Semi-sitting Position in Neurosurgery: A Review

Abstract

Specialists rarely perform neurosurgical procedures on patients in the semi-sitting position. This is due to several factors, most importantly, the perception of risks associated with this position and lack of practice in some services. Nevertheless, the benefit of this position is still the subject of controversy both in neurosurgery and neuroanesthesia. Our objective is to report on the benefits associated to its use for posterior fossa diseases and dorsal cervical spine procedures, through cases in the literature. We survey and analyze state-of -the art works that mention the semi-sitting position, based on searches in Pubmed, Scielo, Science Direct, and Lilacs. We found 46 original articles on the subject that we included in the review. This review demonstrates that the advantages for access in this position include gravitational drainage of venous blood and cerebrospinal fluid, easier surgical access to midline structures, as well as reduced cerebellar edema, surgery time and blood loss. This technique also allows ventilation with low pressure, less impairment of diaphragmatic motion, and better access to the tracheal tube. There are, however, some disadvantages, among which the most serious is paradoxical arterial embolism. We describe early detection methods of complications and discuss situations that can factor in to the choice of position. In summary, a semi-sitting position is safe and effective in neurosurgical posterior fossa and the upper cervical spine, provided there is a joint effort between neurosurgeons and anesthesiologists in selecting patients and complying with the technical standards favorable to this technique.

Resumo

Especialistas raramente realizam procedimentos neurocirúrgicos em pacientes em posição semi-sentada. Vários são os fatores, o mais importante, a percepção dos riscos associados a esta posição e falta de prática em alguns serviços. No entanto, o benefício desta posição ainda é objeto de controvérsia tanto em neurocirurgia e Neuroanestesia. Nosso objetivo é relatar os benefícios associados ao seu uso para doenças da fossa posterior e procedimentos da coluna cervical dorsal. Realizado um levantamento e analise do estado-da-arte dos documentos que mencionam a posição semi-sentada, com base em pesquisas em Pubmed, Scielo, Science Direct e Lilacs. Encontraram-se 46 artigos originais sobre o assunto que foram incluídos na revisão. Esta avaliação demonstra que as vantagens do acesso nesta posição incluem a drenagem gravitacional de sangue venoso e no líquido cefalorraquidiano, o acesso cirúrgico mais fácil para estruturas da linha média, bem como diminuição do edema cerebelar, tempo de cirurgia e perda de sangue. Esta técnica também permite a ventilação com pressão baixa, menor comprometimento da mobilidade diafragmática, e um melhor acesso ao tubo traqueal. Há, algumas desvantagens, entre as quais a mais grave é a embolia arterial paradoxal. Descreve-se métodos de detecção precoce de complicações e discutir situações que pode fator para a escolha de posição. Em resumo, esta posição é segura e eficaz em fossa posterior e da coluna cervical superior, desde que haja um esforço conjunto entre neurocirurgiões e anestesistas na seleção de pacientes e em conformidade com as normas técnicas favoráveis a esta técnica.

