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Cortical Blindness Following Spinal Surgery: Very Rare Cause of Perioperative Vision Loss

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  • All India Institute of Medical Sciences Bathinda

Abstract and Figures

A 38-year-old man was operated with posterior spinal decompression and pedicle screw instrumentation for his L2 fracture with incomplete neurological deficit. In the recovery, he complained of blindness in both eyes after twelve hours. Computed tomographic scan and magnetic resonance angiography revealed bilateral occipital lobe infarcts. He remained permanently blind even after three years follow-up. Though rare, perioperative vision loss is a potential complication following spine surgery in prone position. We report a rare occurrence of cortical blindness following lumbar spine surgery.
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POVL after Spine Surgery
/ 287
Asian Spine Journal Vol. 6, No. 4, pp 287~290, 2012
http: //dx.doi.org/10. 4184/asj.20 12.6.4.287
Copyright
2012 by Korean Society of Spine Surgery
This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/)
which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
Asian Spine Journal • pISSN 1976-1902 eISSN 1976-7846
Received May 23, 2011: Revised Jun 24, 2011; Accepted Jun 30, 2011
Corresponding author: Sujit Kumar Tripathy, MS, DNB, Dip SICOT, MNAMS
Clinical fellow, Department of Orthopaedics, Friarage Hospital,
Northallerton, DL6 1JG, United Kingdom
Tel: +44-7423388617, E-mail: sujitortho@yahoo.co.in
Cortical Blindness Following Spinal Surgery: Very Rare Cause of
Perioperative Vision Loss
Vijay Goni
1
, Sujit Kumar Tripathy
1,2
, Tarun Goyal
1,3
, Tajir Tamuk
1
, Bijnya Birajita Panda
4
, Shashidhar BK
1
1
Department of Orthopaedics, Postgraduate Institute of Medical Education and Research, Chandigarh, India
2
Department of Orthopaedics, Friarage Hospital, Northallerton, United Kingdom
3
Department of Orthopaedics, Freeman Hopstal, Newcastel upon Tyne, United Kingdom
4
Department of Opthalmology, SCB Medical College, Cuttack, India
A 38-year-old man was operated with posterior spinal decompression and pedicle screw instrumentation for his L2 fracture
with incomplete neurological deficit
.
In the recovery
,
he complained of blindness in both eyes after twelve hours
.
Computed
tomographic scan and magnetic resonance angiography revealed bilateral occipital lobe infarcts
.
He remained permanently
blind even after three years follow-up
.
Though rare
,
perioperative vision loss is a potential complication following spine
surgery in prone position
.
We report a rare occurrence of cortical blindness following lumbar spine surgery
.
Key Words: Blindness
,
Prone
,
Surgery
,
Spinal injuries
,
Postoperative vision loss
Introduction
Vision loss is a very rare but devastating complication
of nonocular surgeries, and reported incidence is 0.003%
to 0.0008% in the general surgical population [1]. The risk
of perioperative vision loss (POVL) has been commonly
noted after cardiac and spinal surgeries. The incidence as
reported in literature is 8.64/10,000 for cardiac surgeries and
3.09/10,000 for spinal fusions [2].
Most cases of perioperative vision loss following spine
surgery are mentioned as case reports in literature [3-8].
The specic pathogenesis of POVL remains elusive in most
cases, with much controversy surrounding patient and surgi-
cal risk factors. Important causes of POVL include ischemic
optic neuropathy (ION), retinal vascular occlusion (RVO)
and cortical blindness. Among these major causes, cortical
blindness is the rarest cause of POVL [7-9]. Myers et al.
[7] reported only three cases of cortical ischemia leading to
blindness while reviewing 37 patients of POVL after spine
surgery. Because of the rarity of occurrence and as most of
the data are retrospective, it is difcult to establish denite
cause-effect relationship for the cortical blindness. In this
article we report a case of POVL secondary to cortical isch-
aemia in a 38-year-old man following lumbar spinal fusion
without any predisposing factors for vaso-occlusive disease.
