The Effect of Intraoperative Prone Position on Psoas Morphology and Great Vessel Anatomy: Consequences for Prone Lateral Approach to the Lumbar Spine

This study sought to quantify radiographic differences in psoas morphology, great vessel anatomy, and lumbar lordosis between supine and prone intraoperative positioning to optimize surgical planning and minimize the risk of neurovascular injury. Measurements on supine magnetic resonance imaging and prone intraoperative computed tomography with O-arm from L2 to L5 levels included the anteroposterior and mediolateral proximity of the psoas, aorta, inferior vena cava (IVC), and anterior iliac vessels to the vertebral body. Psoas transverse and longitudinal diameters, psoas cross-sectional area, total lumbar lordosis, and segmental lordosis were assessed. Prone position produced significant psoas lateralization, especially at more caudal levels (P < 0.001). The psoas drifted slightly anteriorly when prone, which was non-significant, but the magnitude of anterior translation significantly decreased at more caudal segments (P = 0.038) and was lowest at L5 where in fact posterior retraction was observed (P = 0.032). When prone, the IVC (P < 0.001) and right iliac vein (P = 0.005) migrated significantly anteriorly, however decreased anterior displacement was seen at more caudal levels (P < 0.001). Additionally, the IVC drifted significantly laterally at L5 (P = 0.009). Mean segmental lordosis significantly increased when prone (P < 0.001). Relative to the vertebral body, the psoas demonstrated substantial lateral mobility when prone, and posterior retraction specifically at L5. IVC and right iliac vein experienced significant anterior mobility—particularly at more cephalad levels. Prone position enhanced segmental lordosis and may be critical to optimizing sagittal restoration.