Blindness: Complication of Spine Surgery

[facetguy]

Does anyone know the incidence of blindness as a complication of spine surgery? After some searching, I've seen figures ranging from 0.2% to 1%, although it is always described as 'rare'. Have surgical/gas techniques changed to address this complication?

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[Dimoak]

In terms of incidence, the numbers you cited are about right. In many cases where blindness results, this is often due to complications during the surgery, and so there aren't many revisions to technique that could be done to minimize that with the exception of being extra careful during the procedure and monitoring the perioperative "numbers" more closely, paying extra extra careful attention to higher-risk patients such as diabetics. Some steps taken include minimizing operative time and more carefully monitoring transfusion in order to minimize blood loss, thereby reducing the primary risk factors associated with post-operative vision loss, such as loss of blood flow to the optic nerve and development of thrombi in the retinal artery.

 

[GeraldMonroe]

Umm, I'm taking neuroscience right now, and the spine and the optic nerve/optic tracts are really, really far from each other.

Why would blindness be a specific complication of spine surgery? If it's caused by blood loss, then it would be a possible danger of nearly any major surgery. I'm sure there's a connection, but how?

 

[Dimoak]

Umm, I'm taking neuroscience right now, and the spine and the optic nerve/optic tractv are really, really far from each other.

Why would blindness be a specific complication of spine surgery? If it's caused by blood loss, then it would be a possible danger of nearly any major surgery. I'm sure there's a connection, but how?

It's application to spine surgery isn't always physiological but rather situational. Spine surgeries tend to be some of the longer procedures done, sometimes done in stages, which often then result in requiring more ccs. The positioning is a key element as well. In the rare case that vision is compromised, it's often due to pressure changes and pressure on the globes. In cases where major blood vessels are ligated (such as those in the neck), you can cause ischemia around the optic tract even though you didn't even touch that area (combined with certain other factors like perioperative hypertension and placement of patient during surgery).

 

[mpp]

The incidence is much lower than that...less than 0.1%
This is typically an ischemic problem (not related to any tracts or specific vessels). The prone positioning increases intraocular pressure. Combine this with relative hypotension during a long procedure where it is not unusual to have significant blood loss leads to the risk of having vision impairment.

The best population-based study is in
Spine. 2008 June 1;33(13)
but there are many papers on this topic.

 

[facetguy]

Great info...thanks for your prompt replies.

When I asked if any technical changes had been made, I was referring to the direct ocular pressure issue. That seems like something that could be modified to help avoid the eyes, but I guess it's not that easy. Besides, it wouldn't have any impact on the blood flow/thrombic factors.

Thanks again.

 

[cchoukal]

This is an area of intense interest in the field of anesthesiology right now. One of our faculty is doing some grant-funded work to elucidate the mechanism, and the American Society of Anesthesiologists started a Postoperative Visual Loss Registry to collect and examine cases. The two leading hypotheses are ischemic optic neuropathy or central retinal artery occlusion. The former is likely secondary to hypoperfusion. Many spine surgeons beg for deliberate hypotension in these cases in the hopes of limiting blood loss. The increase in IOP that occurs naturally with prone positioning probably exacerbates the problem. The latter is probably a consequence increased IOP from external globe compression secondary to improper padding of the face.

For more info, you can do a pubmed butt-sniff on Steven Roth, and I've pasted an abstract from the ASA's large case series.

: Anesthesiology. 2006 Oct;105(4):652-9; quiz 867-8.Links

BACKGROUND: Postoperative visual loss after prone spine surgery is increasingly reported in association with ischemic optic neuropathy, but its etiology is unknown. METHODS: To describe the clinical characteristics of these patients, the authors analyzed a retrospectively collected series of 93 spine surgery cases voluntarily submitted to the American Society of Anesthesiologists Postoperative Visual Loss Registry on standardized data forms. RESULTS: Ischemic optic neuropathy was associated with 83 of 93 spine surgery cases. The mean age of the patients was 50 +/- 14 yr, and most patients were relatively healthy. Mayfield pins supported the head in 16 of 83 cases. The mean anesthetic duration was 9.8 +/- 3.1 h, and the median estimated blood loss was 2.0 l (range, 0.1-25 l). Bilateral disease was present in 55 patients, with complete visual loss in the affected eye(s) in 47. Ischemic optic neuropathy cases had significantly higher anesthetic duration, blood loss, percentage of patients in Mayfield pins, and percentage of patients with bilateral disease compared with the remaining 10 cases of visual loss diagnosed with central retinal artery occlusion (P < 0.05), suggesting they are of different etiology. CONCLUSIONS: Ischemic optic neuropathy was the most common cause of visual loss after spine surgery in the Registry, and most patients were relatively healthy. Blood loss of 1,000 ml or greater or anesthetic duration of 6 h or longer was present in 96% of these cases. For patients undergoing lengthy spine surgery in the prone position, the risk of visual loss should be considered in the preoperative discussion with patients.

 

[blindterry]

Your incidence rate for blindness resulting as a complication due to spine surgery is too low. It should be closer to 5%.

My husband lost his sight two weeks after incurring a spinal cord injury that was incomplete (i.e., spinal cord not severed). He is now a paraplegic and blind.

After 4 years of monitoring and researching, we have found more occurrences than is reported in your blog. We were told by spine neurosurgeons that this complication was frequent in lengthy surgeries (5.5+ hrs) but generally not reported. Immediately after onset, a neuro opthamologist admistered steroid treatments to no avail and said the blindness was due primarily to pressure on the optic nerve during surgery.

Please note that as the spouse, I was never notified about the possibility of blindness following a lengthy spine surgery when we proceeded with the procedure.

Hope this helps...

 

[Chronic Student]

Several responses.

1. Over the past decade I have scrubbed in on hundreds or more likely a thousand or more spine cases. Case of blindness N=0. We frequently do 7 to 10 hour cases.

2. Frequent is a relative thing. When I tell a patient (an unhealthy one) that the risk of a major complication is 10%, I am often told that is not bad by the patient. I tell them that number horrifies me and I think it is very high. What that means to me is that for every 10 patients like them we take to surgery one of them will have a major complication.

