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The Effect of Kneeling During Spine Surgery on Leg Intramuscular Pressure

¹ Department of Orthopaedic Surgery, University of California at San Diego Medical Center, 350 Dickinson Street, Suite 121, San Diego, CA 92103-8894. E-mail address for B.T. Leek: bleek{at}ucsd.edu

Investigation performed at the Department of Orthopaedic Surgery, University of California at San Diego Medical Center, San Diego, California

Disclosure: The authors did not receive any outside funding or grants in support of their research for or preparation of this work. Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the authors, or a member of their immediate families, are affiliated or associated.

Methods: Eight healthy volunteers were positioned in three spine surgery positions: the 90/90 kneeling position, the so-called 45/45 suspended position (with the hips and knees both flexed to 45° with the legs suspended on a sling), and the prone position. Intramuscular pressures were measured in all four left leg compartments with slit catheters. Local blood pressure and applied load beneath the leg were also measured.

Results: The 90/90 kneeling position was associated with significantly increased intramuscular pressure in the anterior compartment (30.8 ± 5.7 mm Hg) in comparison with the prone position (13.5 ± 1.7 mm Hg) and the 45/45 suspended position (13.8 ± 1.7 mm Hg). In the 90/90 kneeling position, these values correlated with subject weight (r = 0.72, p = 0.045) and the applied body weight load measured beneath the leg (r = 0.74, p = 0.037). The mean differences between intramuscular pressure and ankle blood pressure were more pronounced as the position of the ankle dropped below the level of the heart in the 45/45 suspended and the 90/90 kneeling positions.

Conclusions: The 90/90 kneeling position results in elevated intramuscular pressure in the anterior compartment of the leg. This elevated pressure correlates also with subject weight. The 90/90 kneeling position may predispose patients to the development of an acute compartment syndrome during prolonged spine surgery, with heavier patients being at increased risk. In certain instances, the surgeon may consider using the 45/45 suspended position to minimize this risk.

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