Chin-to-chest surgical positioning linked to rare but serious spinal cord injuries

A surgical maneuver designed to protect the spinal cord may, in rare cases, be the very thing that damages it. Chin-to-chest positioning, in which the head is held in pronounced flexion so the chin rests against the sternum, is widely used to stabilize the cervical spine and airway during operations, most famously after tracheal resection. A new scoping review published in Discover Medicine on 17 October 2026 has now pulled together the scattered literature on this practice and its neurological consequences, and the picture that emerges is one of sparse but sobering evidence: case reports describing cervical myelopathy, spastic quadriparesis, motor complete tetraplegia, paraplegia, hyperreflexia, acute dystonia, anisocoria, dural displacement, cervical cord flattening and spinal cord edema, all associated with prolonged or extreme cervical flexion.

The review, led by Jinpyo Hong with colleagues including Ammar Abed, Jayant Bhasin, David Millar, Oliver Mrowczynski and Elias Rizk, set out to fill a gap that the authors say has persisted despite decades of surgical use of the position. Although chin-to-chest positioning is a routine part of post-operative care after tracheal resection, where it reduces tension on the surgical site, no comprehensive effort had previously been made to systematically synthesize and categorize the available data on chin-to-chest deformity and extreme cervical flexion. The team searched Scopus and PubMed on November 4, 2024, using the terms “chin to chest” OR “flexion positioning”, which yielded 64 and 50 results respectively. After screening against predefined eligibility criteria, nine independent articles were included, all of which concerned spinal cord-related outcomes rather than brain outcomes.

The composition of that evidence base is itself a finding. Seven of the nine studies were case reports, and only one had been published in the last three years; the oldest dated from 2010. The authors did not perform a formal risk-of-bias assessment with a single standardized tool, reasoning that with mostly case reports and descriptive observational studies, such an exercise would add little, and instead considered study design, sample size and reported outcomes during synthesis. Notably, the included studies did not provide a consensus on how to prevent the undesirable neurological outcomes they described. The authors of the review acknowledge these constraints directly, noting that the review is inherently limited by the available literature and that the small proportion of recent publications, roughly 11 percent within the last three years, underscores the dearth of data.

What the case reports do show is a recurring and clinically troubling pattern. In the injuries associated with tracheal resection, where a chin-to-chest suture, often called a Grillo suture, is placed to prevent neck hyperextension and protect the anastomotic site from dehiscence, the immediate post-operative period was free of neurological findings in all seven reported cases. The deficits appeared only hours or days after surgery. They ranged from transient anisocoria, a mismatch in pupil size, to permanent quadriplegia. Imaging, including CT and MRI of the spine, was often negative for any mechanical or obstructive cause of spinal cord injury, although one patient whose MRI showed a small annular disc prolapse from C6-C7 developed permanent paraplegia below C5. In several patients, imaging did demonstrate signal changes or spinal cord edema consistent with acute infarction, but in one case only a follow-up MRI taken 19 days after the initial injury revealed signal abnormality from C4 to C7, while imaging at the time of injury had been negative.

One of the most striking cases in the literature involves an 18-year-old female who developed permanent quadriplegia following spinal cord infarction after a cricotracheal resection. A chin-to-chest suture was placed during the procedure to prevent hyperextension, yet despite maintaining a neutral position, severe spinal cord edema and subsequent quadriplegia occurred. The review’s authors point to such cases as evidence that chin-to-chest positioning can compromise blood flow to critical neural structures. Encouragingly, the reports also suggest that swift action matters: nearly all patients immediately had their chin-to-chest sutures removed, with improvement or resolution of symptoms in most patients. The review’s authors emphasize that these studies demonstrate the importance of continuous neurological examinations in the days and weeks following such procedures, precisely because the pathology so often fails to appear on early imaging.

The mechanism behind these injuries remains one of the central mysteries, and the review devotes considerable attention to it. The authors highlight work by Fehre and colleagues, who term such injuries “subacute cervical flexion myelopathy” and theorize a link with Hirayama disease, a lesser-known pathology. Hirayama disease, or monomelic amyotrophy, is a slowly progressive weakness and atrophy of the distal upper extremities seen primarily in young adult and adolescent males. Its cause is theorized to be excessive dural laxity, resulting in anterior displacement of the spinal cord during cervical flexion and microischemic episodes that disproportionately affect the vulnerable anterior horn cells. Supporting this picture, a case described by Sekioka and colleagues involved a 5-year-old boy who presented with anisocoria four days after tracheal resection; CT spine imaging demonstrated forward displacement of the posterior dura, flattening of the cervical cord, and fluid retention in the posterior epidural space, all of which improved two hours after the chin-to-chest suture was removed. The review’s authors suggest that neurologic injuries after cervical hyperflexion could be ischemic, as suggested by imaging findings of spinal cord edema, with patients predisposed to such cervical flexion myelopathies in a manner akin to patients who have Hirayama disease, and they call for future research into the relationship between the two conditions, their underlying mechanisms, and possible strategies to prevent or treat their sequelae.