It also has a lot to do with the person who has the complication. To the vast majority of the patients who don't have this they could care less. To the very few who do have it, the results are devastating.

3. It is also impossible to list every single complication.

We have to talk about the most common ones.

There are, however, literally thousands of potential complications. We could take about the rarer things like penile necrosis, horner syndrome, ischemic orbital compartment syndrome, cylorrhea, meningitis, ischemic bowel, anterior spinal artery syndrome, cerebellar hemorrhage, pharyngeal perforation, air embolism, etc, etc ad nauseum. But the fact of the matter is that those things are extremely rare.

To be quite honest "informed consent" is almost imposible for someone who is not a doctor and probably not even for most doctors. What we can do are talk about the things are likely to happen. Non-union, failure to relieve all pain, CSF leak, injury to recurrent laryngeal nerve, infection, injury to the spinal cord or nerves, recurrence, hemorrhage, facial swelling, corneal edema, DVT, PE, MI, stroke, etc. are many orders of magnitude more likely.

4. I get very frustrated with our anesthesia folks who talk to and terrify our patients just prior to surgery while talking about the rare complication of blindness that the surgeon may cause. Yet those same folks fail to mention the much more likely complication of anesthesia causing chipped teeth, lip lacerations, tongue ulcerations, blepharoplasty via hasty tape removal, or acute renal failure due giving too little IV fluid to avoid the unsightly facial swelling that seems to bother our anesthesia folks soo much. Not to mention the post-op hypotension that accompanies it which requires much higher maintenance fluid and frequent fluid boluses post-op.

No, I'm not bitter.

My main point is to try and keep things in perspective.

Just my .02, your opinion may differ.

 

[GeraldMonroe]

10% risk of a 'major complication'.

What I would like to know is, what is the risk of a debilitating complication that the patient will never recover from nor be able to do anything meaningful afterwards?

I would say that blindness, paralysis, significant brain damage, or destruction of a vital organ that will ultimately prove lethal count as the really major complications. Some of the other ones you list you might be able to recover from, with luck and high end medical care.

But : MI, stroke, a lethal PE, blindness, or severe injury to the spinal cord are all very close to being nearly as bad as dying on the table. If I were a patient, I'd have to be pretty desperate to consent to a surgery with a 10% risk of things like that.

 

[Chronic Student]

Run that thought out to its logical conclusion.

Obviously it would be different for everyone since a "debilitating complication that the patient will never recover from and might want to kill themselves?" Could be a scar for a person with body dysmorphic disorder, while not doing anything for a HNP at C6-7 with significant weakness for a surgeon would be the same.

Its different for everybody.

As you stated you can have an MI with no significant consequences or they can die. Same for PE. Same for infection. etc, etc.

Very hard to put a number to the unquantifiable.

That 10% risk I quoted was for the patient with HTN, DM, COPD, CHF, CAD with CABG x6 type of patient who has cervical spondylytic myelopathy and who are frankly myelopathic who will be soon paralyzed if not operated upon. I'm not talking about an elective disc or fusion.

 

[GeraldMonroe]

I changed my standard "not do anything meaningful afterwards"

If you're dead, or so ill that death will follow after a period of hospitalization, that qualifies.

If you've lost your primary sense (sight), so that you can no longer experience much of anything, that counts.

If you can't even think and aren't even the same person anymore because a stroke killed a key chunk of your brain, that especially counts.

Obviously, even someone with body dismorphic disorder could be treated for a scar. But no treatment can replace lost eyes or brain tissue or lower body control.

But, yes, I've thought about it for about 15 minutes, and it's really hard to put a hard limit on what complications I would consider to be effectively death or as bad as death, such that suicide would be a rational choice. Near complete paralysis, near total blindness AND near total deafness at the same time, a major stroke...the list isn't really all that long. Even if one became blinded, it might be possible to go on living and to eke out enough enjoyment of life that one wanted to continue living.

 

[facetguy]

Several responses.

1. Over the past decade I have scrubbed in on hundreds or more likely a thousand or more spine cases. Case of blindness N=0. We frequently do 7 to 10 hour cases.

This is consistent with a Hopkins study (Spine 1 June 2005;30(11):1299-1302), which found 4 cases of blindness (what they call 'perioperative ischemic optic neuropathy') in 14,102 spine surgeries at Hopkins, or 0.028%.

Using that rate, ChronicStudent could scrub in on a few thousand more spine surgeries before encountering a blindness incident.

Still, 1 in 3000 shouldn't really be considered rare, though, should it? Infrequent maybe, but not rare.

 

[Winged Scapula]

Since this is not a general surgery issue, moving to Neurosurg forum.

 

[mpp]

Your incidence rate for blindness resulting as a complication due to spine surgery is too low. It should be closer to 5%.

My husband lost his sight two weeks after incurring a spinal cord injury that was incomplete (i.e., spinal cord not severed). He is now a paraplegic and blind.

Sorry to hear about this awful complication. All this talk about percentages an so forth really has no bearing because for your husband it may as well have been 100% of the cases.

I also have never seen it at the institution where I work (we have more than 10 spine surgeons and do dozens of prone per week). As far as protecting for this limiting hypotension and length of procedure is really all we have. I suppose for certain cases there can be a choice of anterior versus posterior approach (prone versus supine positioning), but both carry risks. Although we specifically don't write this complication out on a consent form, we do include the non-specific "debilitating neurologic deficit" as well as such things as paraplegia and death.

 

[proman]

Anyone interested in this topic should read this article, available for free at www.anesthesiology.org :

Perioperative Ischemic Optic Neuropathy: A Case Control Analysis of 126,666 Surgical Procedures at a Single Institution
Anesthesiology:
February 2009 - Volume 110 - Issue 2 - pp 246-253

Results: From among 126,666 surgical procedures performed during the study period, the authors identified 17 patients with perioperative ischemic optic neuropathy, yielding an overall incidence of 0.013%. There were no hemodynamic variables that differed significantly between the ischemic optic neuropathy patients and the matched control patients.

