Effect of Lumbar Flexion on Prone Positioning of Patient for Endoscopic Lumbar Spine Surgery: Narrative Review
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Abstract
Endoscopic spine surgery offers significant advantages over conventional techniques, but its success depends on careful attention to many intraoperative factors, particularly patient positioning. This review highlights the importance of understanding spinal anatomy and common variations, as well as the biomechanical effects of the positioning during surgery. Lumbar flexion increases posterior disc height and intradiscal pressure, enhancing disc bulging and widening the interlaminar window, which facilitates safer and more effective discectomy and decompression. These changes, especially over 20-40 degrees of flexion, also increase foraminal dimensions and surgical access, particularly in lower lumbar levels or cases with foraminal stenosis. Regarding positioning for endoscopic lumbar surgery, preoperative imaging and anatomical assessment are crucial to guide the approach and positioning strategy. Lumbar flexion of approximately 40 degrees is recommended for discectomy and decompression, as it improves access and reduces bone resection in both interlaminar and transforaminal approaches. In certain cases, especially central or foraminal pathology, intraoperative repositioning may be necessary to ensure complete decompression and prevent recurrence. Optimal patient positioning in endoscopic lumbar surgery enhances surgical access, ensures safety, and minimizes tissue trauma.
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References
Barber SM, Nakhla J, Konakondla S, Fridley JS, Oyelese AA, Gokaslan ZL, et al. Outcomes of endoscopic discectomy compared with open microdiscectomy and tubular microdiscectomy for lumbar disc herniations: a meta-analysis. J Neurosurg Spine 2019;31(6):802-15. doi: 10.3171/2019.6.SPINE19532.
Muthu S, Ramakrishnan E, Chellamuthu G. Is endoscopic discectomy the next gold standard in the management of lumbar disc disease? Systematic review and superiority analysis. Global Spine J 2021;11(7):1104-20. doi: 10.1177/2192568220948814.
González-Murillo M, Castro-Toral J, Casal-Grau R, BonomeRoel C, Bonome-González C, de Mon-Montoliú JÁ. Technical considerations and avoiding complications in interlaminar endoscopic lumbar discectomy. J Minim Invasive Spine Surg Tech 2024;9 Suppl 2:S136-40. doi: 10.21182/jmisst.2024.01291.
Thijs D, Kashtiara A, Beldé S, Van de Kelft E. Surgical management of lower back pain: is optimizing spinopelvic alignment beneficial for patient outcomes? Life 2025;15(6):833. doi: 10.3390/life15060833.
Uchikado H, Nishimura Y, Hattori G, Ohara Y. Microanatomical structures of the lumbar intervertebral foramen for full-endoscopic spine surgery: review of the literatures. J Spine Surg 2020;6(2):405-14. doi: 10.21037/jss.2019.10.07.
Weinberg DS, Xie KK, Liu RW, Gebhart JJ, Gordon ZL. Increased pelvic incidence is associated with a more coronal facet orientation in the lower lumbar spine: a cadaveric study of 599 lumbar spines. Spine (Phila Pa 1976) 2016;41(19):E1138-45. doi: 10.1097/BRS.0000000000001577.
Patgaonkar P, Goyal V, Patel P, Dhole K, Ravi A, Patel V, et al. An algorithm for selection of full endoscopic approach for symptomatic nerve root decompression. N Am Spine Soc J 2023;15:100244. doi: 10.1016/j.xnsj.2023.100244.
Teo EC, Lee KK, Qiu TX, Ng HW, Yang K. The biomechanics of lumbar graded facetectomy under anterior-shear load. IEEE Trans Biomed Eng 2004;51(3):443-9. doi: 10.1109/TBME.2003.821009.
Lee KK, Teo EC, Qiu TX, Yang K. Effect of facetectomy on lumbar spinal stability under sagittal plane loadings. Spine (Phila Pa 1976) 2004;29(15):1624-31. doi: 10.1097/01.brs.0000132650.24437.15.
Liu Z, Duan Y, Rong X, Wang B, Chen H, Liu H. Variation of facet joint orientation and tropism in lumbar degenerative spondylolisthesis and disc herniation at L4-L5: a systematic review and meta-analysis. Clin Neurol Neurosurg 2017;161:41-7. doi: 10.1016/j.clineuro.2017.08.005.
Kaen A, Romero SR, Romero MJC, Durand F, Martin I. Three types of ligamentum flavum resections for the treatment of lumbar central canal stenosis: BUTTERFLY retrospective study. Asian Spine J 2025;19(2):176-82. doi: 10.31616/asj.2025.0014.
Hu W, Hu F, Liu C, Liu W, Jiang Y, Li J, et al. A comparison between retaining and resecting the posterior longitudinal ligament in percutaneous endoscopic transforaminal discectomy for disc herniation: a retrospective cohort study. Orthop Surg 2022;14(5):892-901. doi: 10.1111/os.13257.
Brouwers E, van de Meent H, Curt A, Starremans B, Hosman A, Bartels R. Definitions of traumatic conus medullaris and cauda equina syndrome: a systematic literature review. Spinal Cord 2017;55(10):886-90. doi: 10.1038/sc.2017.54.
