surgery in the prone position is often a necessity when access to posterior anatomic structures is required. However, many complications are known to be associated with this type of surgery, as physiologic changes occur with increased pressure to anterior structures. While several studies have discussed postoperative vision loss, much fewer studies with lower levels of evidence have addressed other complications. A systematic literature review was conducted using 2 different databases, and 53 papers were regarded as appropriate for inclusion. Qualitative and quantitative analysis was performed. Thirteen complications were identified. Postoperative vision loss and cardiovascular complications, including hypovolemia and cardiac arrest, had the most number of studies and highest level of evidence. Careful planning for optimal positioning, padding, timing, as well as increased vigilance are evidence-based recommendations where operative prone positioning is required.Key words: Prone, Surgery, Trunk, Supine, Retinal, Complications, Evidence based medicine, Qualitative and quantitative methodsProne positioning is a common position used for access to the posterior head, neck, and spine during spinal surgery, access to the retroperitoneum and upper urinary tracts and access to posterior structures when required during plastic surgery.^1,2 Prone surgery is associated with a variety of complications many of which are derived from increased pressure on anterior structures. Rates of pressure sores as an intraoperative complication have been reported to be between 5% and 66%. As such, pressure sores incur longer hospital stays and healthcare costs.³ Postoperative vision loss can result from inappropriate orbital pressure and can also be a permanently debilitating condition. Lateral femoral cutaneous nerve neuropathy in 20% of spinal surgery cases causing pain and dysesthesia in the anterolateral thigh.⁴ Inappropriate pressure on vital structures of the abdomen can cause ischemia and organ failure, resulting in prolonged hospitalization, permanent disability, or death.⁵ Cardiovascular changes associated with prone surgery increase risk of intraoperative cardiac arrest. At the same time, prone surgery is also associated with airway management and CPR issues as access to anterior structures is limited.⁶