title: Contemporary analysis of the intraoperative and perioperative complications of neurosurgical procedures performed in the sitting position.
abstract: OBJECTIVE Historically, performing neurosurgery with the patient in the sitting position offered advantages such as improved visualization and gravity-assisted retraction. However, this position fell out of favor at many centers due to the perceived risk of venous air embolism (VAE) and other position-related complications. Some neurosurgical centers continue to perform sitting-position cases in select patients, often using modern monitoring techniques that may improve procedural safety. Therefore, this paper reports the risks associated with neurosurgical procedures performed in the sitting position in a modern series. METHODS The authors reviewed the anesthesia records for instances of clinically significant VAE and other complications for all neurosurgical procedures performed in the sitting position between January 1, 2000, and October 8, 2013. In addition, a prospectively maintained morbidity and mortality log of these procedures was reviewed for instances of subdural or intracerebral hemorrhage, tension pneumocephalus, and quadriplegia. Both overall and specific complication rates were calculated in relation to the specific type of procedure. RESULTS In a series of 1792 procedures, the overall complication rate related to the sitting position was 1.45%, which included clinically significant VAE, tension pneumocephalus, and subdural hemorrhage. The rate of any detected VAE was 4.7%, but the rate of VAE requiring clinical intervention was 1.06%. The risk of clinically significant VAE was highest in patients undergoing suboccipital craniotomy/craniectomy with a rate of 2.7% and an odds ratio (OR) of 2.8 relative to deep brain stimulator cases (95% confidence interval [CI] 1.2-70, p = 0.04). Sitting cervical spine cases had a comparatively lower complication rate of 0.7% and an OR of 0.28 as compared with all cranial procedures (95% CI 0.12-0.67, p < 0.01). Sitting cervical cases were further subdivided into extradural and intradural procedures. The rate of complications in intradural cases was significantly higher (OR 7.3, 95% CI 1.4-39, p = 0.02) than for extradural cases. The risk of VAE in intradural spine procedures did not differ significantly from sitting suboccipital craniotomy/craniectomy cases (OR 0.69, 95% CI 0.09-5.4, p = 0.7). Two cases (0.1%) had to be aborted intraoperatively due to complications. There were no instances of intraoperative deaths, although there was a single death within 30 days of surgery. CONCLUSIONS In this large, modern series of cases performed in the sitting position, the complication rate was low. Suboccipital craniotomy/craniectomy was associated with the highest risk of complications. When appropriately used with modern anesthesia techniques, the sitting position provides a safe means of surgical access.
authors: Departments of 1 Neurologic Surgery and.
authors: Benjamin T
authors: BT
authors: Himes
authors: Departments of 1 Neurologic Surgery and.
authors: Grant W
authors: GW
authors: Mallory
authors: Anesthesiology, Mayo Clinic, Rochester, Minnesota.
authors: Arnoley S
authors: AS
authors: Abcejo
authors: Anesthesiology, Mayo Clinic, Rochester, Minnesota.
authors: Jeffrey
authors: J
authors: Pasternak
authors: Departments of 1 Neurologic Surgery and.
authors: John L D
authors: JLD
authors: Atkinson
authors: Departments of 1 Neurologic Surgery and.
authors: Fredric B
authors: FB
authors: Meyer
authors: Departments of 1 Neurologic Surgery and.
authors: W Richard
authors: WR
authors: Marsh
authors: Departments of 1 Neurologic Surgery and.
authors: Michael J
authors: MJ
authors: Link
authors: Departments of 1 Neurologic Surgery and.
authors: Michelle J
authors: MJ
authors: Clarke
authors: Anesthesiology, Mayo Clinic, Rochester, Minnesota.
authors: William
authors: W
authors: Perkins
authors: Departments of 1 Neurologic Surgery and.
authors: Jamie J
authors: JJ
authors: Van Gompel
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D002648:Child; D002675:Child, Preschool; D004618:Embolism, Air / Q000453:epidemiology; D005260:Female; D006801:Humans; D007431:Intraoperative Complications / Q000453:epidemiology*; D008297:Male; D008875:Middle Aged; D019635:Neurosurgical Procedures / Q000379:methods*; D056888:Patient Positioning / Q000009:adverse effects*; D011183:Postoperative Complications / Q000453:epidemiology*; D018570:Risk Assessment; D000077708:Sitting Position; D055815:Young Adult
keywords: ACLS = advanced cardiovascular life support; CI = confidence interval; DBS = deep brain stimulator; OR = odds ratio; PFO = patent foramen ovale; TEE = transesophageal echocardiography; VAE = venous air embolism; posterior fossa surgery; sitting position; surgical technique; venous air embolism