Spine Surgeons Striving to Increase POVL Awareness

Jens Chapman, MD

Without doubt, the subjects of posterior ischemic optic neuropathy (PION), specifically, and perioperative blindness, in general, remain particularly bitter and challenging aspects of surgical care for all parties involved. Despite best efforts by many dedicated researchers there continues to be a lack of understanding of the true incidence of this potentially devastating event, with many of its pathophysiologic causes and potential for intraoperative monitoring unclear. Sadly, prevention efforts for PION and actual treatment remain at least equally as elusive to date. As far as we now know, major reconstructive spine surgery is one of the subspecialties more prevalently affected by perioperative visual loss (POVL), with magnitude and duration of surgery as well as positioning identified as potential contributing factors.

In this context, preoperative counseling of patients achieves a higher relevance than might usually be considered for adverse occurrences considered exceedingly rare by many surgeons. Similar to other well-recognized devastating perioperative events, such as death, paralysis, and stroke, blindness, due to its potential impact on patients’ lives, should receive equal recognition in discussions with patients prior to engaging in elective procedures. Of course this discussion is difficult in many ways, since the topic of blindness especially strikes many patients entirely unprepared as they contemplate a procedure such as elective spine surgery. With no firm footing as to data on incidence and clear prevention strategies available to clinicians, entering this area of discussion is undoubtedly uncomfortable for many of us surgeons. As we strive for excellence in all aspects of health care delivery and are often challenged to present complex clinical information pertinent to specific conditions to patients in a meaningful condensed fashion, the added discussion of such extraneous sounding events as POVL may sound like an unwanted distraction from our essential mission. However, having personally been involved in the care of patients who have experienced POVL for unknown reasons, there is little doubt that a clear preoperative discussion of this entity helps set the stage for a continued, productive physician-patient interaction in the unlikely case of its actual occurrence. As devastated as patients, their families, and all affected care providers are about unexpected significant POVL, the most meaningful care under such circumstances can be provided in an atmosphere of trust and open communication between these affected parties. As spine surgeons, we are striving to increase awareness about POVL through several of our professional societies. I personally view preoperative consenting with inclusion of perioperative blindness as a first step to raising disease awareness as well as diagnosis and treatment. Through more transparent documentation, we all can hope to make headway on the physiology, prevention, monitoring, and eventual treatment of these conditions.

Dr. Chapman is Professor and Director, Spine Service, and holder of the Hans Jöerg Wyss Endowed Chair at the University of Washington, Seattle, WA.