Patient Positioning for Craniotomy: Supine, Park-Bench, Prone and Sitting Set-Ups

Principles that apply to every surgery position

Whatever the position, the aims are the same: expose the target, keep the neck neutral and venous outflow free, protect the eyes, airway and bony prominences, and keep the head above heart level where the case allows, to help venous drainage and reduce brain swelling. Positioning for surgery is a team task with agreed roles for the surgeon, anaesthetist and nurses.

Confirm the table, its limits and all accessories before the patient arrives. Check that the head holder base fits the table side rails, that locks are tight, and that cables and lines have enough length for planned table movements.

Supine and lateral: the park bench position

Supine, with the head turned or tilted, is the workhorse for frontal, temporal and many parietal approaches. A shoulder roll helps avoid excessive neck rotation. For posterior fossa, occipital and some temporal cases the park bench position is used: the patient lies lateral with the upper shoulder tilted forward and the head fixed in the planned rotation, supported by padding for the arm, hip and chest.

The DORO systems support supine, prone, lateral and sitting positions. The DORO QR3 clamp fits every head size and its extra height leaves room for intubation, even in prone position. For a park bench set-up, check that the clamp and base do not press on the neck or shoulder and that the rotation of the head is within the patient's comfortable range.

Prone positioning

Prone is used for posterior fossa and occipital approaches. The head is fixed either with a clamp and pins or on a horseshoe support, and the chest and pelvis are supported to allow the abdomen to move freely. Pay particular attention to the face, eyes, nose and ears, and ensure the endotracheal tube is secure and accessible.

A non-invasive DORO Horseshoes headrest on shape-taking gel pads may be chosen when pins are not wanted, with attention to pressure on the face. For the benefits of that approach see the horseshoe headrest guide.

After the final position is set, take a moment to confirm that the table movements planned during the case, such as tilt or reverse Trendelenburg, will not stress the head holder or the patient, and that lines have enough slack.

Sitting position in neurosurgery

The sitting position neurosurgery teams use for some posterior fossa and cervical approaches gives gravity-assisted drainage of blood and cerebrospinal fluid, but it carries specific risks: venous air embolism, haemodynamic instability and pressure on the sciatic nerve and heels. It requires an experienced team, monitoring protocols agreed in advance and a clamp rated for the load.

The head must be rigidly fixed, with the clamp on a table or chair designed for the position. The DORO Multi-Purpose Skull Clamp offers pin and non-invasive options, adult and paediatric pin holders and an optional 90 N torque screw for finer pin-force control, and links with the Quick-Rail for retractors.

• Supine: shoulder roll, neutral neck, eyes protected
• Park bench: pad arm, axilla and hip; avoid neck rotation beyond tolerance
• Prone: free abdomen, accessible airway, check face pressure
• Sitting: air embolism plan, lower-limb support, secure fixation

A short set-up checklist

Before draping: confirm head fixation is tight and the table locked, eyes protected, airway secure, pressure points padded, lines unobstructed and the clamp, base and swivel adaptor locked. After any table movement, check them again. For the pin step see Mayfield head holder pin placement.

Beckfinity supplies DORO head fixation and can advise on a combination for your table and case mix. Contact us for a consultation.