Keywords

semi-sitting position - surgery

Palavras-chave

posição semissentada - cirurgia

• References

• 1 Schaffranietz L, Grothe A, Olthoff D. [Use of the sitting position in neurosurgery. Results of a 1998 survey in Germany]. Anaesthesist 2000; 49 (4) 269-274
• 2 Kida H, Nishikawa N, Matsunami K, Kawahito M, Ota M, Miyao S. [Sitting position in the neurosurgery: the results of a questionnaire sent to neurosurgeons of medical colleges]. Masui 2000; 49 (5) 566-569
• 3 Faberowski LW, Black S, Mickle JP. Incidence of venous air embolism during craniectomy for craniosynostosis repair. Anesthesiology 2000; 92 (1) 20-23
• 4 Fathi AR, Eshtehardi P, Meier B. Patent foramen ovale and neurosurgery in sitting position: a systematic review. Br J Anaesth 2009; 102 (5) 588-596
• 5 Albin MS, Carroll RG, Maroon JC. Clinical considerations concerning detection of venous air embolism. Neurosurgery 1978; 3 (3) 380-384
• 6 Black S, Ockert DB, Oliver Jr WC, Cucchiara RF. Outcome following posterior fossa craniectomy in patients in the sitting or horizontal positions. Anesthesiology 1988; 69 (1) 49-56
• 7 Duke DA, Lynch JJ, Harner SG, Faust RJ, Ebersold MJ. Venous air embolism in sitting and supine patients undergoing vestibular schwannoma resection. Neurosurgery 1998; 42 (6) 1282-1286 , discussion 1286–1287
• 8 Weingart JD, Brem H. Basic principles of cranial surgery for brain tumors. In: Winn HR, editor. Youmans neurological surgery. Philadelphia: Elsevier Saunders; 2011. . p. 1261–6.
• 9 Harrison EA, Mackersie A, McEwan A, Facer E. The sitting position for neurosurgery in children: a review of 16 years' experience. Br J Anaesth 2002; 88 (1) 12-17
• 10 Orliaguet GA, Hanafi M, Meyer PG , et al. Is the sitting or the prone position best for surgery for posterior fossa tumours in children?. Paediatr Anaesth 2001; 11 (5) 541-547
• 11 Rath GP, Bithal PK, Chaturvedi A, Dash HH. Complications related to positioning in posterior fossa craniectomy. J Clin Neurosci 2007; 14 (6) 520-525 10.1016/j.jocn.2006.02.010
• 12 Ganslandt O, Merkel A, Schmitt H , et al. The sitting position in neurosurgery: indications, complications and results. a single institution experience of 600 cases. Acta Neurochir (Wien) 2013; 155 (10) 1887-1893
• 13 Leslie K, Hui R, Kaye AH. Venous air embolism and the sitting position: a case series. J Clin Neurosci 2006; 13 (4) 419-422
• 14 Girard F, Ruel M, McKenty S , et al. Incidences of venous air embolism and patent foramen ovale among patients undergoing selective peripheral denervation in the sitting position. Neurosurgery 2003; 53 (2) 316-319 , discussion 319–320
• 15 Papadopoulos G, Kuhly P, Brock M, Rudolph KH, Link J, Eyrich K. Venous and paradoxical air embolism in the sitting position. A prospective study with transoesophageal echocardiography. Acta Neurochir (Wien) 1994; 126 (2–4) 140-143
• 16 Michenfelder JD, Miller RH, Gronert GA. Evaluation of an ultrasonic device (Doppler) for the diagnosis of venous air embolism. Anesthesiology 1972; 36 (2) 164-167
• 17 Stendel R, Gramm HJ, Schröder K, Lober C, Brock M. Transcranial Doppler ultrasonography as a screening technique for detection of a patent foramen ovale before surgery in the sitting position. Anesthesiology 2000; 93 (4) 971-975
• 18 Lobato EB, Black S, De Soto H. Venous air embolism and selective denervation for torticollis. Anesth Analg 1997; 84 (3) 551-553
• 19 Palmon SC, Moore LE, Lundberg J, Toung T. Venous air embolism: a review. J Clin Anesth 1997; 9 (3) 251-257
• 20 Albin MS. Letter to editor: the paradox of paradoxic air embolism – PEEP, valsalva, and patent foramen ovale, should the sitting position be abandoned?. Anesthesiology 1984; 61: 222-3
