Montana Anesthesia Services

Patient Comfort During Surgery in Prone Position

Ensuring correct positioning of the patient is crucial for the safe and successful completion of a surgical procedure. Various factors, such as the access route, procedure duration, type of anesthesia, and equipment used, influence the ideal position. Common positions in the operating room include supine, prone, Trendelenburg, reverse Trendelenburg, and lateral decubitus among others. Surgery in the prone position has particular challenges for patient comfort.

Surgeons, anesthesiologists, and nurses in the operating room all play a role in establishing and maintaining the proper patient position. It often involves finding a balance between the optimal position for surgical access and the patient’s comfort. Whenever possible, the position should be one that the patient would find comfortable while fully awake. Patients should be asked about any limitations in their range of motion and their ability to lie comfortably in the expected position. In cases of uncertainty, it is advisable to position the patient as a trial before administering sedation or anesthesia. Positioning for surgery can lead to cardiovascular and pulmonary changes which may be exacerbated under anesthesia or during surgery.

The prone position is utilized in various procedures, including posterior spine surgeries, certain craniotomies, rectal and buttock procedures, superficial back surgeries, and procedures on the posterior extremities. Typically, patients are initially anesthetized while lying supine on a stretcher and then carefully positioned prone on the operating table after intubation. In some instances, patients may position themselves prone, often with their head turned to the side on a pillow. Having the patient position themselves may help with comfort during surgery while prone. This approach is commonly employed in procedures such as those involving the back or rectum under monitored anesthesia care, and spinal anesthesia for lumbar disk surgery.

Safety considerations with prone positioning include the risk of hemodynamic compromise and nerve injury. A key goal of prone positioning is to avoid pressure on the abdomen to minimize compression of the vena cava and abdominal contents. Abdominal compression can affect cardiovascular physiology, typically resulting in a reduction in cardiac index due to decreased venous return to the heart and reduced left ventricular compliance from increased intrathoracic pressure. In rare cases, prone positioning without proper abdominal support can lead to hypotension, possibly due to pooling in the splanchnic vasculature or kinking of the vena cava. Monitoring for patient tolerance, including nerve injuries, is essential, especially in the upper extremities, which can be placed at the sides or extended along the head on arm boards, with caution to avoid overextension to prevent neurovascular bundle compression in the axilla. Preoperative testing of the patient’s shoulder joint range of motion is recommended to determine the safe degree of extension.

Several measures can be taken to minimize the risks associated with surgery in the prone position and improve patient comfort. The head can be supported using a foam or gel headrest or held in place with skull pins using the Mayfield apparatus. Torso support can be provided by a surgical frame, chest rolls, or pillows. Arms can be positioned with the shoulders and elbows flexed and the hands up or tucked at the patient’s side, while the hips and knees should be flexed, with the lower leg supported to prevent pressure on the toes. Additionally, firm rolls or bolsters can be placed laterally from the clavicle to the iliac crests to minimize pressure on the abdomen and thorax. The neck should be positioned neutrally, without excessive flexion or extension, with adjustments made to the torso or head support as needed. Special pillows with cutouts for the eyes, nose, and mouth can be used, avoiding the horseshoe headrest due to the risk of central retinal artery occlusion.

The prone position is commonly utilized for surgery but comes with safety and comfort considerations that the anesthesia team should be aware of. Techniques and adjustments can be made to mitigate potential disadvantages of the position.


Welch MB, Brummett CM, Welch TD, Tremper KK, Shanks AM, Guglani P, Mashour GA. Perioperative peripheral nerve injuries: a retrospective study of 380,680 cases during a 10-year period at a single institution. Anesthesiology. 2009 Sep;111(3):490-7. doi: 10.1097/ALN.0b013e3181af61cb. PMID: 19672188.

Chui J, Murkin JM, Posner KL, Domino KB. Perioperative Peripheral Nerve Injury After General Anesthesia: A Qualitative Systematic Review. Anesth Analg. 2018 Jul;127(1):134-143. doi: 10.1213/ANE.0000000000003420. PMID: 29787414.

Kutteruf R, Wells D, Stephens L, Posner KL, Lee LA, Domino KB. Injury and Liability Associated With Spine Surgery. J Neurosurg Anesthesiol. 2018 Apr;30(2):156-162. doi: 10.1097/ANA.0000000000000448. PMID: 28763433.

Warner MA, Warner DO, Matsumoto JY, Harper CM, Schroeder DR, Maxson PM. Ulnar neuropathy in surgical patients. Anesthesiology. 1999 Jan;90(1):54-9. doi: 10.1097/00000542-199901000-00009. PMID: 9915312.

Choi S, Kim YJ, Oh H, Yuh WT, Lee CH, Yang SH, Kim CH, Chung CK, Park HP. Factors Associated With Perioperative Hospital Acquired Pressure Injury in Patients Undergoing Spine Surgery in the Prone Position: A Prospective Observational Study. J Neurosurg Anesthesiol. 2024 Jan 1;36(1):45-52. doi: 10.1097/ANA.0000000000000867. Epub 2022 Aug 25. PMID: 36006663.

Nam Y, Yoon AM, Kim YH, Yoon SH. The effect on respiratory mechanics when using a Jackson surgical table in the prone position during spinal surgery. Korean J Anesthesiol. 2010 Nov;59(5):323-8. doi: 10.4097/kjae.2010.59.5.323. Epub 2010 Nov 25. PMID: 21179294; PMCID: PMC2998652.

Park JH, Kwon JY, Lee SE, Kim YH, Kim SH. Sudden hemodynamic collapse after prone positioning on a Jackson spinal table for spinal surgery. Korean J Anesthesiol. 2020 Feb;73(1):71-74. doi: 10.4097/kja.d.18.00339. Epub 2018 Dec 28. PMID: 30590915; PMCID: PMC7000273.