ISSN 0972-978X 

  About COAA







Lateral Decubitus Position in Spinal Surgery - Current Concepts

Dr. P. Gopinath
Asst Professor in Orthopaedics
Medical College Calicut

Addresses for Correspondence

Dr. P. Gopinath
Asst Professor in Orthopaedics
Medical College Calicut,
Kerala, India.
Phone: +91 495 2390014

JJ.Orthopaedics 2005;2(5)e1



Spinal surgeries were traditionally under taken in the prone position for a long time. But some authors used operate the spine in lateral position. The prone position has the   many anesthetic surgical disadvantages difficult ventilation compression of he endotracheal tube  and the presence of many pressure points. Eye ball compression has been documented to result in vagal stimulation cardiac arrest and even blindness. A catastrophic complication like cardiac arrest during surgery is likely to fatal since resuscitation is often not possible in this position. Abdominal pressure is likely to result in profuse epidural bleeding and difficult ventilation. Lateral position during spinal surgeries has the no disadvantage as mentioned above but surgeon has to have adequate training to operate the spine in lateral position. The purpose of this review article is  to under stand the current concept regarding the ideal position to operate the spine with a review of author’s own experience.


Fourney DR et al(1) concluded from their study that they have performed done simultaneous anterior and posterior  approach with the patients in the lateral decubitus position. They further stated that the simultaneous anterior-posterior approach is a safe and feasible alternative for the exposure tumors of the thoracic and lumbar spine that involve both the anterior and posterior columns. Advantages of the approach include direct visualization of adjacent neurovascular structures, the ability to achieve complete resection of lesions involving all three columns simultaneously (optimizing hemostasis), and the ability to perform excellent dorsal and ventral stabilization in one operative session.

Dagher C et al (2)  inferred that Lumbar microdiscectomy surgery is already performed under spinal anesthesia (SA) in many institution. Following light sedation, SA is performed with the patient in the left lateral decubitus position, one to two levels above the herniated disc level. Isobaric 0.5% bupivacaine 3-3.5 ml was injected intrathecally followed by wound infiltration with 15 ml of bupivacaine with 1/200 000 epinephrine prior to surgical incision.

Cybulski GR et al(3) used a modified lateral decubitus position with the scapula falling away from the side of exposure was used for T1-5 segment lesions, and a prone position was used for the (T-6)-(T-12) segment. Adequate decompression of the spinal canal was achieved in all cases. All patients who were ambulating preoperatively maintained ambulatory ability, and pain and/or further neurological improvement as well occurred in 75%.

 Baulot E et al (4) performed thoracoscopy  in the lateral decubitus position. The patient was prepared in the standard manner for a full thoracotomy. Surgical instruments that are needed for conversion to an open procedure must be in the operative room in the same position. Ventilation was stopped to the ipsilateral lung.

Sukegawa I et al (5)reported two cases of the rhabdomyolysis of the erector spine muscles occurring after nephrectomy in lateral flexed decubitus position.  A 39-year-old man (170-cm, 85-kg) underwent right nephrectomy for a right renal tumor. The patient was placed in a left flexed lateral decubitus position with a roll placed under the dependent iliac crest and upper half of the body was rotated backward for 6 h. . Direct, prolonged pressure on the paravertebral muscle was the etiology of rhabdomyolysis in their cases. Although their cases were not severe and the complications were not induced, it must be kept in mind that excessive pressure in a limited area can damage the muscle during prolonged surgery

Wawro  et al(6)concluded from their study that the correction of posttraumatic kyphosis in the thoracolumbar region almost always requires a combined anterior and posterior approach because of the particular anatomic situation and the pathomorphologic changes. We suggest that the patient be placed in a right lateral decubitus position. This allows dual access to the spine by a posterior midline approach and a retroperitoneal thoracolumbar approach, so that simultaneous anterior and posterior manipulation, correction and stabilization of the spine are possible with no need to turn the patient intraoperatively