And: The incidence of perioperative ION after CABG surgery at our institution during this period was 0.33% (9 patients with ION from a total of 2,749 CABG surgeries). The incidence after spine surgery was 0.36% (4 patients with ION from a total of 1,110 spine surgeries).

There's some evidence from animal models that the optic nerve is more sensitive to ischemia than previously thought (and that perfusion pressures need to be higher). The anatomy of the human orbit is also different. I am not aware of any evidence supporting the notion of direct pressure being associated with PION.

I include PION as part of my anesthetic consent (due to the devastating nature), none of our spine surgeons do.

 

[cchoukal]

Several responses.


4. I get very frustrated with our anesthesia folks who talk to and terrify our patients just prior to surgery while talking about the rare complication of blindness that the surgeon may cause. Yet those same folks fail to mention the much more likely complication of anesthesia causing chipped teeth, lip lacerations, tongue ulcerations, blepharoplasty via hasty tape removal, or acute renal failure due giving too little IV fluid to avoid the unsightly facial swelling that seems to bother our anesthesia folks soo much. Not to mention the post-op hypotension that accompanies it which requires much higher maintenance fluid and frequent fluid boluses post-op.

The anesthesiologists taking care of your patients probably feel the need to discuss the possibility of perioperative visual complications because it is frequently seen as THEIR complication. It is they who manage the BP, volume, transfusions, and positioning, and it is they who will be opening their checkbook (probably along with the surgeon) when the patient wakes up blind. I'm trying to imagine myself getting "frustrated" watching "my surgical folks" discussing potential surgical complications with the patients.

With regard to the facial swelling, I doubt that it's the appearance that bothers them. More likely it's that when facial edema is present, so too is laryngeal edema, which may require continued intubation/mechanical ventilation postoperatively, one complication of which (ventilator-associated pneumonia) could be detrimental in a patient with new hardware.

 

[Chronic Student]

The anesthesiologists taking care of your patients probably feel the need to discuss the possibility of perioperative visual complications because it is frequently seen as THEIR complication. It is they who manage the BP, volume, transfusions, and positioning, and it is they who will be opening their checkbook (probably along with the surgeon) when the patient wakes up blind. I'm trying to imagine myself getting "frustrated" watching "my surgical folks" discussing potential surgical complications with the patients.

With regard to the facial swelling, I doubt that it's the appearance that bothers them. More likely it's that when facial edema is present, so too is laryngeal edema, which may require continued intubation/mechanical ventilation postoperatively, one complication of which (ventilator-associated pneumonia) could be detrimental in a patient with new hardware.

Interesting.

I say this because they always mention it in relation to my particular surgeon due to the fact that he is slow. They do not mention it with other surgeons and they say something to the effect of "Due to the extremely long operative times of Dr. ____ there is a greatly increased possibility that you can wake up blind".

It is the undue emphasis on this one particular complication with this one particular surgeon that bothers me.

It is also interesting to note that I have never seen anesthesia hesitate to extubate anyone with undue facial swelling and not a single one of those patients has ever been left intubated. In fact, I cannot remember a single elective spine case (of ours) where the patient was left intubated. Really I can only even remember 2 cases of corneal edema.

These same anesthesia folks do not specifically mention stroke, kidney failure, Anterior spinal artery syndrome, etc. These same things would fit your bill of complications more commonly attributed to problems with anesthesia and that they would have to "open their wallet for". Why do the not stress these more common complications as much and focus on something that is much more rare.

 

[GeraldMonroe]

Why is "open up your wallet" the biggest concern? I mean, I know that attendings become pretty jaded, but would you not still feel a little bit of empathy and guilt if you made someone blind?

 

[Dimoak]

Why is "open up your wallet" the biggest concern? I mean, I know that attendings become pretty jaded, but would you not still feel a little bit of empathy and guilt if you made someone blind?

"Open up your wallet" is trade lingo, and is certainly not to be confused with the physician being indifferent about a severe complication. When such tragedies happen, physicians take it much harder than some people realize. But complications come with the territory; when one does happen, the best thing the physician can do is learn every possible thing they can from the experience and go forward from there.

 

[cchoukal]

Interesting.

I say this because they always mention it in relation to my particular surgeon due to the fact that he is slow. They do not mention it with other surgeons and they say something to the effect of "Due to the extremely long operative times of Dr. ____ there is a greatly increased possibility that you can wake up blind".

Wow, that's interesting. On the surface that sounds pretty unprofessional. I wonder if they've been thrown under the bus by this guy in the past... It is true, however, at least based on qualitative analysis of the ASA's registry, that visual loss is associated with longer operative times. Still, no patient deserves to hear "yeah, this guy who's doing you're surgery, well, he's a bit of a hack, so, uh, good luck!" on their way to the OR.

And to the other guy, yes, "open your wallet" is a colloquialism, not meant to imply primacy.

 

[Chronic Student]

That was kind of what I was getting at. It seems unprofessional.

He has not thrown them under the bus, but he has very long operative times. The anesthesia folks, the nurses and administration all hate it.

Hell, I hate it and I'm his PA.

However, the fact of the matter is that he is meticulous and his patients do better than anyone else for hundreds of miles around. I cannot remember the last infection. I cannot ever remember having to take someone back to the OR for bleeding, he rarely loses more than 20-50 ml of blood. It is also very rare to have a patient wake up with any pain at all.

Our rads guys routinely comment on the quality of the work they see on our post-op CT's, etc and I can tell you who anesthesia, docs and their families and the hospital employees go to when they hurt.

They don't seem to mind working with the hack with numerous lawsuits, who fuses everyone and then brings them back for hardware removal and who can rip through a multi-level lumbar fusion in an hour and fifteen minutes.

 

[Dimoak]

Wow, that's interesting. On the surface that sounds pretty unprofessional. I wonder if they've been thrown under the bus by this guy in the past... It is true, however, at least based on qualitative analysis of the ASA's registry, that visual loss is associated with longer operative times. Still, no patient deserves to hear "yeah, this guy who's doing you're surgery, well, he's a bit of a hack, so, uh, good luck!" on their way to the OR.