Yuan SG, Wen YL, Zhang P, Li YK. Ligament, nerve, and blood vessel anatomy of the lateral zone of the lumbar intervertebral foramina. Int Orthop 2015;39(11):2135-41. doi: 10.1007/s00264-015-2831-6.
Min JH, Kang SH, Lee JB, Cho TH, Suh JG. Anatomic analysis of the transforaminal ligament in the lumbar intervertebral foramen. Neurosurgery 2005;57(1 Suppl):37-41. doi: 10.1227/01.neu.0000163481.58673.1a.
Kim HS, Kim JY, Wu PH, Jang I-T. Effect of dorsal root ganglion retraction in endoscopic lumbar decompressive surgery for foraminal pathology: a retrospective cohort study of interlaminar contralateral endoscopic lumbar foraminotomy and discectomy versus transforaminal endoscopic lumbar foraminotomy and discectomy. World Neurosurg 2021;148:e101-14. doi: 10.1016/j.wneu.2020.12.176.
Lewandrowski KU, Dowling Á, Calderaro AL, Dos Santos TS, Bergamaschi JPM, León JFR, et al. Dysethesia due to irritation of the dorsal root ganglion following lumbar transforaminal endoscopy: analysis of frequency and contributing factors. Clin Neurol Neurosurg 2020;197:106073. doi: 10.1016/j.clineuro.2020.106073.
Artico M, Carloia S, Piacentini M, Ferretti G, Dazzi M, Franchitto S, et al. Conjoined lumbosacral nerve roots: observations on three cases and review of the literature. Neurocirugia (Astur) 2006;17(1):54-9. doi: 10.1016/s1130-1473(06)70370-0.
Pamir MN, Ozek MM, Ozer AF, Keleş GE, Erzen C. Surgical considerations in patients with lumbar spinal root anomalies. Paraplegia 1992;30(5):370-5. doi: 10.1038/sc.1992.85.
Li Z, Gui G, Zhang Y, Zhou Y, Yang M, Chang Y, et al. Are facet joint parameters risk factors for recurrent lumbar disc herniation? A pilot study in a Chinese population. J Clin Neurosci 2020;77:36-40. doi: 10.1016/j.jocn.2020.05.048.
Kim HS, Paudel B, Jang JS, Oh SH, Lee S, Park JE, et al. Percutaneous full endoscopic bilateral lumbar decompression of spinal stenosis through uniportal-contralateral approach: techniques and preliminary results. World Neurosurg 2017;103:201-9. doi: 10.1016/j.wneu.2017.03.130.
Lee CK, Rauschning W, Glenn W. Lateral lumbar spinal canal stenosis: classification, pathologic anatomy and surgical decompression. Spine (Phila Pa 1976) 1988;13(3):313-20. doi: 10.1097/00007632-198803000-00015.
Lehrman JN, Mulholland CB, de Andrada Pereira B, Sawa AGU, Kelly BP, Tumialán LM. Dimensional characterization of the human lumbar interlaminar space as a guide for safe application of minimally invasive dilators. Oper Neurosurg 2021;21(2):E89-94. doi: 10.1093/ons/opab011.
Liebsch C, Wilke HJ. The intradiscal pressure of the lumbar spine is affected by intervertebral disc degeneration, age, level, and motion direction: evaluation of an in vitro database comprising 107 specimens. Spine J 2025;25(6):1276-87. doi: 10.1016/j.spinee.2025.01.024.
Fredericson M, Lee SU, Welsh J, Butts K, Norbash A, Carragee EJ. Changes in posterior disc bulging and intervertebral foraminal size associated with flexion-extension movement: a comparison between L4-5 and L5-S1 levels in normal subjects. Spine J 2001;1(1):10-7. doi: 10.1016/s1529-9430(01)00014-6.
Sayit E, Daubs MD, Aghdasi B, Montgomery SR, Inoue H, Wang CJ, et al. Dynamic changes of the ligamentum flavum in the cervical spine assessed with kinetic magnetic resonance imaging. Global Spine J 2013;3(2):69-74. doi: 10.1055/s-0033-1337121.
Ren Z, Liu A, Yang K, Wang D, Buser Z, Wang JC. Evaluation of changes in lumbar neuroforaminal dimensions in symptomatic young adults using positional MRI. Eur Spine J 2017;26(8):1999-2006. doi: 10.1007/s00586-017-4953-6.
Inufusa A, An HS, Lim TH, Hasegawa T, Haughton VM, Nowicki BH. Anatomic changes of the spinal canal and intervertebral foramen associated with flexion-extension movement. Spine (Phila Pa 1976) 1996;21(21):2412-20. doi: 10.1097/00007632-199611010-00002.
DePasse JM, Palumbo MA, Haque M, Eberson CP, Daniels AH. Complications associated with prone positioning in elective spinal surgery. World J Orthop 2015;6(3):351-9. doi: 10.5312/wjo.v6.i3.351.
Cunha PD, Barbosa TP, Correia G, Silva R, Cruz Oliveira N, Varanda P, et al. The ideal patient positioning in spine surgery: a preventive strategy. EFORT Open Rev 2023;8(2):63-72. doi: 10.1530/EOR-22-0135.