Case Report
A 38-year-old manual labourer was brought to the emer-
gency after a high energy motor vehicle accident. He was
hemodynamically stable at the time of admission. On pri-
mary and secondary survey a lumbar spine fracture possibil-
ity was suspected. Radiographic evaluation conrmed our
diagnosis and X-ray showed fracture of the second lumbar
vertebra (Fig. 1A). Neurologically he had diminished power
in both lower limbs (motor power of grade 3 or less around
288 /
ASJ: Vol. 6, No. 4, 2012
hip, knee and ankle joints). He had complete loss of bladder
and bowel sensations, but no sensory impairment was elic-
ited in the lower limbs.
His past medical history was not suggestive of any neuro-
logical problems, vision problems, diabetes, hypertension,
coronary artery disease, deep vein thrombosis, peripheral
vascular disease, collagen vascular disorder or previous
chest or heart problems. He was a non smoker and a social
drinker. His body mass index was 32.4.
Magnetic resonance imaging of the lumbar spine was per-
formed to better delineate the severity of spinal cord injury
and compression (Fig. 1B). He was operated after 72 hours
of injury. Surgery was carried out with posterior decompres-
sion and fusion using pedicle screw instrumentation in the
prone position under general anaesthesia (Fig. 2). Constant
monitoring of the arterial blood pressure was performed
during the surgery. Total duration of surgery was 105 min-
utes. Perioperative blood loss was 420 ml. Systolic blood
pressure throughout the surgery was in the range of 90 to
110 mm Hg. The oxygen saturation as measured by pulse
oxymeter was above 98% at all times. There was no other
anaesthetic or surgical complication intraoperatively. In
the recovery, patient complained of complete loss of vision
after twelve hours. He was evaluated by an ophthalmolo-
gist, neurologist and a cardiologist. His ocular examination
revealed complete bilateral loss of vision with preservation
of papillary and corneal reexes and normal ocular move-
ments. Intraocular pressure and fundus examination were
within normal limits. There was no new neurological decit
occurring after surgery and his cerebellar functions were
intact. His postoperative haemoglobin was 10.6 g and he
did not require any blood transfusion in the perioperative
period.
The computed tomographic scan and magnetic resonance
angiography of the brain revealed infarcts in bilateral oc-
cipital lobes (Fig. 3). Electrocardiography and echocardiog-
raphy evaluation for underlying cardiac problem did not
reveal any cardiac source of emboli. He was treated by the
ophthalmologist, but no recovery in vision was observed
even after three years follow-up.
Discussion
The article by Berg et al. [10] was surprising to the spine
surgeons where they mentioned that the incidence of POVL
following ocular surgeries is much lower than that seen in
nonocular surgeries. Incidence estimates for POVL after
nonocular surgery range from 0.013% for all surgeries up to
0.2% following spine surgery. Ischemic optic neuropathy is
the most common cause of POVL accounting for more than
81%, followed by retinal artery thrombosis. Cortical blind-
ness is the rarest cause of POVL with a handful of cases in
the literature [11].
Work up of a patient with perioperative visual loss in-
volves consideration of anatomy of the visual pathway.
Anterior ischemic optic neuropathy and retinal vascular oc-
clusion reveal remarkable changes on fundus examination,
but no such changes are observed in posterior ischemic op-
tic neuropathy (PION). The diagnosis in PION can be made
Fig. 1. Radiograph (A) and magnetic resonance imaging (B)
of the lumbar spine showing fracture of the L2 vertebra (ar-
row).
A B
Fig. 2. Radiogarphs (antero-posterior and lateral views)
after posterior spinal decompression and pedicle screw xa-
tion for L2 vertebra fracture.
A
B
POVL after Spine Surgery
/ 289
by contrast enhancement seen in the optic nerve on ocular
magnetic resonance imaging. Cortical blindness is diag-
nosed by looking for the ischemic changes in the occipital
lobe on intracranial imaging. In our case, the diagnosis was
made by cortical occipital changes seen on magnetic reso-
nance imaging with the absence of fundoscopic examina-
tionndings.