Gonzalez Della Valle A et al(7)inferred from their study that the lateral decubitus position can cause dependent shoulder discomfort or result in traction on the brachial plexus. They measured pressure beneath the dependent shoulder and lateral angulation of the cervical spine in patients positioned in the lateral decubitus position for total hip replacement under epidural anesthesia. Inflatable pillows (Shoulder-Float) beneath the chest wall and head reduced pressure beneath the dependent shoulder from 66 to 12 mm Hg (P < 0.001) and lateral angulation of the cervical spine from 14 degrees to 4 degrees (P < 0.001). In a randomized crossover study of a further 15 patients, the use of inflatable pillows resulted in significantly less pressure beneath the dependent shoulder and chest wall than either a gel-pad or a 1000-mL lactated Ringer's bag. Inflatable pillows placed beneath the chest wall and head in the lateral decubitus position provided lower pressure beneath the dependent shoulder than other support devices and facilitated alignment of the cervical spine.  When patients lie on their side, this results in pressure beneath the shoulder and tilting of the head and neck to one side. These problems were effectively corrected with an inflatable pillow (Shoulder-Float).

Sato K etal(8)concluded that hypotension after positioning is sometimes seen especially in patients with cervical spinal lesion operated on under prone position. Patients with spinal lesion and those with brain lesion are compared in the frequency of hypotension after positioning to prone. Sixty-one cases operated on with prone position were studied. Ages ranged from 40 to 82 (mean 61) years and ASA grade was 1 or 2 in each case. Cervical laminoplasty (group C) or craniotomy (group B) are performed in 40 and 21 patients, respectively. Ephedrine was administrated when the systolic blood pressure decreased under 80 mmHg and the frequency of ephedrine use was compared. There were no differences in age and sex distribution between group C and B. The induction doses of propofol and fentanyl in group B were larger than those of group C, but ephedrine use in group C was more frequent than in group B. In T2-weighted image of the cervical cord, high signal intensity areas were depicted in cases with hypotension. The sympathetic flow descends in the medial part in the lateral funiculus. Damage of this pathway would cause autonomic dysfunction in patients with cervical spinal lesion and strict monitoring is necessary during positioning to prone

Papin P et al (9)inferred that  thoracoscopic release and fusion of the discs space followed in the same time by a posterior instrumentation and fusion is a good option. Six cases were done in the prone position, two in the lateral decubitus with shorter surgical time.

Chang SH et al(10) studied  the incidence of perioperative ischemic optic neuropathy (POION) in spine surgery at our institution. .  POION is a rare but potentially devastating and untreatable complication of spine surgery, particularly that performed with the patient in the prone position. Anemia, hypotension, long duration of surgery, and significant intraoperative hydration may all be risk factors for this condition. All patients undergoing spine surgery should be informed about the low but definite risk of this condition, and every attempt should be made during surgery to maintain stable hemoglobin and mean arterial pressure and to avoid overhydration. 

Sucato DJ  et al(11)  concluded that the results and complications of patients undergoing a thoracoscopic anterior release and fusion comparing those performed prone with those in the lateral position. A thoracoscopic anterior spinal release and fusion in the prone position appears to achieve the same results as when performed in the lateral position for pediatric spinal deformity.

The authors own(12,13,14) experience is to perform operations like  anterior instrumentation, posterior instrumentation, disectomy, anterior and posterior scoliosis correction , spondylolisthsis  reduction in the lateral position with definite advantage to patient, anaethesiologist ,surgeon and other OT personnel  with the best possible out come


Traditionally spine surgeries were under taken in prone position which could be knee chest, kneeling, jack knife position etc. This additional gadgets like frames bolsters etc. This position has been has been accepted out of  familiarity, training and experience. The problems faced by the surgeons including bleeding from excessive abdominal pressure resulting in epidural venous engorgement. Other disadvantages including static position during surgery and alteration position is almost impossible ,combined anterior and posterior exposure not possible, maneuvering equipments like C-Arm image intensifier and operating microscope is diificult and strain on the surgeon.

The disadvantages to anaesthesiologists include the universal need for GA and catastrophic complications like cardio respiratory is almost impossible to manage.

The other OT personnel are at disadvantage because combined ant and posterior approach needs frequent change of position. The disadvantage to the patients include increased stress in small areas, cervical spine injury during position and high risk for elderly and obese patients.  Many current articles support position of the patient in the lateral position with no disadvantages mentioned above.   The patient can be positioned for combined anterior and posterior approach of the spine in lateral position.  There is no bleeding, because there is less pressure occurring in the anterior abdominal wall and reduced venous engorgement.  Anaesthetic risk is reduced in lateral position.  Patient can be positioned into Kyphosis and Lordosis by just altering the hip and knee positions. 