I agree with you regarding unprofessionalism. IMHO, one shouldn't discuss their feelings about colleagues with the patient; if you have an issue with a chosen modality or treatment plan, you discuss them with your peers, and not potential laymen who can easily misunderstand or misconstrue what you're saying. It's almost like the imaging tech telling a patient that the EP who ordered the study has a tendency to overimage everyone, or an EP telling a patient that their PCP has been mismanaging them.

In terms of visual loss, IMHO, at least half of the fault lays with Anesthesia. Certainly operative times should be reduced whenever feasible, but the sedation, ventilation, peri-operative anesthetic and perfusive responsibilities are within the Anesthesiologist's scope. Anesthesiologists are very defensive about their turf in terms of utilizing the appropriate anesthesia modality for the given procedure, and with input from the rest of the team, generally have the final say (and rightfully so because they're the experts). So if they're pushing too much nitroglycerin and the pt suffers hypotensive complications, they're still responsible for the management. A surgeon's duty is to perform within the realm of their best judgment for how to best achieve the desired outcome; if an anesthesiologist is uncomfortable doing such a case, it is their responsibility to pass it along to someone who may be a better provider for it. Just my 2¢.

 

[cchoukal]

In terms of visual loss, IMHO, at least half of the fault lays with Anesthesia. Certainly operative times should be reduced whenever feasible, but the sedation, ventilation, peri-operative anesthetic and perfusive responsibilities are within the Anesthesiologist's scope. Anesthesiologists are very defensive about their turf in terms of utilizing the appropriate anesthesia modality for the given procedure, and with input from the rest of the team, generally have the final say (and rightfully so because they're the experts). So if they're pushing too much nitroglycerin and the pt suffers hypotensive complications, they're still responsible for the management. A surgeon's duty is to perform within the realm of their best judgment for how to best achieve the desired outcome; if an anesthesiologist is uncomfortable doing such a case, it is their responsibility to pass it along to someone who may be a better provider for it. Just my 2¢.

This is all well and good, but believe it or not, there is occasionally a lot of pressure (often in the form of whining, foot stomping, and the like) to lower a patient's BP in these cases. I've even heard things like, "I'll have to stop the case if we can't get the BP down so this bleeding stops." Who's to blame, the surgeon for requesting/demanding it, or the anesthesiologist for giving in? Recognize that when you say "pass it along to someone who may be a better provider for it," what that really means in this case is "someone more willing to acquiesce to the surgeon's demand for lower BP and/or take the heat for a bad outcome." It's not like there's some secret technique that some "better provider" is going to come up with to protect the eye in the face of hypoperfusion.

The truth is, no one really knows how low is too low, so saying, "look, I'm not going to go below X" doesn't really get you anywhere. "Why X, and not Y?" It really depends on the patient, their baseline, their position, and, probably more than anything, bad luck. That's not to try to weasel out of the blame, but just to point out that it's more complex than it sounds. The caveat is those cases where it's due to central retinal artery occlusion, it is probably mostly or solely the anesthesiologist's responsibility since they confirm and monitor the patient's position.

Anyway, this really wasn't supposed to be a discussion about who's to blame when it happens, but I'm postcall, so you get a rant.

 

[Dimoak]

This is all well and good, but believe it or not, there is occasionally a lot of pressure (often in the form of whining, foot stomping, and the like) to lower a patient's BP in these cases. I've even heard things like, "I'll have to stop the case if we can't get the BP down so this bleeding stops." Who's to blame, the surgeon for requesting/demanding it, or the anesthesiologist for giving in? Recognize that when you say "pass it along to someone who may be a better provider for it," what that really means in this case is "someone more willing to acquiesce to the surgeon's demand for lower BP and/or take the heat for a bad outcome." It's not like there's some secret technique that some "better provider" is going to come up with to protect the eye in the face of hypoperfusion.

The truth is, no one really knows how low is too low, so saying, "look, I'm not going to go below X" doesn't really get you anywhere. "Why X, and not Y?" It really depends on the patient, their baseline, their position, and, probably more than anything, bad luck. That's not to try to weasel out of the blame, but just to point out that it's more complex than it sounds. The caveat is those cases where it's due to central retinal artery occlusion, it is probably mostly or solely the anesthesiologist's responsibility since they confirm and monitor the patient's position.

Anyway, this really wasn't supposed to be a discussion about who's to blame when it happens, but I'm postcall, so you get a rant.

Yes, and in the majority of routine and elective cases, accomodating a surgeon unhappy with the BP will most likely not lead to seriously adverse consequences. But for lengthier cases such as trauma and deformity repairs, research is beginning to emerge suggesting that depressing BP to a certain point for a certain length of time is EBM counterindicated in certain conditions, unless certain other steps are taken. The point I was trying to make is that if Anesthesiologists find themselves in positions where the care they are expected to provide exceeds what they are comfortable in doing, they should seek assistance from someone who can provide the necessary care. Given the extremely rare incidence of complications from inducing hypotension, I assume most Anesthesiologists wouldn't have too much of a problem doing this. But the surgeon shouldn't have sole responsibility to be flexibile in how the procedure is done, or to work faster than they are reasonably comfortable; the entire healthcare team goes works together to achieve the maximum desired outcome, and as such, no one member should be expected to shoulder all the blame.

 

[Planktonmd]

4. I get very frustrated with our anesthesia folks who talk to and terrify our patients just prior to surgery while talking about the rare complication of blindness that the surgeon may cause. Yet those same folks fail to mention the much more likely complication of anesthesia causing chipped teeth, lip lacerations, tongue ulcerations, blepharoplasty via hasty tape removal, or acute renal failure due giving too little IV fluid to avoid the unsightly facial swelling that seems to bother our anesthesia folks soo much. Not to mention the post-op hypotension that accompanies it which requires much higher maintenance fluid and frequent fluid boluses post-op.

No, I'm not bitter.

So, you are frustrated with the anesthesiologists who are trying to inform the patients about a potentially devastating complication like blindness!
Let me ask you this: since you are frustrated, would you promise us that if a patient loses vision you would go straight to them and tell them that the blindness was actually a surgical complication and it's not an anesthetic complication?
Would you have the courage to go tell them that the main reason they became blind was that your surgery was too long or was because you lost too much blood?
I hope that your frustration with us does not prevent you from being straight forward with the patients when a bad outcome happens and I hope that you are not frustrated enough with us that you would lie to the patients and tell them that they became blind because of anesthesia (as I had heard with my own ears once before).