Despite numerous efforts and explanations, pathogenesis
of POVL is still elusive. Various aetiologies such as fall in
systemic blood pressure, anaemia, direct ocular compres-
sion, hypercoagulable states, embolism, increased venous
pressure, prone positioning during surgery and increased
cerebrospinal uid pressure have been elucidated but none
has proved so far [12-15]. Two important factors in cortical
blindness are generalised cerebral hypoperfusion and em-
bolism. It has been suggested that more than one factor may
be working in any patient making this a multifactorial event
[7,10]. Pathogenesis in cardiac surgery is relatively easy to
explain. Embolisation may take place due to cardiac and
great vessel manipulation, atrial or ventricular brillation [7].
The source of emboli in spinal surgery is difcult to explain.
It is also unclear why this phenomenon is commoner in sur-
geries carried out in the prone position. Direct pressure on
eye, raised intraocular pressure or vascular congestion does
not explain cortical infarcts, but may explain other causes of
vision loss such as ION and RVO. Intraoperative hypoten-
sion, hypoxia, blood loss and anaemia are contributory fac-
tors, but are not found in this patient. Further, they should
classically affect the watershed areas of blood supply in the
brain which innervate the proximal muscles of upper and
lower limb. Also, it has been shown that the use of deliber-
ate hypotensive anaesthesia during spine surgery does not
increase chances of POVL [7]. Huber and Grob [8] sug-
gested that abnormal posture of the neck when the patient is
being positioned prone for surgery could be a contributory
factor for reducing perfusion in the vertebra-basilar area
manifesting as stroke. This is purely hypothetical thought
and cannot be denitively proved. It has been recommended
to keep the neck at the level of heart or above in a neutral
forward position at the time of surgery to avoid chances of
hypoperfusion due to vertebra-basilar compression. The
bilateral infarction as in the present case does not support
the hypothesis. Review of POVL following general surger-
ies include many procedure carried out in the lower limb in
prone position [7,16]. Irrespective of the types of surgeries,
the prone position itself is a predisposing factor for POVL.
Shen et al. [2] found some important nding on periopera-
tive visual loss following spinal surgeries. Incidences were
higher for age less than 18 or more than 65 years, male
gender, anaemia, and posterior approach. Many cases occur
in patients who have no identied preoperative risk factors,
although hypertension, smoking, diabetes, and vascular dis-
ease appear to lead to increased risk. None of these risk fac-
tors was present in this patient. He had no cardio-pulmonary
comorbidities and he had no fluctuation in hemodynamic
status in the perioperative period as well. Considering these
situations, other than the prone position we could not nd
any predisposing condition in our case.
Most of patients with cortical blindness have a partial vi-
sion loss. They often have other associated symptoms such
Fig. 3. Magnetic resonance angiography of brain reveals bilateral infarction of occipital lobe.
290 /
ASJ: Vol. 6, No. 4, 2012
as cerebellar signs and other focal neurological decits, de-
pending upon the area of infarct. This patient had purely vi-
sion loss with no other decit. There is no denite treatment
for cortical blindness. No drugs including steroids have
shown to reduce morbidity in these cases and most postop-
erative visual decits do not show signicant improvement
with time. There is a hope of some improvement in initial
months, but once the window time period has passed there
is no hope of any further improvement.
This case report warns the spine surgeon about such fatal
complication following spine surgery in prone position. Ex-
treme cautions at every step should be taken to prevent the
development of perioperative visual loss. Despite these pre-
cautions, some cases may still land up with visual loss and
the patient should be explained about the grievous situation
well before the surgical procedure.
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... Our patient was normotensive during the two-stage procedure and postoperatively, as vital sign monitoring proved. In the recent literature, five cases of PRES related to spine surgery were reported [23][24][25][26][27]. According to the authors of these cases, the possible pathophysiologic mechanisms were related to hypotension [23], severe anemia [24], prone positioning [25], hypertension due to an epidural thoracic test with bupivacaine [26], and autonomic dysreflexia in a cervical trauma case with spinal cord involvement [27]. ...
... In the recent literature, five cases of PRES related to spine surgery were reported [23][24][25][26][27]. According to the authors of these cases, the possible pathophysiologic mechanisms were related to hypotension [23], severe anemia [24], prone positioning [25], hypertension due to an epidural thoracic test with bupivacaine [26], and autonomic dysreflexia in a cervical trauma case with spinal cord involvement [27]. Prone positioning during spine surgery could lead to PRES from the increase in cerebrospinal fluid pressure [3,25]. ...