• 21 Druz WS, Sharp JT. Activity of respiratory muscles in upright and recumbent humans. J Appl Physiol 1981; 51 (6) 1552-1561
• 22 Druz WS, Sharp JT. Electrical and mechanical activity of the diaphragm accompanying body position in severe chronic obstructive pulmonary disease. Am Rev Respir Dis 1982; 125 (3) 275-280
• 23 Mier-Jedrzejowicz A, Brophy C, Moxham J, Green M. Assessment of diaphragm weakness. Am Rev Respir Dis 1988; 137 (4) 877-883
• 24 Fromageot C, Lofaso F, Annane D , et al. Supine fall in lung volumes in the assessment of diaphragmatic weakness in neuromuscular disorders. Arch Phys Med Rehabil 2001; 82 (1) 123-128
• 25 Valta P, Corbeil C, Lavoie A , et al. Detection of expiratory flow limitation during mechanical ventilation. Am J Respir Crit Care Med 1994; 150 (5 Pt 1): 1311-1317
• 26 Tablan OC, Anderson LJ, Besser R, Bridges C, Hajjeh R ; CDC; Healthcare Infection Control Practices Advisory Committee. Guidelines for preventing health-care—associated pneumonia, 2003: recommendations of CDC and the Healthcare Infection Control Practices Advisory Committee. MMWR Recomm Rep 2004; 53 (RR-3): 1-36
• 27 Drakulovic MB, Torres A, Bauer TT, Nicolas JM, Nogué S, Ferrer M. Supine body position as a risk factor for nosocomial pneumonia in mechanically ventilated patients: a randomised trial. Lancet 1999; 354 (9193) 1851-1858
• 28 van Nieuwenhoven CA, Vandenbroucke-Grauls C, van Tiel FH , et al. Feasibility and effects of the semirecumbent position to prevent ventilator-associated pneumonia: a randomized study. Crit Care Med 2006; 34 (2) 396-402
• 29 Agostoni E, Hyatt RE. (1986) Static behaviour of the respiratory system. In: Handbook of physiology, sect 3, vol III, part 1, chap 9. American Physiological Society, Washington, pp 113–130
• 30 Behrakis PK, Baydur A, Jaeger MJ, Milic-Emili J. Lung mechanics in sitting and horizontal body positions. Chest 1983; 83 (4) 643-646
• 31 Baydur A, Sassoon CS, Carlson M. Measurement of lung mechanics at different lung volumes and esophageal levels in normal subjects: effect of posture change. Lung 1996; 174 (3) 139-151
• 32 Knowles JH, Hong SK, Rahn H. Possible errors using esophageal balloon in determination of pressure- volume characteristics of the lung and thoracic cage. J Appl Physiol 1959; 14: 525-530
• 33 Reeve BK, Cook DJ. Semi- recumbency amoung mechanically ventilated ICU patients: a multicenter observational study. Clin Intensive Care 1999; 10: 241-244
• 34 Grap MJ, Munro CL, Hummel III RS, Elswick Jr RK, McKinney JL, Sessler CN. Effect of backrest elevation on the development of ventilator-associated pneumonia. Am J Crit Care 2005; 14 (4) 325-332 , quiz 333
• 35 Servillo G, Svantesson C, Beydon L , et al. Pressure-volume curves in acute respiratory failure: automated low flow inflation versus occlusion. Am J Respir Crit Care Med 1997; 155 (5) 1629-1636
• 36 Maggiore SM, Jonson B, Richard JC, Jaber S, Lemaire F, Brochard L. Alveolar derecruitment at decremental positive end-expiratory pressure levels in acute lung injury: comparison with the lower inflection point, oxygenation, and compliance. Am J Respir Crit Care Med 2001; 164 (5) 795-801
• 37 Truwit JD, Marini JJ. Evaluation of thoracic mechanics in the ventilated patient. Part II: applied mechanics. J Crit Care 1988; 3: 199-213
• 38 Burns SM, Egloff MB, Ryan B, Carpenter R, Burns JE. Effect of body position on spontaneous respiratory rate and tidal volume in patients with obesity, abdominal distension and ascites. Am J Crit Care 1994; 3 (2) 102-106
• 39 Boles JM, Bion J, Connors A , et al. Weaning from mechanical ventilation. Eur Respir J 2007; 29 (5) 1033-1056