Vision loss after spine surgery: review of the literature and recommendations

Abstract

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.

Lumbar spine fusion surgery and stroke: a national cohort study

“…This information might be useful for spine surgeons and anesthesiologists. Although post-operative stroke rarely happens in lumbar spinal surgery, it is repeatedly reported with various kinds of manifestations including blindness, weakness, impaired cognitive function, or even death [6][7][8][21][22][23][24][25][26]. Patients with spinal diseases usually need to pass a series of cardiac and pulmonary evaluations before being considered as candidates for spinal surgery, especially if they are old or have risk factors for cerebrovascular or heart diseases.…”

Transient bilateral post-operative visual loss in spinal surgery

“…This is a unique case, in that most other reports on POVL show patients who do not improve after suffering this devastating complication [1,4,[11][12][13]. Our patient had transient POVL, which resolved completely within 48 h. ION occurs after an ischemic insult to the optic nerve and can be divided into anterior ischemic optic neuropathy (AION) and PION depending on the location of the lesion [14].…”

A Comparative Assessment of Intraocular Pressure in Prolonged Steep Trendelenburg Position Versus Level Supine Position Intervention

“…Baig and colleagues [8] projected a 0.2% incidence of POVL in spine procedures and .05% of all cases. Contributing medical conditions were hypertension (41%) and diabetes (16%).…”

“…Baig and colleagues [8] reviewed POVL caused by PION after spine surgery. They suggested that the posterior optic nerve may be susceptible to decreased perfusion caused by increased venous pressure.…”