 

[Planktonmd]

The only accepted risk factors for visual loss as far as we know today are:
1- Length of surgery
2- Low hematocrit
3- Blood transfusion
4- Prone position
5- Low BP

 

[Bertelman]

Yes, and in the majority of routine and elective cases, accomodating a surgeon unhappy with the BP will most likely not lead to seriously adverse consequences. But for lengthier cases such as trauma and deformity repairs, research is beginning to emerge suggesting that depressing BP to a certain point for a certain length of time is EBM counterindicated in certain conditions, unless certain other steps are taken. The point I was trying to make is that if Anesthesiologists find themselves in positions where the care they are expected to provide exceeds what they are comfortable in doing, they should seek assistance from someone who can provide the necessary care. Given the extremely rare incidence of complications from inducing hypotension, I assume most Anesthesiologists wouldn't have too much of a problem doing this. But the surgeon shouldn't have sole responsibility to be flexibile in how the procedure is done, or to work faster than they are reasonably comfortable; the entire healthcare team goes works together to achieve the maximum desired outcome, and as such, no one member should be expected to shoulder all the blame.

But you believe anesthesia should carry more blame than anyone else?

Plank's risk factors associated with POVL are correct. Count how many are modified by anesthesia. (hint- it's not "more than half")

In terms of visual loss, IMHO, at least half of the fault lays with Anesthesia.

 

[Gern Blansten]

The only accepted risk factors for visual loss as far as we know today are:
1- Length of surgery
2- Low hematocrit
3- Blood transfusion
4- Prone position
5- Low BP

for anterior ischemic optic neuropathy, add congenitally small, crowded optic disk. Crowding of the nerve fibers as they pass through the lamina which is rigid and non- distensible. Is not a factor in posterior ION. These are the patients who have blindness from AION after taking sildenafil and other PDE-type 5 inhibitor drugs.

 

[pgg]

Yet those same folks fail to mention the much more likely complication of anesthesia causing chipped teeth, lip lacerations, tongue ulcerations, blepharoplasty via hasty tape removal, or acute renal failure due giving too little IV fluid to avoid the unsightly facial swelling that seems to bother our anesthesia folks soo much. Not to mention the post-op hypotension that accompanies it which requires much higher maintenance fluid and frequent fluid boluses post-op.

FWIW, as an anesthesia resident, I always tell all of my patients "it's possible but very unlikely that you'll have a bruised lip or chipped tooth from the breathing tube" and my consent spiel always, always includes the words "organ damage or death" at some point ... typically with some appropriate qualifier like "there's nothing about you that makes us think you're at significant risk for any of these problems." Or if the patient is stupendously obese, has an EF of 20%, a huge mediastinal mass, etc I'll tell them that whatever condition they have puts them at somewhat higher risk, that we'll be especially attentive to that issue, but that some risk is unavoidable.

Most patients aren't stupid. They know they're not in the hospital for ice cream or the pleasure of a bowel prep; they're in the hospital to get knocked out and cut on. I find they're appreciative of a frank, compassionate discussion about risk. It's possible to tell patients about the risk of catastrophic complications without freaking them out ... all in the delivery. And worth the extra 30 seconds to do properly.

I always mention blindness for cardiac and prone spine cases.

I agree that informed consent is a myth; no lay person can possibly be truly informed. They count on us to use our education, training, and experience to help them weigh the risks and benefits of surgery and anesthesia. Obviously we can't list, explain, and give odds for every single conceivable complication but I do think that especially devastating complications, even if very rare, deserve mentioning.

Blindness certainly qualifies, especially since it's non-intuitive to the lay person. Most CABG patients understand someone's going to cut on their heart and they may worry about the risk of a catastrophic perioperative MI or death; but blindness? Not even on their radar. Patients get angry and sue when they feel lied to or patronized - it's easy for me to see how a devastating complication that literally comes out of nowhere (from their perspective) can tilt them toward anger at the surgeon or anesthesiologist who didn't see fit to mention it.

 

[beaverfetus]

FWIW, as an anesthesia resident, I always tell all of my patients "it's possible but very unlikely that you'll have a bruised lip or chipped tooth from the breathing tube" and my consent spiel always, always includes the words "organ damage or death" at some point ... typically with some appropriate qualifier like "there's nothing about you that makes us think you're at significant risk for any of these problems." Or if the patient is stupendously obese, has an EF of 20%, a huge mediastinal mass, etc I'll tell them that whatever condition they have puts them at somewhat higher risk, that we'll be especially attentive to that issue, but that some risk is unavoidable.

Most patients aren't stupid. They know they're not in the hospital for ice cream or the pleasure of a bowel prep; they're in the hospital to get knocked out and cut on. I find they're appreciative of a frank, compassionate discussion about risk. It's possible to tell patients about the risk of catastrophic complications without freaking them out ... all in the delivery. And worth the extra 30 seconds to do properly.

I always mention blindness for cardiac and prone spine cases.

I agree that informed consent is a myth; no lay person can possibly be truly informed. They count on us to use our education, training, and experience to help them weigh the risks and benefits of surgery and anesthesia. Obviously we can't list, explain, and give odds for every single conceivable complication but I do think that especially devastating complications, even if very rare, deserve mentioning.

Blindness certainly qualifies, especially since it's non-intuitive to the lay person. Most CABG patients understand someone's going to cut on their heart and they may worry about the risk of a catastrophic perioperative MI or death; but blindness? Not even on their radar. Patients get angry and sue when they feel lied to or patronized - it's easy for me to see how a devastating complication that literally comes out of nowhere (from their perspective) can tilt them toward anger at the surgeon or anesthesiologist who didn't see fit to mention it.

pretty great post. I'd certainly appreciate the discussion you're describing.