... According to the authors of these cases, the possible pathophysiologic mechanisms were related to hypotension [23], severe anemia [24], prone positioning [25], hypertension due to an epidural thoracic test with bupivacaine [26], and autonomic dysreflexia in a cervical trauma case with spinal cord involvement [27]. Prone positioning during spine surgery could lead to PRES from the increase in cerebrospinal fluid pressure [3,25]. Another cause for PRES is embolism, which is a very uncommon phenomenon if it is present in bilateral cortical areas and is more frequent in cardiovascular anomalies [28,29]. ...
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Posterior reversible encephalopathy syndrome (PRES) usually manifests with severe headaches, seizures, and visual disturbances due to uncontrollable hypertension. A patient (age in the early 60s) with a history of renal cell cancer presented with lower-extremity weakness and paresthesias. Magnetic resonance imaging (MRI) of the thoracic spine revealed a T8 vertebral body metastatic lesion with cord compression at that level. The patient underwent preoperative embolization of the tumor followed by posterior resection and placement of percutaneous pedicle screws and rods. Postoperatively, the patient experienced decreased visual acuity bilaterally. Abnormal MRI findings consisted of T2 hyperintense lesions and fluid-attenuated inversion recovery changes in both occipital lobes, consistent with the unique brain imaging pattern associated with PRES. The patient's blood pressure was normal and stable from the first day of hospitalization. The patient was kept on high-dose steroid therapy, which was started intraoperatively, and improved within 48 hours after symptom onset.
... Of the 21 single case studies reviewed, the etiology of the POVL included: AACG (three patients), ION (three patients) CB (three patients), CRAO (four patients), ischemic orbital compartment syndrome/compression (one patients), CRA branch occlusion (one patient), or general POVL/unspecified etiology (six patients) [ Tables 1 and 4].[ 1, 4,9,10,12,[14][15][16]18,21,23,26,29,30,31,34,36,37,39,40] They variously cited a 0.28-0.2% versus 0.01-1% frequency of POVL following prone surgery, most commonly noting that hypotension was the major contributor. ...
... In Goni et al. study in 2012, a 38-year-old male undergoing a laminectomy with pedicle screw instrumentation for an L2 fracture developed bilateral CB attributed to occipital lobe infarcts (computed tomography and magnetic resonance confirmed) within [Tables 1 and 4]. [10] The patient was followed for 3 postoperative years, during which time the deficit remained permanent and irreversible. ...
... In 2012, Goni et al. presented a 38-year-old male who, 12 h following a lumbar laminectomy/pedicle screw instrumentation addressing an L2 fracture, developed permanent CB. [10] This was attributed to bilateral occipital lobe infarcts confirmed on both MR and CT studies Transient bilateral POVL following spinal surgery ...
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Background: Postoperative visual loss (POVL) following prone spine surgery occurs in from 0.013% to 1% of cases and is variously attributed to ischemic optic neuropathy (ION: anterior ION or posterior ION [reported in 1.9/10,000 cases: constitutes 89% of all POVL cases], central retinal artery occlusion [CRAO], central retinal vein occlusion [CRVO], cortical blindness [CB], direct compression [horseshoe, prone pillows, and eye protectors Dupaco Opti-Gard]), and acute angle closure glaucoma (AACG). Methods: Risk factors for ION include prolonged operative times, long-segment spinal instrumentation, anemia, intraoperative hypotension, diabetes, obesity, male sex, using the Wilson frame, microvascular pathology, decreased the percent of colloid administration, and extensive intraoperative blood loss. Risk factors for CRAO more typically include improper positioning during the surgery (e.g., cervical rotation), while those for CB included prone positioning and obesity. Results: POVL may be avoided by greater utilization of crystalloids versus colloids, administration of α-2 agonists (e.g., decreases intraocular pressure), avoidance of catecholamines (e.g., avoid vasoconstrictors), avoiding intraoperative hypotension, and averting anemia. Patients with glaucoma or glaucoma suspects may undergo preoperative evaluation by ophthalmologists to determine whether they require prophylactic treatment prior to prone spinal surgery and whether and if prophylactic treatment is warranted. Conclusions: The best way to avoid POVL is to recognize its multiple etiologies and limit the various risk factors that contribute to this devastating complication of prone spinal surgery. Furthermore, routinely utilizing a 3-pin head holder will completely avoid ophthalmic compression, while maintaining the neck in a neutral posture, largely avoiding the risk of jugular vein and/or carotid artery compromise and thus avoiding increasing IOP.
