To the Editor
The image of the Titan Atlas holding planet earth on his shoulders comes to mind when thinking about the issue I wish to discuss here: is postoperative visual loss (POVL) after surgery and specifically after spine surgery an anesthetic issue? Is POVL an anesthetic complication per se?1,2 Tremendous effort and resources have been placed to attempt to elucidate and therefore control some of the factors associated with this complication in an effort to decrease this devastating consequence of spine surgery, but there are still more questions than answers.3 Medico-legally this has tremendous implications, and although I am glad and proud that anesthesiology as a specialty has taken a leading role in trying to prevent and treat this condition, I am not so content that it seems that we are like Atlas, “holding the planet on our shoulders.” Our contribution to the prevention and treatment of the pathophysiological effects of the prone position is very important but limited.4 We have no control over some of the variables that seem to be of importance: size and weight of the patients, coexistent diseases like diabetes and peripheral vascular disease, and last and not least surgical factors: are we responsible for factors like extent of bleeding and/or duration of surgery? How often do we have to discuss (dare I say argue) with our surgical colleagues about the need to transfuse patients during spine procedures? What about issues of induced hypotension? When we are asked to lower the BP for surgical reasons, are there any real anesthetic advantages of doing this or do we do it because of surgical issues? Are most surgeons really open minded to even discuss staged procedures? I could go on and on. The bottom line is that I believe surgical and surgeon factors should be heavily scrutinized and the issue of POVL should be viewed as a shared responsibility between surgeons and anesthesiologists. We should continue to study and lead the research in this field to attempt to establish and treat the etiological factors associated with this dreadful complication, but we should not be in this alone and surgeons should be not just interested as I am sure they are, but should play an active role in this topic that obviously impacts their patients and them as well.
Warner MA. Postoperative visual loss: experts, data, and practice. Anesthesiology 2006;105:641-2.
Lee LA, Roth S, Posner KL, et al. The American Society of Anesthesiologists Postoperative Visual Loss Registry: analysis of 93 spine surgery cases with postoperative visual loss. Anesthesiology 2006;105:652-9; quiz 867-8.
Heitz JW, Grunwald Z. Etiology of postoperative visual loss not always as obvious as it appears to be. Anesth Analg 2007;105:1171-2; author reply 1172.
Edgcombe H, Carter K, Yarrow S. Anaesthesia in the prone position. Br J Anaesth 2008;100:165-83.