Complications associated with prone surgical positioning during elective spine surgery have the potential to cause serious patient morbidity. Although many of these complications remain uncommon, the range of possible morbidities is wide and includes multiple organ systems. Perioperative visual loss (POVL) is a well described, but uncommon complication that may occur due to ischemia to the optic nerve, retina, or cerebral cortex. Closed-angle glaucoma and amaurosis have been reported as additional etiologies for vision loss following spinal surgery. Peripheral nerve injuries, such as those caused by prolonged traction to the brachial plexus, are more commonly encountered postoperative events. Myocutaneous complications including pressure ulcers and compartment syndrome may also occur after prone positioning, albeit rarely. Other uncommon positioning complications such as tongue swelling resulting in airway compromise, femoral artery ischemia, and avascular necrosis of the femoral head have also been reported. Many of these are well-understood and largely avoidable through thoughtful attention to detail. Other complications, such as POVL, remain incompletely understood and thus more difficult to predict or prevent. Here, the current literature on the complications of prone positioning for spine surgery is reviewed to increase awareness of the spectrum of potential complications and to inform spine surgeons of strategies to minimize the risk of prone patient morbidity. Core tip: This review addresses the complications of prone positioning for spine surgery, which is an important and relatively underrepresented topic in the literature. Here, we address the wide range of complications by system, covering the most common complications, current understanding of pathophysiology, and strategies for prevention. Individual cases of very rare complications are also addressed. This article provides increased awareness and understanding of the risks of prone positioning, which is important for patient morbidity.

The spinal surgeon's intraoperative radiation exposure may be unacceptable. Spinal surgeons should be considered classified workers and monitored accordingly. Methods to lower radiation dosage seem strongly indicated.

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The authors describe their experience in successfully treating an isolated Morel-Lavallée lesion of the lumbar spine after delayed presentation. In addition to thorough irrigation, debridement, and pseudo-capsulectomy, surgical management included transcutaneous transmyofascial bolstering with a progressive tension suturing technique to close the cavity over drains in a “quilting” fashion. This was followed by 6 days of incisional wound vacuum treatment and 13 days of drainage through 2 Jackson-Pratt drains. At 6-month follow-up, the patient noted resolution of pain and return to baseline level of functioning. No evidence of recurrence was noted. The Morel-Lavallée lesion of the low back represents a difficult soft tissue injury to treat with substantial risk of complications and recurrence. Diagnosing and treating physicians should be familiar with common injury mechanisms and clinical presentations, as well as a variety of nonoperative and operative treatment options. [ Orthopedics . 2019; 42(4):e399–e401.]