Prone versus sitting position in pediatric low-grade posterior fossa tumors

  • Valentina BaroEmail author
  • Riccardo Lavezzo
  • Elisabetta Marton
  • Pierluigi Longatti
  • Andrea Landi
  • Luca Denaro
  • Domenico d’Avella
Original Article



The choice between sitting and prone position to access the infratentorial space in a suboccipital craniotomy is still a matter of debate. The comparisons in terms of complications and outcome of both positions are scarce, and the pediatric population is indeed more infrequent in these in scientific reviews. In this paper, we assess intraoperative and postoperative complications and neurological outcome in pediatric patients undergoing posterior cranial fossa surgery for pilocytic astrocytoma in sitting and prone position respectively.


We retrospectively analyzed 30 consecutive patients undergoing surgery for cerebellar pilocytic astrocytoma at the two neurosurgical units referring to the University of Padova Medical School from 1999 to 2017. Preoperative, intraoperative, and postoperative data were retrieved from our medical archives.


The statistical analysis did not show any differences between the two groups in terms of preoperative, intraoperative, and postoperative data. The neurological status at last follow-up was similar in both groups of patients.


Our results suggest that both sitting and prone position can be considered safe in suboccipital craniotomies. Further studies are needed to show if there are possible differences between these positions for other frequent pediatric tumors such as medulloblastomas and ependymomas.


Surgical positions Complications Outcome Pilocytic astrocytoma Children 



Pilocytic astrocytoma


Posterior fossa cerebral tumor


Venous air embolism


Pediatric intensive care unit


Patent foramen ovale


Transesophageal echocardiography


Prone position


Sitting position


Prone position group


Sitting position group


External ventricular drainage


Cerebrospinal fluid


Medical research council


Standard deviation


Compliance with ethical standards

Conflict of interest

The authors report no conflict of interest concerning the materials or methods used in this study or the findings disclosed in this paper.