The authors own experience supports lateral decubitus position in all types of spinal surgeries with great advantage to the surgeon, anaesthesiologist, assistant, other OT personals and the patient.           


  1. Fourney DR, Abi-Said D, Rhines LD, Walsh GL, Lang FF, McCutcheon IE, Gokaslan ZL. Simultaneous anterior-posterior approach to the thoracic and lumbar spine for the radical resection of tumors followed by reconstruction and stabilization, J Neurosurg. 2001 Apr;94(2 Suppl):232-44.
  2. Dagher C, Naccache N, Narchi P, Hage P, Antakly MC. Regional anesthesia for lumbar microdiscectomy: J Med Liban. 2002 Sep-Dec;50(5-6):206-10.
  3. Cybulski GR, Stone JL, Opesanmi O. Spinal cord decompression via a modified costotransversectomy approach combined with posterior instrumentation for management of metastatic neoplasms of the thoracic spine. : Surg Neurol. 1991 Apr;35(4):280-5
  4. Baulot E, Trouilloud P, Ragois P, Giroux EA, Grammont PM. Anterior spinal fusion by thoracoscopy. A non-traumatic technique: Rev Chir Orthop Reparatrice Appar Mot. 1997;83(3):203-9.
  5. Sukegawa I, Miyabe M, Fujii T, Hoshi T, Takahashi S, Toyooka H Rhabdomyolysis after nephrectomy in the lateral flexed decubitus position: Masui. 2003 Aug;52(8):882-5.
  6. Wawro W, Boos N, Aebi M. Technique of surgical correction of post-traumatic kyphosis Unfallchirurg. 1992 Jan;95(1):41-6.
  7. Gonzalez Della Valle A, Salonia-Ruzo P, Peterson MG, Salvati EA, Sharrock NE.
    Inflatable pillows as axillary support devices during surgery performed in the lateral decubitus position under epidural anesthesia. Anesth Analg. 2001 Nov;93(5):1338-43
  8. Sato K, Kato M Hypotension after turning to the prone position Masui. 2003 Jan;52(1):46-8.
  9. Papin P, Arlet V, Marchesi D, Laberge JM, Aebi M Treatment of scoliosis in the adolescent by anterior release and vertebral arthrodesis under thoracoscopy. Preliminary results Rev Chir Orthop Reparatrice Appar Mot. 1998 May;84(3):231-8.
  10. Chang SH, Miller NR. The incidence of vision loss due to perioperative ischemic optic neuropathy associated with spine surgery: the Johns Hopkins Hospital Experience. Spine. 2005 Jun 1;30(11):1299-302
  11. Sucato DJ, Elerson E A comparison between the prone and lateral position for performing a thoracoscopic anterior release and fusion for pediatric spinal deformity. Spine. 2003 Sep 15;28(18):2176-80.
  12. Dr.P.Gopinathan et al : Lumbar Segmental Instability Treated by Expandable Spinal Spacer in PLIF, J.Orthopaedics 2004; 1(3)e4
  13. Dr.P.Gopinathan et al: Jacking up the spine – A better way of treating lumbar spine instability, J. Orthopaedics 2005; 2(1)e3.

  14. Dr.P.Gopinathan  et al  lateral  position the gold standard position in spinal surgeries JCOA: Vol3, No.2 page 34- 39


 This is a peer reviewed paper 

Please cite as :P Gopinath: Lateral Decubitus Position in Spinal Surgery - Current Concepts

J.Orthopaedics 2005;2(6)e1






Arthrocon 2011

Refresher Course in Hip Arthroplasty

13th March,  2011

At Malabar Palace,
Calicut, Kerala, India

Download Registration Form

For Details
Dr Anwar Marthya,
Ph:+91 9961303044



Powered by



© Copyright of articles belongs to the respective authors unless otherwise specified.Verbatim copying, redistribution and storage of this article permitted provided no restrictions are imposed on the access and a hyperlink to the original article in Journal of Orthopaedics maintained. All opinion stated are exclusively that of the author(s).
Journal of Orthopaedics upholds the policy of Open Access to Scientific literature.