... Oleh karena itu, direkomendasikan untuk menjaga leher agar tetap satu level dengan jantung atau posisi netral pada saat operasi untuk menghindari peluang terjadinya hipoperfusi karena kompresi vertebrabasillar. 17,18 Dampak posisi prone terhadap kardiovaskuler yang perlu diwaspadai pada pasien ini adalah meningkatnya tahanan pembuluh darah paru dan perifer serta menurunnya aliran balik vena (venous return). Aliran balik ini akan sangat menurun terutama bila posisi kaki jauh lebih rendah dibanding posisi tubuh yang lain. ...
... Dibandingkan posisi terlentang, volume sekuncup dan indeks kardiak akan menurun bila berada dalam posisi pronasi. 16,17 Ekstubasi Pertimbangan melakukan ekstubasi pasien ini setelah operasi tulang belakang sangat tergantung pada prosedur bedah lesi pada tingkat servikal. Pada operasi lama (> 6 jam) atau pasien yang memiliki edema wajah yang signifikan, akan lebih aman untuk tetap mengintubasi pasien dan menaikkan kepala tempat tidur sebesar 45 derajat. ...
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Compression of the spinal cord can cause irritation to the autonomic nervous system. Hyperinervation of sympathetic nerves at high risk for arrhythmias characterized by electrocardiographic results in changes in P-wave duration, QRS duration, ST-segment depression, T-wave peak interval, and ventricular extrasystole. A 52-year-old male with an intra-extramedullar tumor in cervical 2-3, tetraparesis, dysrhythmias, and ventricular extrasystole bigemini. Wide excision of tumor and posterior stabilization would be performed. The pulse was 90x/minute palpable irregularly. Electrocardiography examination revealed irregular rhythm 82 x/minute and ventricular extrasystole 10 x/minute. Echocardiography showed grade 3 diastolic dysfunction with preserved LV function. Before the procedure, the patient was given management for the dysrhythmia and ventricular extrasystole with analgetics and amiodaron 150mg (10ml) in the first 10 minutes followed by 360mg (200mg) for the next 6 hours, 540mg for the next 18 hours and analgetics. General anesthesia carried out with midazolam 3mg, fentanyl 200mcg, lidocaine 60mg, propofol 100mg, and atricurium 30mg, with manual intubation in-line. After arterial line and central venous catheter insertion, the patient was placed in the prone position. Surgery lasted for approximately 6 hours. The patient was treated in the ICU for 2 days before moving to the usual ward. Amiodarone can be considered in ventricular extrasystole requiring immediate treatment with stable hemodynamic.
... Postoperative vision loss, which may be partial or complete and unilateral or bilateral, is a serious complication of surgery in the prone position, and it occurs with greater frequency after spine, head and neck, and some orthopedic procedures. 1,2 Following surgery in the prone position, there have been reports of postoperative vision loss associated with increased intraocular pressure (IOP), [3][4][5][6][7][8][9][10][11][12][13][14][15][16][17][18][19][20] as well as reports of chemosis, 20 subconjunctival hemorrhage, 21 ocular or subperiosteal orbital hemorrhage, [22][23][24] orbital compartment syndrome, 24,25 acute angle-closure glaucoma, 26,27 and Horner syndrome. 28 When the patient is in the prone position, IOP increases and the extent of this increase is related to the amount of time the patient is in the prone position. ...
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... There is significant variation in the reported incidence of POVL ranging from 0.056 to 1.3% (1). Surgical procedures posing the highest risk for POVL are cardiac (incidence = 0.09%) and spinal surgeries (incidence as high as 0.2%) (2,3). Etiologies of POVL include ischemic optic neuropathy (ION), central retinal artery occlusion (CRAO), cortical blindness (CB), and corneal abrasion (CA) (4). ...
