Correction of lumbar lordosis is essential in achieving optimal outcomes in spinal deformity surgery. While surgical approach, implant selection and bony resection can all influence lordosis correction, intraoperative positioning remains a significant factor in optimizing lumbar alignment. The 1995 retrospective radiographic study by Peterson et al focused on the effect of intraoperative positioning on lumbar lordosis, examining both the "90-90" position and the prone position. The results revealed that the "90-90" position led to a significant loss of lumbar lordosis, reducing segmental lordosis by 60% at multiple levels (L2-L5) and total lordosis by more than 35%. In contrast, the prone position maintained total lumbar lordosis and increased lordosis at L5-S1 by 22%. In 1996, Guanciale and et al conducted a prospective study comparing the effects of the Andrews-type table and a four-poster frame in terms of their ability to maintain physiologic lordosis. The four-poster frame preserved lumbar lordosis more effectively, with patients positioned on this frame showing an average intraoperative lumbar lordosis of 47.71 degrees compared to 32.81 degrees on the Andrews table. Segmental lordosis at L5-S1 was less affected by frame type, highlighting that multisegmental lordosis is more dependent on positioning. The 2009 study by Harimaya and colleagues examined the change in lumbar lordosis in patients with adult spinal deformity who underwent posterior spinal fusion using the OSI "Jackson" frame. The results revealed that patients with preoperative hypolordosis experienced a significant increase in lordosis when positioned prone during surgery. In these patients, lumbar lordosis increased by an average of 18.1 degrees from their preoperative upright radiographs to their intraoperative prone radiographs. In contrast, patients with normal or high preoperative lordosis showed no significant changes during prone positioning. The studies presented above highlight the role of intraoperative positioning in spinal surgery, particularly its impact on lumbar lordosis. To our surgeon readers, how do you approach patient positioning to maximize lordosis in your fusion patients? What tips and tricks do you use? Lali Sekhon, MD PhD MBA David Yam Simon Sandler Dr Michael Coroneos Prof. Mohamed Mohi Eldin Mike Selby Patrick Knight Ralph Mobbs A Agarwal MD References: 1) Peterson MD, et al. The effect of operative position on lumbar lordosis. A radiographic study of patients under anesthesia in the prone and 90-90 positions. Spine (Phila Pa 1976). 1995 Jun 15;20(12):1419-24.? 2) Guanciale AF, et al.. Lumbar lordosis in spinal fusion. A comparison of intraoperative results of patient positioning on two different operative table frame types. Spine (Phila Pa 1976). 1996 Apr 15;21(8):964-9. 3) Harimaya K, et al. Increasing lumbar lordosis of adult spinal deformity patients via intraoperative prone positioning. Spine (Phila Pa 1976). 2009 Oct 15;34(22):2406-12.?
This is an important issue. Correction of lordosis is important to have a good sagittal balance. That is important to the degree that some spine surgeons returned back to the monoaxial screws for better postoperative configuration and balance. All what you said regarding positioning is great. To me, the important point is that in most prone lumbar procedures we need to have some flexion to open the interlaminar spaces. This should be kept in mind after screws insertion and before rod adjustment and tightening, by re correction of the flexion posture.
Dr Michael Coroneos
1 个月
Nice graphic on point! The majority of surgery in general units is lumbar discectomy and decompression. Best access is knee chest using gluteal seat frame in knee chest position accentuating kyphosis and interlaminar opening with hanging abdomen.Minimal bleeding and excellent neural and disc access. II lateral only but suffices as no fixation. With lumbar fixation then Jackson type table for lumbar lordosis induction. Lordosis reduces interlaminar access. Greater imaging access.
OSI. Then drill off the facets. Expandable cage. Compress the construct. No tricks.
Ray Oshtory, MD, MBA
1 个月
Important post as alignment is king for fusion. That’s why I think prone positioning is really important for lateral interbody constructs. I will often put blankets under the knees to extend the hip and increase lordosis even more. This technique also draws the psoas and plexus even more posteriorly helping with the approach. For discectomy/decompression, I want the opposite so that the interlaminar window opens up as much as possible minimizing the need for bone resection. I use a Wilson frame and crank it all the way up. Then I flex the hips and knees using the regular OR table rather than a Jackson (trying to simulate an Andrews table as much as possible as we don’t have any at my hospitals).
Rayyan AlShengiti
1 个月
1? lordosis can be maximized by using prone positioning, especially in patients with preoperative hypolordosis, as this has been shown to improve lordosis. Using frames like the four-poster, which preserve lumbar curvature better than other systems, is another strategy. Positioning on tables such as the Jackson frame can also help maintain or improve lordosis. 2. What tips and tricks are used? ? A key tip is selecting the appropriate intraoperative table or frame that supports natural spinal alignment. Prone positioning is particularly useful, especially for patients with reduced preoperative lordosis. Another trick may include adjusting the level of flexion at specific segments (like L5-S1) to optimize postoperative outcomes.
Patrick Knight
1 个月
Great point. When I do lumbar spine simple surgery- direct decompression I want the interlaminar space open so I wind my Wilson’s frame all the way up. For fusions I want to maintain and or correct the lordosis so I use pelvic and shoulder bolsters or a “flat” Wilson’s. For trauma I place the bolsters and padding in such a way that the positioning reverses the forces of the mechanism of injury. Therefore most of the reduction is done gradually and passively as I do my bony exposure. By the time I’m ready to put screws down it’ll be nearly completely reduced and then various reduction manouvres or techniques are used to finalize said reduction.
Ahmed Allam, MD, PhD
1 个月
You are right A great deal of final lordosis is achieved by good postioning. In the TL spine i find Jackson style chest and hip support tables give best initial lordosis , followed by a wilson frame cranked down to the maximum possible. I also find that more elevation and flexion at the knees by 2 pilows under the ankle and a gel pad under the knee imrpoved hip extension and subsequently lordosis.
Simon Sandler
1 个月
Pro axis for lateral and ankylosed fractures where the fracture has fished mouth open and you want to shut down the fracture. Otherwise OSI. Used to use Andrew’s for Lami a long time ago. And sometimes Wilson frame.
Neurological Surgeon
1 个月I have used a Mizuho OSI ProAxis and then Proaxis 2 since 2010. It was first used to break patients for lateral fusion but then I realized it's power at increasing lordosis Prone. When the latest hospital I worked for wouldn't buy one, I worked to design my own working with industry. Hoping to share that work very soon.