  1. 1.
    Abdollahzadeh M, Hoffman HJ, Blazer SI, Becker LE, Humphreys RP, Drake JM, Rutka JT (1994) Benign cerebellar astrocytoma in childhood: experience at the Hospital for Sick Children 1980-1992. Childs Nerv Syst 10(6):380–383CrossRefGoogle Scholar
  2. 2.
    Albin MS, Carroll RG, Maroon JC (1978) Clinical considerations concerning detection of venous air embolism. Neurosurgery 3(3):380–384Google Scholar
  3. 3.
    Bithal PK, Pandia MP, Dash HH, Chouhan RS, Mohanty B, Padhy N (2004) Comparative incidence of venous air embolism and associated hypotension in adults and children operated for neurosurgery in the sitting position. Eur J Anaesthesiol 21(7):517–522CrossRefGoogle Scholar
  4. 4.
    Black S, Muzzi DA, Nishimura RA, Cucchiara RF (1990) Preoperative and intraoperative echocardiography to detect right-to-left shunt in patients undergoing neurosurgical procedures in the sitting position. Anesthesiology 72(3):436–438CrossRefGoogle Scholar
  5. 5.
    Black S, Ockert DB, Oliver WC Jr, Cucchiara RF (1988) Outcome following posterior fossa craniectomy in patients in the sitting or horizontal positions. Anesthesiology 69(1):49–56CrossRefGoogle Scholar
  6. 6.
    Cabezudo JM, Gilsanz F, Vaquero J, Areitio E, Martinez R (1981) Air embolism from wounds from a pin-type head-holder as a complication of posterior fossa surgery in the sitting position case report. J Neurosurg 55(1):147–148CrossRefGoogle Scholar
  7. 7.
    Cucchiara RF, Bowers B (1982) Air embolism in children undergoing suboccipital craniotomy. Anesthesiology 57(4):338–339CrossRefGoogle Scholar
  8. 8.
    Di Lorenzo N, Caruso R, Floris R, Guerrisi V, Bozzao L, Fortuna A (1986) Pneumocephalus and tension pneumocephalus after posterior fossa surgery in the sitting position: a prospective study. Acta Neurochir 83(3):112–115CrossRefGoogle Scholar
  9. 9.
    Dubey PK, Singh AK (2000) Venous oxygen embolism due to hydrogen peroxide irrigation during posterior fossa surgery. J Neurosurg Anesthesiol 12(1):54–56CrossRefGoogle Scholar
  10. 10.
    Edgcombe H, Carter YS (2008) Anaesthesia in the prone position. Br J Anaesth 100(2):165–183CrossRefGoogle Scholar
  11. 11.
    Elton RJ, Horwell RS (1994) The sitting position in neurosurgical anaesthesia: a survey of British practice in 1991. Br J Anaesth 73:247–248CrossRefGoogle Scholar
  12. 12.
    Ganslandt O, Merkel A, Schmitt H, Tzabazis A, Buchfelder M, Eyupoglu I, Muenster T (2013) The sitting position in neurosurgery: indications, complications and results. A single institution experience of 600 cases. Acta Neurochir 155(10):1887–1893CrossRefGoogle Scholar
  13. 13.
    Gelabert-González M, Fernández-Villa J (2001) Mutism after posterior fossa surgery. Review of the literature. Clin Neurol Neurosurg 103(2):111–114CrossRefGoogle Scholar
  14. 14.
    Gildenberg PL, O ‘Brien RP, Britt WJ, Frost EAM (1981) The efficacy of Doppler monitoring for the detection of venous air embolism. J Neurosurg 54(1):75–78CrossRefGoogle Scholar
  15. 15.
    Günther F, Frank P, Nakamura M, Hermann EJ, Palmaers T (2017) Venous air embolism in the sitting position in cranial neurosurgery: incidence and severity according to the used monitoring. Acta Neurochir 159(2):339–346CrossRefGoogle Scholar
  16. 16.
    Harrison EA, Mackersie A, McEwan A, Facer E (2002) The sitting position for neurosurgery in children: a review of 16 years’ experience. Br J Anaesth 88(1):12–17CrossRefGoogle Scholar
  17. 17.
    Himes BT, Mallory GW, Abcejo AS, Pasternak J, Atkinson JLD, Meyer FB, Marsh WR, Link MJ, Clarke MJ, Perkins W, Van Gompel JJ (2017) Contemporary analysis of the intraoperative and perioperative complications of neurosurgical procedures performed in the sitting position. J Neurosurg 127(1):182–188CrossRefGoogle Scholar
  18. 18.
    Hunt K, Bajekal R, Calder I, Meacher R, Eliahoo J, Acheson JF (2004) Changes in intraocular pressure in anesthetized prone patients. J Neurosurg Anesthesiol 16(4):287–290CrossRefGoogle Scholar
  19. 19.
    Kelleher A, Mackersie A (1995) Cardiac arrest and resuscitation of a 6-month old achondroplastic baby undergoing neurosurgery in the prone position. Anaesthesia 50(4):348–350CrossRefGoogle Scholar
  20. 20.
    Lee S, Lui T, Chang C, Cheng W (1990) Early postoperative seizures after posterior fossa surgery. J Neurosurg 73(4):541–544CrossRefGoogle Scholar
  21. 21.
    Longatti P, Marton E, Feletti A, Falzarano M, Canova G, Sorbara C (2015) Carbon dioxide field flooding reduces the hemodynamic effects of venous air embolism occurring in the sitting position. Child Nerv Syst 31(8):1321–1326CrossRefGoogle Scholar
  22. 22.
    Luostarinen T, Lindroos A, Nilya T, Silvasti-Lundell M, Schramjo A, Hernesniemi J, Randell T, Niemi T (2017) Prone versus sitting position in neurosurgery—differences in patients’ hemodynamic management. World Neurosurg 97:261–266CrossRefGoogle Scholar
  23. 23.
    Maduri R, Daniel RT, Diezi M, Cotting J, Messerer M (2017) Paraplegia after posterior fossa surgery in prone position: can we prevent it? Child Nerv Syst 33(1):25–26CrossRefGoogle Scholar
  24. 24.
    Martínez-Lage JF, Almagro MJ, Izura V, Serrano C, Ruiz-Espejo A, Sánchez-del-Rincón I (2009) Cervical spinal cord infarction after posterior fossa surgery: a case-based update. Child Nerv Syst 25(12):1541–1546CrossRefGoogle Scholar
  25. 25.
    Matjasko J, Petrozza P, Cohen M, Steinberg P (1985) Anesthesia and surgery in the seated position: analysis of 554 cases. Neurosurg 17(5):695–672CrossRefGoogle Scholar