 

[Chronic Student]

So, you are frustrated with the anesthesiologists who are trying to inform the patients about a potentially devastating complication like blindness!
Let me ask you this: since you are frustrated, would you promise us that if a patient loses vision you would go straight to them and tell them that the blindness was actually a surgical complication and it's not an anesthetic complication?
Would you have the courage to go tell them that the main reason they became blind was that your surgery was too long or was because you lost too much blood?
I hope that your frustration with us does not prevent you from being straight forward with the patients when a bad outcome happens and I hope that you are not frustrated enough with us that you would lie to the patients and tell them that they became blind because of anesthesia (as I had heard with my own ears once before).

I think you are taking it personal and have not really read what I have written.

Point #1: They are stressing a single rare complication above all others while failing to mention much more likely and just as serious, if not more so, complications.

Point #2: No I would not claim it as a strictly surgical complication, because we don't know the exact etiology. We would however have accepted fault right away.

Point #3: We always let patients know how long the surgery would be and would admit that it may have played a role. I can remember over a dozen patients over the years who have refused surgery due to stated length of operation.

Point #4: As I have already stated, if you would have read, it is rare for us to lose more than 20-50 cc's on an ACDF and more than 200-250 cc's on a lumbar fusion. Fanatical for hemostasis. Not from hypotension either. Careful tissue handling and gentle bipolar cautery.

Point #5: My we are sensitive. I would not lie to a patient and the first complication I always mention is death.

I always include these things: Death, infection, continuation of pain, recurrence, non-union (if indicated), injury to recurrent laryngeal nerve (if indicated), hemorrhage, infection, injury to nerves or nerve roots, CSF leak, weakness, paralysis, blindness, instability, devastating neurologic complication, DVT, PE, stroke and MI. All of these in capital letters and I always ask if they have questions, if all of their questions are answered and if there is anything that I have not explained well. I go to greater length and pain than anyone else I know of.

In the end my frustration is the same. Trumpeting one rare complication above all others, while ignoring other more likely scenarios and doing it in holding. Why not do it in pre-op clinic where I can then have time to give them information, answer questions and ally fears of the patients and family members.

What they and the family hear right before going back is you can go blind and thats what the families tell me they think about the entire time in the waiting room.

Forgot to add that most of the folks who do this are CRNAs and they make it sound as if its commonplace.

 

[Chronic Student]

FWIW, as an anesthesia resident, I always tell all of my patients "it's possible but very unlikely that you'll have a bruised lip or chipped tooth from the breathing tube" and my consent spiel always, always includes the words "organ damage or death" at some point ... typically with some appropriate qualifier like "there's nothing about you that makes us think you're at significant risk for any of these problems." Or if the patient is stupendously obese, has an EF of 20%, a huge mediastinal mass, etc I'll tell them that whatever condition they have puts them at somewhat higher risk, that we'll be especially attentive to that issue, but that some risk is unavoidable.

Most patients aren't stupid. They know they're not in the hospital for ice cream or the pleasure of a bowel prep; they're in the hospital to get knocked out and cut on. I find they're appreciative of a frank, compassionate discussion about risk. It's possible to tell patients about the risk of catastrophic complications without freaking them out ... all in the delivery. And worth the extra 30 seconds to do properly.

I always mention blindness for cardiac and prone spine cases.

I agree that informed consent is a myth; no lay person can possibly be truly informed. They count on us to use our education, training, and experience to help them weigh the risks and benefits of surgery and anesthesia. Obviously we can't list, explain, and give odds for every single conceivable complication but I do think that especially devastating complications, even if very rare, deserve mentioning.

Blindness certainly qualifies, especially since it's non-intuitive to the lay person. Most CABG patients understand someone's going to cut on their heart and they may worry about the risk of a catastrophic perioperative MI or death; but blindness? Not even on their radar. Patients get angry and sue when they feel lied to or patronized - it's easy for me to see how a devastating complication that literally comes out of nowhere (from their perspective) can tilt them toward anger at the surgeon or anesthesiologist who didn't see fit to mention it.

I agree with you totally and would have absolutely no problem with this approach.

 

[Licoricestick]

It is also very rare to have a patient wake up with any pain at all.

I love it when the surgeons take the credit for pain free patients post op. Of course, the uncomfortable patient is the anesthesiologist's fault.

 

[Dimoak]

But you believe anesthesia should carry more blame than anyone else?
Plank's risk factors associated with POVL are correct. Count how many are modified by anesthesia. (hint- it's not "more than half")

Certainly not; as I mentioned in my earlier posts, I believe that if there is any blame to be had for any potentially avoidable (I use that term loosely) complication, it falls on the entire health care team, and not on any one of the providers. The line you quoted below your post was in reference to POVL caused by parameters controlled by the Anesthesia and not meant to be taken out of context. In a case where POVL occurs as a result of hypotension, the blame shouldn't rest entirely on the surgeon for taking too long.

 

[Bertelman]

Certainly not; as I mentioned in my earlier posts, I believe that if there is any blame to be had for any potentially avoidable (I use that term loosely) complication, it falls on the entire health care team, and not on any one of the providers. The line you quoted below your post was in reference to POVL caused by parameters controlled by the Anesthesia and not meant to be taken out of context. In a case where POVL occurs as a result of hypotension, the blame shouldn't rest entirely on the surgeon for taking too long.

In the end, I'm not convinced anyone can reliably look at a case record of POVL and state with confidence it occurred solely because of hypotension. There are instances of POVL where hypotension was not present. So it's nice to say anesthesia should shoulder more than half the blame when hypotension occurs, but it's not always so easy to attribute the POVL to hypotension alone.

 

[Planktonmd]

So, you tell them that they might die because of the surgery but you think telling them that they might become blind is not needed because it's so rare?
Do you have more patients that die than patients that become blind?
Is it possible that if you included that complication in your discussion with the patient there wouldn't be a reason for you to get so frustrated with us telling them?
Although I understand that this might make it difficult to say it's anesthesia's fault when it really happens but I am sure you still can find a way to imply that we caused it.
I am not taking it personal, I am just demonstrating the issues with your statement about being frustrated with us talking to patients about a complication that you intentionally ignore which I personally find frustrating and annoying.

I always include these things: Death, infection, continuation of pain, recurrence, non-union (if indicated), injury to recurrent laryngeal .....

