Anaes · Neuro / orthopaedic anaesthesia
Prone spine surgery and perioperative visual loss
Also known as spine prone visual loss
Exam-exhaustive prone spine anaesthesia and POVL: ASPF registry risk factors for ION, CRAO vs posterior ION, positioning checklist, blood pressure and anaemia targets, neuromonitoring constraints, and vision emergency response for ANZCA Final.
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Red flags
- POVL after prone spine fusion is often posterior ischemic optic neuropathy — may be bilateral and irreversible.
- ASPF registry risk factors include male sex, obesity, Wilson frame, longer anaesthesia, greater blood loss, and lower percent colloid in non-blood replacement.
- Direct eye compression can cause CRAO — check eyes after positioning and at intervals.
- Sustained hypotension plus anaemia plus prolonged prone time compounds optic nerve ischaemia risk.
Meet the patient
A 52-year-old obese man is listed for an eight-hour instrumented lumbar fusion on a Wilson frame — male, heavy, long case, large expected blood loss. Every one of those is an ASPF registry risk factor for ischaemic optic neuropathy. Before induction the registrar asks whether you would run deliberate hypotension to keep the field dry.[1]
The two questions that decide this man's optic nerve are the two that decide every prone spine case: are the eyes free of pressure? and am I stacking the four insults — duration, anaemia, hypotension, and venous congestion? Hold those two and the whole topic slots into place.[1]
References4ShowHide
- [1]The Postoperative Visual Loss Study Group Risk factors associated with ischemic optic neuropathy after spinal fusion surgery Anesthesiology, 2012.PMID 22185873
- [2]Shakur H, Roberts I, Bautista R, et al. Effects of tranexamic acid on death, vascular occlusive events, and blood transfusion in trauma patients with significant haemorrhage (CRASH-2): a randomised, placebo-controlled trial Lancet, 2010.PMID 20554319
- [3]Frerk C et al. Difficult Airway Society 2015 guidelines for management of unanticipated difficult intubation in adults Br J Anaesth, 2015.PMID 26556848
- [4]American Society of Anesthesiologists Task Force on Perioperative Visual Loss Practice Advisory for Perioperative Visual Loss Associated with Spine Surgery 2019: An Updated Report by the American Society of Anesthesiologists Task Force on Perioperative Visual Loss, the North American Neuro-Ophthalmology Society, and the Society for Neuroscience in Anesthesiology and Critical Care Anesthesiology, 2019.PMID 30531555