HE focus of this review was to present the issue of vision loss associated with modern spinal surgery. Vision loss after spinal surgery is a unique complication of optic nerve damage resulting from ION, most often located in the posterior portion of the orbital optic nerve. This is surprising because the posterior area is rarely affected by ischemia. Such "posterior" lesions are designated PION. They have been uncommon until recently, mostly found in association with lumbar spinal surgery. We present the unique factors associated with lumbar surgeries and the patients undergoing them. Vision loss linked to ION and associated with lumbar surgery should be termed LION.Of the many different complications resulting from spinal surgery, POVL is an uncommon but devastating morbidity, with dire consequences. It is estimated that 1 case per 100 spine surgeons annually will have a significant vision complication after surgery.35 Recent studies have shown that spinal surgery is the leading cause of POVL, replacing cardiac surgery. 6,37,42 Postoperative vision loss has been the subject of investigation even before the era of modern spinal instrumentation and fusion techniques. 22,41Although the number of cases reported in the literature is on the rise, many questions remain regarding its origin, risk factors, pathophysiology, and prevention. We attempt to summarize the evidence in literature, highlight the limitations of existing knowledge, and recommend practical guidelines for avoiding this outcome. Summary of Literature Search MethodologyWe searched the National Library of Medicine's PubMed using key words, with subsequent review of the accompanying references and its citations. The key words included a combinations of the following: spine and postoperative visual loss, or spinal postoperative visual loss, spine and postoperative blindness, spine/spinal and posterior ischemic optic neuropathy, spine/spinal and retrobulbar optic neuropathy or spine/spinal and ischemic optic neuropathy. In our review we included articles dealing with visual complications after spinal surgery and excluded non-English language literature and duplicate results.Using these criteria, we identified 166 cases of perioperative vision loss in 21 reports (Table 1) (Fig. 1). 1,3,5,[8][9][10]13,14,17,[25][26][27][28][29][30][31][32][34][35][36]42 Neurosurg. In recent studies spinal surgery has replaced cardiac surgery as a leading cause of postoperative vision loss (POVL). Estimates of the incidence of POVL after spinal surgery range from 0.028 to 0.2%, but with advances in complex spinal instrumentation and the rise in annual spinal operations, POVL may see an ominous increase in its incidence. Postoperative vision loss is an uncommon but devastating complication, with unknown origin and pathogenesis. The authors undertook a literature review and summarize the current understanding of its pathophysiology, highlight the limitations of existing knowledge, and recommend practical guidelines for avoiding this devastating outcome.

With the aid of the endoscope and image guidance, it is possible to approach the ventral craniovertebral junction transorally with minimal tissue dissection, no palatal splitting, and no compromise of surgical freedom. In addition, the use of an angled-lens endoscope can significantly improve the exposure of the clivus without splitting the soft palate. An endoscope-assisted transoral approach is a direct and powerful tool for the treatment of surgical pathology at the craniovertebral junction.

✓In recent studies spinal surgery has replaced cardiac surgery as a leading cause of postoperative vision loss (POVL). Estimates of the incidence of POVL after spinal surgery range from 0.028 to 0.2%, but with advances in complex spinal instrumentation and the rise in annual spinal operations, POVL may see an ominous increase in its incidence. Postoperative vision loss is an uncommon but devastating complication, with unknown origin and pathogenesis. The authors undertook a literature review and summarize the current understanding of its pathophysiology, highlight the limitations of existing knowledge, and recommend practical guidelines for avoiding this devastating outcome.