 

[Chronic Student]

So, you tell them that they might die because of the surgery but you think telling them that they might become blind is not needed because it's so rare?
Do you have more patients that die than patients that become blind?
Is it possible that if you included that complication in your discussion with the patient there wouldn't be a reason for you to get so frustrated with us telling them?
Although I understand that this might make it difficult to say it's anesthesia's fault when it really happens but I am sure you still can find a way to imply that we caused it.
I am not taking it personal, I am just demonstrating the issues with your statement about being frustrated with us talking to patients about a complication that you intentionally ignore which I personally find frustrating and annoying.

Once again, you might actually read my post.

If you look through the list of complications I routinely mention blindness is there.

For spine surgery the number of patients that we have had that become blind and/or die is the same N=0.

I don't know how many times I can repeat this same thing but, I'll try anyway. My issue is with the fact that one rare complication is stressed above all others while more common things are ignored. In addition, doing it right before we take someone back for surgery annoys me.

I also assume you are calling me a liar. Obviously, all you have is my word and obviously you do not trust that. I'm fairly certain that I'm not going to change your mind.

 

[Chronic Student]

I love it when the surgeons take the credit for pain free patients post op. Of course, the uncomfortable patient is the anesthesiologist's fault.

Most of the folks who have true radiculopathy have pain no matter how much medication is onboard. If you give them enough to take it away completely they are comatose.

After watching hundreds of radiculopathy patients wake up I can tell you that even properly medicated patients can tell upon waking when pain, tingling and numbness are gone and when strength returns in holding.

Why do you all have to make this an anesthesia vs surgery thing.

I have very few problems with our anesthesia folks. We rarely have cases cancel, the appropriate things are done and we don't have patients vomiting all over the place post-op or crying for pain meds.

This one issue I mentioned is one of the very few sore points in an otherwise happy relationship.

I just wonder if the stressing of this one complication is due to the recent focus on it and if it won't be some other rare complication a couple of years from now.

MH used to be treated like this when it had gotten more attention and then folks stopped mentioning that complication as much.

 

[Dimoak]

In the end, I'm not convinced anyone can reliably look at a case record of POVL and state with confidence it occurred solely because of hypotension. There are instances of POVL where hypotension was not present. So it's nice to say anesthesia should shoulder more than half the blame when hypotension occurs, but it's not always so easy to attribute the POVL to hypotension alone.

I'm not sure if I've ever heard of a POVL case where there was no unintended surgical nerve compromise and no perioperative bp suppression. That's not to say it never happened, of course, but I'd imagine such a case would be fairly uncommon in terms of developing EBM guidelines. The ASA are the experts in this phenomenon, and it seems that the causes have been narrowed down to hypoperfusion of the optic nerve and intraocular pressure from pts laying prone for too long. In the former case, the etiology has not been conclusively established, but the educated suspicions include hypotension (which is why many are now suggesting reducing the degree of bp suppression during certain surgeries) and occlusive phenomena (which is also within the scope of Anesthesia). At the same time, the rest of the operative team should also be working to reduce the other potential risk factors, including operative time, blood loss, etc. IMHO, even though there isn't any one cause proven to cause POVL, it's still everyone's duty to adhere to suggestions established based on educated suspicions as far as it would be feasible.

 

[Gern Blansten]

I'm not sure if I've ever heard of a POVL case where there was no unintended surgical nerve compromise and no perioperative bp suppression.

What nerve are you talking about compromising surgically? I thought the discussion was spine surgery and POVL.
The cases you have never heard of exist. Those cases where there is minimal blood loss, no hypotension, short duration, and no pressure on the eyes make it difficult to nail down the ultimate risk factors. It is true that most cases involve one of the major risk factors elucidated above by Plankton, but the outliers exist and Lorri Lee has discussed these cases in her publications on the topic.

 

[Gern Blansten]

MH used to be treated like this when it had gotten more attention and then folks stopped mentioning that complication as much.

MH is captured when you say potentially life threatening reactions to medications. Blindness is nowhere on the patients radar screen. Most people understand reactions to medicines can occur, even though they may not understand the implications of MH.
I warn all of my spine patients of the extremely rare complication of vision loss. I don't try to frighten them and I make sure they understand that I believe it to be extremely unlikely that it would occur, but not impossible. I would never imply that a certain complication is more likely due to the surgeon they have chosen.

 

[Raygun77]

I changed my standard "not do anything meaningful afterwards"

If you're dead, or so ill that death will follow after a period of hospitalization, that qualifies.

If you've lost your primary sense (sight), so that you can no longer experience much of anything, that counts.

If you can't even think and aren't even the same person anymore because a stroke killed a key chunk of your brain, that especially counts.

Obviously, even someone with body dismorphic disorder could be treated for a scar. But no treatment can replace lost eyes or brain tissue or lower body control.

But, yes, I've thought about it for about 15 minutes, and it's really hard to put a hard limit on what complications I would consider to be effectively death or as bad as death, such that suicide would be a rational choice. Near complete paralysis, near total blindness AND near total deafness at the same time, a major stroke...the list isn't really all that long. Even if one became blinded, it might be possible to go on living and to eke out enough enjoyment of life that one wanted to continue living.

It 'might' be possible to go on living and 'eke' out enjoyment????

Wow.
So you've never come across a blind person who's happy, outgoing and generally okay with their lot in life? The way you paint it they'd be the exception to the rule, however in my experience, it's the vice versa.

Research shows that people adapt to blindness. Neuroplasticity enables the other senses to compensate- in fact one of our professors, when describing neuroplasticity, told us that blind patients reading braille in fact engaged the same regions of the brain as that for reading visually (ie, regions in the occipital lobe)- which to me indicates equality in perception and quality of the experience. Sure, you or I could probably not imagine being blind, or reading with our fingers...but give it a decade and I'm sure our brain would rewire itself such that it felt like the most natural thing in the world!

I guess I have a problem with how dire you paint blindness out to be. It's true- people equate living with seeing, and blindness would seem like a devastating complication to the majority of people. But people don't realise how much they'll adapt. And in a risk-benefit analysis (and let's face it- everything in medicine is) shouldn't other, more common risks be emphasised more than say blindness, rather than blindness getting it's own special spiel just because it has this stigma?