Prevention strategies remain underexplored, but the review does surface some concrete proposals from the case literature. Kumar and colleagues described a 24-year-old man with progressive quadriparesis beginning 17 hours after tracheal resection and post-operative administration of fentanyl, with symptoms resolving completely upon release of the chin-to-chest suture and initiation of intravenous methylprednisolone. The authors theorized that the post-operative fentanyl induced drowsiness and droopiness of the head while the patient was in the sitting position, leading to cervical hyperflexion and compression of the anterior spinal artery, with imaging consistent with acute ischemic insult of the spinal cord. Their recommendations include placing a guardian roll, a small log of cotton wool, between the patient’s chin and sternum to prevent hyperflexion, keeping the patient in a semi-seated position between approximately 60 and 70 degrees rather than 90 degrees, and carefully using or avoiding sedative and analgesic medications entirely to prevent both drowsiness in the sitting position and delayed recognition of neurologic deficits.

Alternative methods of neck stabilization have also been examined. Aydinyan and colleagues performed a retrospective review of 20 pediatric patients at the University of Oklahoma from 2005 to 2016, comparing the efficacy of the Grillo suture, the Aspen cervical collar, and the Johnson cervical-thoracic-orthosis in preventing dehiscence at anastomotic sites after tracheal resection. The team found similar levels of effectiveness across all three methods and, most notably, identified that the Aspen collar led to mild neck hyperextension compared with the flexion produced by the Grillo suture and the Johnson CTO. The review’s authors argue that further study of alternative methods of neck stabilization after resection could lead to improved neurological outcomes. Beyond the tracheal surgery literature, the review also compiled case reports of chronic cervical flexion injuries, in which patients presented with slowly progressive neurologic deficits over months to years, caused by diverse conditions including postural disturbance secondary to schizophrenia, dropped head syndrome, acute dystonia secondary to haloperidol, neurofibromatosis type 1, and failed prior cervical spine fusion leading to significant kyphosis and vertebral displacement. All of those patients were treated with cervical spinal fusion with resolution of symptoms, which the authors suggest supports a causal link between the cervical flexion and the neurologic deficits.

Chin-to-chest positioning has also appeared in the neurosurgical setting itself. Suboccipital craniotomies were routinely performed in the upright sitting position in the past to improve exposure of the surgical site, but the approach slowly fell out of favor due to numerous associated risks, including venous air embolism, postural hypotension, and reports of neurologic deficits such as quadriplegia after surgery. Such procedures are still infrequently performed in the sitting position, however, and the danger of spinal cord injury or infarction remains present. The case reports in this domain consider the potential role of monitoring somatosensory evoked responses or potentials as an alert for intraoperative spinal cord injury, an area the review’s authors identify as needing further research. Taken together, the review concludes that cervical flexion approaches in intraoperative patient positioning have been associated with adverse neurological outcomes, with common offenders being chin-to-chest sutures in tracheal resection surgeries and sitting positions in neurosurgery, particularly those accessing the cervical spine or posterior fossa. The proposed mechanism of injury is stretch-induced microischemic episodes in the spinal cord. While fusion surgeries and prompt initiation of steroid therapy can lead to recovery of function, the proposed preventive measures include maintaining a neutral neck position to avoid cervical hyperflexion, close monitoring of patients during and after risky operations with somatosensory evoked responses and neurological examinations, and further exploration of alternate surgical approaches that avoid the risk of cervical flexion injuries. The authors are careful to note that the reported injuries raise concerns about the practice even though further investigation is needed to better characterize the associated risks, and that the evidence base, dominated by case reports, is far too thin to settle the questions it raises.

Subject of Research: Neurosurgical complications associated with chin-to-chest cervical flexion positioning

Article Title: Current evidence on the neurosurgical impact of chin to chest positioning

Article References: Hong, J., Abed, A., Bhasin, J., Millar, D., Mrowczynski, O., & Rizk, E. (2026). Current evidence on the neurosurgical impact of chin to chest positioning. Discover Medicine, 3(1), Article 160. https://doi.org/10.1007/s44337-026-00727-0

Image Credits: AI Generated

DOI: 10.1007/s44337-026-00727-0

Keywords: chin-to-chest positioning, cervical flexion, spinal cord injury, tracheal resection, Grillo suture, Hirayama disease, scoping review, cervical myelopathy, quadriplegia, spinal cord infarction, neurosurgery, case reports