Positioning issues of spinal surgery during pregnancy

Background: Albeit rarely, different spinal pathologies may require surgical treatment during pregnancy. The management of such cases poses a series of challenges, starting with adequate body positioning. Objective: To illustrate limits and indications of the different surgical positioning strategies for pregnant women undergoing spine surgery. Methods: We performed a systematic review of literature about the described surgical positioning strategies used for spinal surgery during pregnancy, discussing advantages, indications, and limits. We also describe of a novel three-quarters prone positioning for dorsal pathology. Results: The surgical strategy may vary according to several factors, such as the location and the nature of the underlying pathology, the stage of the pregnancy, and the clinical condition of mother and fetus. During the second trimester, the habitus begins to raise issues about both the abdominal and the aortocaval compressions. The third trimester implies neonatal and ethical challenges: both fetal monitoring and the possibility of urgently proceeding to delivery should be guaranteed. The prone position is feasible during the second trimester provided an adequate frame is supplied. The lateral or three-quarters prone positioning may offer the safest option in the last stages of pregnancy, whereas both supine and sitting positionings are anecdotal. Conclusions: Gestational age, surgical comfort and maternofetal safety should be balanced by a multidisciplinary team to tailor an adequate positioning plan for each individual case. The early third trimester is the more limiting period because of the womb hindrance favoring lateral or three-quarters positionings.