Personally I think "major neurological deficit" should be explained to include sensory deficit, including vision. It definitely should get it's own mention. But more common risks should definitely get more time in their explanation. Just because patient's can't 'see' their pulmonary embolism, doesn't mean it won't detriment their quality of life significantly.

My opinion, so feel free to constructively criticize.

 

[Dimoak]

What nerve are you talking about compromising surgically? I thought the discussion was spine surgery and POVL.
The cases you have never heard of exist. Those cases where there is minimal blood loss, no hypotension, short duration, and no pressure on the eyes make it difficult to nail down the ultimate risk factors. It is true that most cases involve one of the major risk factors elucidated above by Plankton, but the outliers exist and Lorri Lee has discussed these cases in her publications on the topic.

Gern, I was referring to NS cases in general that involved vision loss.
As I mentioned in my previous post, I'm certain such cases have indeed happened. I admittedly am not too familiar with the literature, but from what I've read, including some of Lorri Lee's recent publications that were available (ASA registry, etc.) even then she seems to be focusing on hypotension and blood loss as the most likely culprits for ION-induced POVL, with obstruction of blood supplies being a rather distant second. The outlier cases are available, but are almost statistically insignificant compared to the more common incidences of POVL, and so at this point, offer little recourse on how to address them.

 

[facetguy]

Speaking of spine surgery complications, I just read this tonight:


DEATHS AFTER BACK SURGERY OFTEN RELATED TO ANALGESICS:
NEW YORK (Reuters Health) Apr 10 - Roughly one in five deaths after lumbar fusion surgery is related to analgesic use, according to a report in the April 1st issue of Spine.
The results indicate that the risk of such deaths is particularly high in young and middle-aged workers with degenerative disc disease.
To examine complications after lumbar fusion surgery, lead author Dr. Sham Maghout Juratli from the University of Washington, Seattle, and colleagues analyzed workers' compensation claims filed by lumbar fusion patients in Washington State from 1994 to 2001. Washington State vital statistics records were used to assess mortality through 2004.
Data from 2378 patients were included in the analysis. The mortality rate at 90 days was 0.29%, the authors note. Over 3 years, 103 patients died, for a 3-year cumulative mortality rate of 1.93%.
Repeat fusions were found to predict perioperative mortality.
After adjusting for age and gender, 3.1 deaths occurred per 1000 worker-years.
There were 22 analgesic-associated deaths (19 accidental poisonings, 3 suicides). These accounted for 21% of all deaths and for 31.4% of all potential life lost.
Use of cage devices for fusion and the presence of degenerative disc disease were both risk factors for analgesic-related death. In subjects between 45 and 54 years of age, degenerative disc disease increased the odds of analgesic-related death by 7.45-fold (p = 0.01).
"The most important finding of this study was that analgesic-related deaths, both suicidal and accidental, claimed the highest potential life lost (31.4%), more than heart disease (9.2%), cancer (9.1%), and liver disease (5.1%), combined," the investigators conclude.
Spine 2009;34.

 

[Planktonmd]

Why do you find this surprising?
This study is basically saying that unfortunately we are turning chronic pain patients in to drug abusers and drug addicts and that many abusers and addicts die of overdose (intentionally or by accident).

Speaking of spine surgery complications, I just read this tonight:


DEATHS AFTER BACK SURGERY OFTEN RELATED TO ANALGESICS:
NEW YORK (Reuters Health) Apr 10 - Roughly one in five deaths after lumbar fusion surgery is related to analgesic use, according to a report in the April 1st issue of Spine.
The results indicate that the risk of such deaths is particularly high in young and middle-aged workers with degenerative disc disease.
To examine complications after lumbar fusion surgery, lead author Dr. Sham Maghout Juratli from the University of Washington, Seattle, and colleagues analyzed workers' compensation claims filed by lumbar fusion patients in Washington State from 1994 to 2001. Washington State vital statistics records were used to assess mortality through 2004.
Data from 2378 patients were included in the analysis. The mortality rate at 90 days was 0.29%, the authors note. Over 3 years, 103 patients died, for a 3-year cumulative mortality rate of 1.93%.
Repeat fusions were found to predict perioperative mortality.
After adjusting for age and gender, 3.1 deaths occurred per 1000 worker-years.
There were 22 analgesic-associated deaths (19 accidental poisonings, 3 suicides). These accounted for 21% of all deaths and for 31.4% of all potential life lost.
Use of cage devices for fusion and the presence of degenerative disc disease were both risk factors for analgesic-related death. In subjects between 45 and 54 years of age, degenerative disc disease increased the odds of analgesic-related death by 7.45-fold (p = 0.01).
"The most important finding of this study was that analgesic-related deaths, both suicidal and accidental, claimed the highest potential life lost (31.4%), more than heart disease (9.2%), cancer (9.1%), and liver disease (5.1%), combined," the investigators conclude.
Spine 2009;34.

 

[facetguy]

Why do you find this surprising?
This study is basically saying that unfortunately we are turning chronic pain patients in to drug abusers and drug addicts and that many abusers and addicts die of overdose (intentionally or by accident).

I didn't mean to imply that I was particularly surprised. I guess it just struck me that, despite undergoing surgery, so many patients still require so much medication that they are dying from it.

 

[Bertelman]

Gern, I was referring to NS cases in general that involved vision loss.
As I mentioned in my previous post, I'm certain such cases have indeed happened. I admittedly am not too familiar with the literature, but from what I've read, including some of Lorri Lee's recent publications that were available (ASA registry, etc.) even then she seems to be focusing on hypotension and blood loss as the most likely culprits for ION-induced POVL, with obstruction of blood supplies being a rather distant second. The outlier cases are available, but are almost statistically insignificant compared to the more common incidences of POVL, and so at this point, offer little recourse on how to address them.

Another interpretation is that she focused on hypotension and blood loss because those factors are somewhat within our control.

 

[Dimoak]

Another interpretation is that she focused on hypotension and blood loss because those factors are somewhat within our control.

Hence the last sentence in my post.