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... He was discharged from the hospital with no focal neurological deficits. high embolic loads such as angiography [7,8]. ...
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Incidence estimates for perioperative vision loss (POVL) after nonocular surgery range from 0.013% for all surgeries up to 0.2% following spine surgery. The most common neuro-ophthalmologic causes of POVL are the ischemic optic neuropathies (ION), either anterior (AION) or posterior (PION). We identified 111 case reports of AION following nonocular surgery in the literature, with most occurring after cardiac surgery, and 165 case reports of PION following nonocular surgery, with most occurring after spine surgery or radical neck dissection. There were an additional 526 cases of ION that did not specify if the diagnosis was AION or PION. We also identified 933 case reports of central retinal artery occlusion (CRAO), 33 cases of pituitary apoplexy, and 245 cases of cortical blindness following nonocular surgery. The incidence of POVL following ocular surgery appears to be much lower than that seen following nonocular surgery. We identified five cases in the literature of direct optic nerve trauma, 47 cases of AION, and five cases of PION following ocular surgery. The specific pathogenesis and risk factors underlying these neuro-ophthalmic complications remain unknown, and physicians should be alert to the potential for loss of vision in the postoperative period.
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Perioperative visual loss (POVL), a rare, but devastating complication, can follow non-ocular surgery. Highest rates of visual loss are with cardiac and spine surgery. The main causes of visual loss after non-ocular surgery are retinal vascular occlusion and ischaemic optic neuropathy. This review updates readers on the incidence, suspected risk factors, diagnosis, and treatment of POVL due to these conditions.
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Study Design. Thirty-seven patients who experienced visual loss after spine surgery were identified through a survey of the members of the Scoliosis Research Society and a review of the recent literature. Objectives. Records were reviewed in an attempt to identify preoperative and intraoperative risk factors and to assess the likelihood of recovery. Summary of Background Data. Postoperative blindness after spine surgery has been documented in case reports or small series. The authors report the largest group of such cases to date and the first to allow conclusions regarding risk and prognosis. Methods. Letters were sent to members of the Scoliosis Research Society requesting copies of medical records concerning patients who experienced postoperative visual deficits after spine surgery. An additional 10 well-documented recent cases were identified from published reports. Results. Patients with visual loss had a mean age of 46.5 years. Surgery included instrumented posterior fusion in 92% of the cases, with an average operative time of 410 minutes and blood loss of 3500 mL. Most cases had significant intraoperative hypotension, with a mean drop in systolic blood pressure from 130 to 77 mm Hg. However, comparison with a matched group of patients with no visual symptoms showed no differences in the hematocrit or blood pressure values. Visual loss occurred because of ischemic optic neuropathy, retinal artery occlusion, or cerebral ischemia. Eleven cases were bilateral, and 15 patients had complete blindness in at least one eye. Most deficits were permanent. Conclusions. The authors conclude that blindness after spine surgery is more common than has been recognized previously. Most cases are associated with complex instrumented fusions.