  26. 26.
    Meridy HW, Creighton RE, Humphreys R (1974) Complications during neurosurgery in the prone position in children. Can Anaesth Soc J 21(5):445–453CrossRefGoogle Scholar
  27. 27.
    Michenfelder JD, Miller RH, Gronert GA (1972) Evaluation of an ultrasonic device (Doppler) for the diagnosis of venous air embolism. Anestesiology 36(2):164–167CrossRefGoogle Scholar
  28. 28.
    Morandi X, Riffaud L, Amlashi SF, Brassier G (2004) Extensive spinal cord infarction after posterior fossa surgery in the sitting position: case report. Neurosurg 54(6):1515–1516CrossRefGoogle Scholar
  29. 29.
    Olympio M, Bell WO (1994) Venous air embolism after craniotomy closure: tension pneumocephalus implicated. J Neurosurg Anesthesiol 6(1):35–39CrossRefGoogle Scholar
  30. 30.
    Orliaguet GA, Hanafi M, Meyer PG, Blanot S, Jarreau MM, Bresson D, Carli PA (2001) Is the sitting or the prone position best for surgery for posterior fossa tumours in children? Paediatr Anaesth 11(5):541–547CrossRefGoogle Scholar
  31. 31.
    Pandit UA, Mudge BJ, Keller TS, Samra SK, Kilaru P, Pandit SK, Cohen PJ (1982) Pneumocephalus after posterior fossa exploration in the sitting position. Anaesth 37(10):996–1001CrossRefGoogle Scholar
  32. 32.
    Padopoulos G, Kuhly P, Brock M, Rudolph KH, Link J, Eyrich K (1994) Venous and paradoxical air embolism in the sitting position. A prospective study with transoesophageal echocardiography. Acta Neurochir 126(2):140–143CrossRefGoogle Scholar
  33. 33.
    Pencalet P, Maixner W, Sainte-Rose C, Lellouch-Tubiana A, Cinalli G, Zerah M, Pierre-Kahn A, Hoppe-Hirsch E, Bourgeois M, Renier D (1999) Benign cerebellar astrocytomas in children. J Neurosurg 90(2):265–273CrossRefGoogle Scholar
  34. 34.
    Pollack IF (1994) Brain tumors in children. N Engl J Med 331(22):1500–1507CrossRefGoogle Scholar
  35. 35.
    Pollack IF, Polinko P, Albright AL, Towbin R, Fitz C (1995) Mutism and pseudobulbar symptoms after resection of posterior fossa tumors in children: incidence and pathophysiology. Neurosurg 37(5):885–893CrossRefGoogle Scholar
  36. 36.
    Porter JM, Pidgeon C, Cunningham AJ (1999) The sitting position in neurosurgery: a critical appraisal. Br J Anaesth 82(1):117–128CrossRefGoogle Scholar
  37. 37.
    Prabhu M, Samra S (2000) An unusual cause of rhabdomyolysis following surgery in the prone position. J Neurosurg Anesthesiol 12(4):359–363CrossRefGoogle Scholar
  38. 38.
    Ramsbacher J, Brock M, Kombos T (1997) Permanent postoperative anosmia: a hitherto undescribed complication following surgery of the posterior cranial fossa in the sitting position. Acta Neurochir 139(5):482–483CrossRefGoogle Scholar
  39. 39.
    Rath GP, Bithal PK, Chaturved A, Dash HH (2007) Complications related to positioning in posterior fossa craniectomy. J Clin Neurosci 14(6):520–525CrossRefGoogle Scholar
  40. 40.
    Rau C, Liang C, Lui C, Lee T, Lu K (2002) Quadriplegia in a patient who underwent posterior fossa surgery in the prone position. J Neurosurg 96(1):101–103Google Scholar
  41. 41.
    Shenkin HN, Goldfedder P (1969) Air embolism from exposure of posterior cranial fossa in prone position. JAMA 210(4):726CrossRefGoogle Scholar
  42. 42.
    Sinha A, Agarwal A, Gaur A, Pandey CK (2001) Oropharyngeal swelling and macroglossia after cervical spine surgery in the prone position. J Neurosurg Anesthesiol 13(3):237–239CrossRefGoogle Scholar
  43. 43.
    Standefer M, Bay JW, Trusso R (1984) The sitting position in neurosurgery: a retrospective analysis of 488 cases. Neurosurgery 14(6):649–658CrossRefGoogle Scholar
  44. 44.
    Ting CK, Tsou MY, Su NY, Chu CC, Lin SM, Lui PW, Lee TY (2001) Repeated attacks of venous air embolism during craniotomy--a case report. Acta Anaesthesiol Sin 39(1):41–45Google Scholar
  45. 45.
    Toung TJK, McPherson RW, Ahn H, Donham RT, Alano J, Long D (1986) Pneumocephalus: effects of patient position on the incidence and location of Aerocele after posterior Fossa and upper cervical cord surgery. Anesth Analg 65(1):65–70CrossRefGoogle Scholar
  46. 46.
    Van Mourik M, Catsman-Berrevoets CE, Yousef-Bak E, Paquier PF, Van Dongen HR (1998) Dysarthria in children with cerebellar or brainstem tumors. Pediatr Neurol 18(5):411–414CrossRefGoogle Scholar
  47. 47.
    Viano JC, Herrera EJ, Suárez JC (2001) Cerebellar astrocytomas: a 24-year experience. Child Nerv Syst 17(10):607–610CrossRefGoogle Scholar
  48. 48.
    Voorhies RM, Fraser RA, Van Poznak A (1983) Prevention of air embolism with positive end expiratory pressure. Neurosurg 12(5):503–506CrossRefGoogle Scholar
  49. 49.
    Wells EM, Walsh KS, Khademian ZP, Keating RF, Packer RJ (2008) The cerebellar mutism syndrome and its relation to cerebellar cognitive function and the cerebellar cognitive affective disorder. Dev Disabil Res Rev 14(3):221–228CrossRefGoogle Scholar
  50. 50.
    Young ML, Smith DS, Murtagh F, Vasquez A, Levitt J (1986) Comparison of surgical and anesthetic complications in neurosurgical patients experiencing venous air embolism in the sitting position. Neurosurg 18(2):157–161CrossRefGoogle Scholar

Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2019

Authors and Affiliations

  1. 1.Academic Neurosurgery, Department of NeurosciencesUniversity of Padova Medical SchoolPadovaItaly
  2. 2.Department of Neurosurgery, Treviso HospitalUniversity of Padova Medical SchoolTrevisoItaly

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