Introduction: The sitting cervical position affords advantages over prone positioning for elective posterior cervical decompression and fusion. A potential disadvantage is the risk for venous air embolism.

Methods: We retrospectively identified all adult elective posterior cervical surgeries at our institution between 2009 and January of 2014. Using ICD-9 coding, we searched for incidences of air embolism, myocardial infarction, pulmonary embolism, and deep vein thrombosis. Operative time, estimated blood loss, and case type distribution were also recorded. Surgeries for trauma, tumor, or which involved occipital-cervical junction were excluded.

Results: Between 2009 and January of 2014, 560 surgeries were performed in the sitting cervical position and 20 in the prone position. No venous air embolisms were reported for either group. The average surgical time was 1 hour 46 minutes for prone positioned patients and 1 hour 25 minutes for surgeries in the sitting position (p=0.003). 30-day perioperative complications among the sitting position patients included 2 myocardial infarctions, 1 pulmonary embolism attributed to venous thrombosis, and 2 other patients with deep venous thromboses, for a total cardiovascular complication rate of 0.9%.

Conclusions: Our study adds to the literature supporting the safety of the sitting cervical position. The sitting position is preferred by many surgeons at our institution. It provides a dry surgical field, easily verified spinal alignment prior to fusion, and superior visualization on intraoperative x-rays due to reduced shoulder artifact. Furthermore, our data suggest that operative times may be shorter. While the risk of venous air embolism exists, clinically significant occurrences are extremely rare. Given our large volume of surgeries in the sitting position, we believe the advantages outweigh the risks.

Patient Care: The sitting cervical position helps reduce intraoperative blood loss, improves visualization of landmarks, reduces shoulder artifact on intraoperative x-ray, and allows better confirmation of straight positioning prior to spinal fusion. Despite recent concern, particularly among Anesthesiologists, our study demonstrates that the risk of clinically significant venous air embolism is exceedingly low for elective spinal surgery in the sitting position and should not prevent surgeons from taking advantage of the many benefits of the sitting cervical position.

Learning Objectives: By the conclusion of this session, participants should be able to: 1) Describe the advantages of the sitting cervical position, 2) Discuss, in small groups, the rare potential risk of venous air embolism, 3) Identify effective positioning techniques to help further reduce the risk of clinically significant air embolism in the sitting cervical position.

References: 1. Gan C, King JA, Maartens NF. The role and safety of the sitting position in instrumented cervical surgery. J Clin Neurosci. Mar 2016;25:75-78. 2. Porter JM, Pidgeon C, Cunningham AJ. The sitting position in neurosurgery: a critical appraisal. British journal of anaesthesia. Jan 1999;82(1):117-128.