Visual loss after spine surgery: a population-based study.
Patil CG, Lad EM, Lad SP, Ho C, Boakye M.
Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA, USA.
Retrospective cohort study using National inpatient sample administrative data.
To determine national estimates of visual impairment and ischemic optic neuropathy after spine surgery.
SUMMARY OF BACKGROUND DATA:
Loss of vision after spine surgery is rare but has devastating complications that has gained increasing recognition in the recent literature. National population-based studies of visual complications after spine surgery are lacking.
All patients from 1993 to 2002 who underwent spine surgery (Clinical Classifications software procedure code: 3, 158) and who had ischemic optic neuropathy (ION) (ICD9-CM code 377.41), central retinal artery occlusion (CRAO) (ICD9-CM code 362.31) or non-ION, non-CRAO perioperative visual impairment (ICD9-CM codes: 369, 368.4, 368.8-9368.11-13) were included. Univariate and multivariate analysis were performed to identify potential risk factors.
The overall incidence of visual disturbance after spine surgery was 0.094%. Spine surgery for scoliosis correction and posterior lumbar fusion had the highest rates of postoperative visual loss of 0.28% and 0.14% respectively. Pediatric patients (<18 years) were 5.8 times and elderly patients (>84 years) were 3.2 times more likely than, patients 18 to 44 years of age to develop non-ION, non-CRAO visual loss after spine surgery. Patients with peripheral vascular disease (OR = 2.0), hypertension (OR = 1.3), and those who received blood transfusion (OR = 2.2) were more likely to develop non-ION, non-CRAO vision loss after spine surgery. Ischemic optic neuropathy was present in 0.006% of patients. Hypotension (OR = 10.1), peripheral vascular disease (OR = 6.3) and anemia (OR = 5.9) were the strongest risk factors identified for the development of ION.
We used multivariate analysis to identify significant risk factors for visual loss after spine surgery. National population-based estimate of visual impairment after spine surgery confirms that ophthalmic complications after spine surgery are rare. Since visual loss may be reversible in the early stages, awareness, evaluation and prompt management of this rare but potentially devastating complication is critical.
Lumbar artery injury following posterior spinal instrumentation for scoliosis.
Sandri A, Regis D, Marino MA, Puppini G, Bartolozzi P.
Department of Orthopedic Surgery, Azienda Ospedaliera Universiteria Integrata, Policlinico GB Rossi, Italy. firstname.lastname@example.org
Vascular injuries are uncommon but potentially serious complications of spinal surgery. Lumbar artery lesion complicating posterior spinal instrumentation for scoliosis has been occasionally described. A 39-year-old woman with adult scoliosis was treated with correction and stabilization from T8 to L5 via a midline posterior approach. Transpedicular screws were inserted from levels L1 to L5 on the convex left side and at T11, T12, L4, and L5 on the concavity right side. Pedicle screws were not inserted from L2 to L4 on the right side due to difficulty identifying the pedicle channel with the probe. The instrumentation was completed with 2 hooks at T8 and T5 on the left side and 1 at T7. Five hours postoperatively, the patient suffered a hypotensive attack and her abdomen was distended. Her hemoglobin level was 4.5 g/dL. Hemodynamic stabilization was achieved with emergent therapy, including fluid resuscitation, blood, and plasma transfusion. An urgent contrast-enhanced abdominal computed tomography scan showed a large hematoma at the right retroperitoneum with active extravasation of contrast medium, but the source of bleeding was not detectable because of metallic artifacts. Immediate angiography demonstrated rupture of the third right lumbar artery. Selective microcoil embolization was performed with occlusion of the corresponding branch. The bleeding stopped and hemodynamic parameters were stable. No spinal cord impairment or muscle infarction occurred, and 1-year follow-up was uneventful. Lumbar artery injury should be considered as a complication after posterior spinal surgery for scoliosis and prompt diagnosis and intervention are required. Selective lumbar artery embolization is a safe and effective procedure to stop bleeding in hemodynamically stable patients after fluid resuscitation and blood transfusion.
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Visual loss as a complication of spine surgery. A review of 37 cases.
Myers MA, Hamilton SR, Bogosian AJ, Smith CH, Wagner TA.
Orthopedic Physician Associates, Seattle, Washington, USA.
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.