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Perioperative visual loss (POVL) accompanying nonocular surgery is a rare and potentially devastating complication but its frequency in commonly performed inpatient surgery is not well defined. We used the Nationwide Inpatient Sample to estimate the rate of POVL in the United States among the eight most common nonocular surgeries. More than 5.6 million patients in the Nationwide Inpatient Sample who underwent principal procedures of knee arthroplasty, cholecystectomy, hip/femur surgical treatment, spinal fusion, appendectomy, colorectal resection, laminectomy without fusion, coronary artery bypass grafting, and cardiac valve procedures from 1996 to 2005 were included. Rates of POVL, defined as any discharge with an International Classification of Diseases, Ninth Revision, Clinical Modification code of ischemic optic neuropathy (ION), cortical blindness (CB), or retinal vascular occlusion (RVO), were estimated. Potential risk factors were assessed by univariate and multivariable analyses. Cardiac and spinal fusion surgery had the highest rates of POVL. The national estimate in cardiac surgery was 8.64/10,000 and 3.09/10,000 in spinal fusion. By contrast, POVL after appendectomy was 0.12/10,000. Those undergoing cardiac surgery, spinal fusion, and orthopedic surgery had a significantly increased risk of developing ION, RVO, or CB. Patients younger than 18 yr had the highest risk for POVL, because of higher risk for CB, whereas those older than 50 yr were at greater risk of developing ION and RVO. Other significant positive predictors for some diagnoses of POVL were male gender, Charlson comorbidity index, anemia, and blood transfusion. There was no increased risk associated with hospital surgical volume. During the 10 yr from 1996 to 2005, there was an overall decrease in POVL in the procedures we studied. The results confirm the clinical suspicion that the risk of POVL is higher in cardiac and spine fusion surgery and show for the first time a higher risk of this complication in patients undergoing lower extremity joint replacement surgery. The prevalence of POVL in the eight most commonly performed surgical operations in the United States has decreased between 1996 and 2005. Increased odds of POVL with male gender and comorbidity index indicate that some risk factors for POVL may not presently be modifiable. The conclusions of this study are limited by factors affecting data accuracy, such as lack of data on the intraoperative course and inability to confirm the diagnostic coding of any of the discharges in the database.
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This 48-year-old hypertensive man, a cigarette smoker, awoke in the recovery room with visual loss in the right eye after uncomplicated lumbar spine surgery. His intraoperative blood pressure had been maintained at relatively low levels to reduce bleeding; a loss of 1500 cc of blood was reported. Postoperative hemoglobin was 4.2 g/dl less than the preoperative hemoglobin; however, the patient did not receive a blood transfusion. A postoperative ophthalmological examination revealed decreased visual acuity, color vision, and visual field in the right eye. The right optic nerve and retina were initially normal but the patient eventually developed optic nerve atrophy consistent with the clinical diagnosis of ischemic optic neuropathy. Neurosurgeons should be aware that this condition may follow uncomplicated lumbar spine surgery and should obtain prompt ophthalmological consultation when patients develop postoperative visual loss. Aggressive and rapid correction of blood pressure and hematocrit may be helpful in individuals who develop ischemic optic neuropathy after lumbar spine surgery.
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Reported herein is the unusual complication of blindness resulting from massive blood loss during a lumbar spine surgery. Amaurosis resulting from distant hemorrhage is rare and, to the authors' knowledge, has not been reported in the orthopedic literature. Although there have been several case reports in the ophthalmologic journals, none were secondary to an orthopedic surgical procedure.
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Central retinal artery occlusion is a well-documented entity that occurs after trauma and embolic, thrombotic, or spasmodic episodes in both children and adults. Its occurrence as a complication of elective surgery is very rare but quite tragic. This report describes a case of central retinal artery occlusion occurring in a child after scoliosis surgery in which a horseshoe headrest was used. Recommendations are given on how to avoid this serious complication.
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Thirty-seven patients who experienced visual loss after spine surgery were identified through a survey of the members of the Scoliosis Research Society and a review of the recent literature. Records were reviewed in an attempt to identify preoperative and intraoperative risk factors and to assess the likelihood of recovery. Postoperative blindness after spine surgery has been documented in case reports or small series. The authors report the largest group of such cases to date and the first to allow conclusions regarding risk and prognosis. Letters were sent to members of the Scoliosis Research Society requesting copies of medical records concerning patients who experienced postoperative visual deficits after spine surgery. An additional 10 well-documented recent cases were identified from published reports. Patients with visual loss had a mean age of 46.5 years. Surgery included instrumented posterior fusion in 92% of the cases, with an average operative time of 410 minutes and blood loss of 3500 mL. Most cases had significant intraoperative hypotension, with a mean drop in systolic blood pressure from 130 to 77 mm Hg. However, comparison with a matched group of patients with no visual symptoms showed no differences in the hematocrit or blood pressure values. Visual loss occurred because of ischemic optic neuropathy, retinal artery occlusion, or cerebral ischemia. Eleven cases were bilateral, and 15 patients had complete blindness in at least one eye. Most deficits were permanent. The authors conclude that blindness after spine surgery is more common than has been recognized previously. Most cases are associated with complex instrumented fusions.