Prone Spine Surgery Research Articles

Investigating Optic Nerve Sheath Diameter in Prone Position Spinal Surgery Patients: A Pilot Study.

This study aimed to evaluate the effect of intraoperative positioning and ocular immobility on the amount of cerebrospinal fluid around the optic nerve in patients undergoing prone spinal surgery by measuring the optic nerve sheath diameter (ONSD) using ultrasound. Consecutive participants (n = 15 patients, 30 eyes) were scanned preoperatively, intraoperatively approximately 20 minutes before the end of the surgery, and postoperatively in the post-anesthesia care unit at least 10 min after the completion of the surgery at one academic hospital. On average, patients who underwent prone spinal surgery had a 21% increase in ONSD intraoperatively, with a positive time-dependent relationship with the overall length of surgery (P 0.001). ONSDs postoperatively returned to baseline and were not significantly different from preoperative measurements. Our findings suggest pooling and inadequate clearance of perioptic cerebrospinal fluid during prone spinal surgery that improves following termination of the procedure and return of the patient to an upright position.

Hemodynamic effects of withholding vs. continuing angiotensin II receptor blockers on the day of prone positioning spinal surgery in elderly patients.

The hemodynamic effects of withholding vs. continuing angiotensin II receptor blockers (ARBs) before surgery in elderly patients undergoing spinal surgery in a prone position during anesthesia induction to skin incision are still unknown. In this prospective study, 80 patients undergoing spinal surgery in a prone position with general anesthesia, aged 60-79 years, American Society of Anesthesiologists (ASA) II or III, were enrolled. Patients who had ARBs only in their preoperative medication list were randomly divided into two groups at a 1:1 ratio: In Group A, ARBs were continued on the morning of surgery, while in Group B, they were withhold. Norepinephrine was infused to maintain the blood pressure at the baseline level of ±20% during anesthesia induction in all patients. The primary outcome was the consumption of norepinephrine in each group from anesthesia induction to skin incision. The secondary outcomes include changes in invasive arterial blood pressure and heart rate, the fluid infusion volumes, the amounts of anesthetic drugs, and the total time from induction to skin incision. There were no significant differences in the demographics, the fluid infusion volumes, the amounts of anesthetic drugs, the total time from induction to skin incision, and hemodynamics at different time points (p > 0.05), while significant differences were found in norepinephrine consumption between the two groups (p < 0.001). Compared with Group B, the consumption of norepinephrine increased significantly in Group A (93.3 ± 29.8 vs. 124.1 ± 38.7 μg, p = 0.000). In addition, the same trend was illustrated in the pumping rate of norepinephrine between Group B (0.04 ± 0.01 μg·kg-1·min-1) and Group A (0.06 ± 0.02 μg·kg-1·min-1) (p = 0.004). Our study conducted in elderly patients with hypotension undergoing prone spinal surgery demonstrated a greater pumping rate of norepinephrine during anesthesia induction in patients with ARBs continuing before surgery than those withholding, indicating that it was more difficult to maintain hemodynamic stability.Clinical Trial Registration: https://www.chictr.org.cn/showproj.html?proj=141081, ChiCTR2100053583.

Advances in the Use of Prone Cardiopulmonary Resuscitation During Spinal Surgery in the Prone Position

Spinal surgery is usually performed in the prone position, which is a longer and more difficult procedure and is prone to complications such as circulatory dysfunction and stress injuries. Among them, stress injury is the main complication of prone spine surgery, but the reasons for stress injury in prone spine surgery are not clear, and whether prone cardiopulmonary resuscitation (CPR) can be used needs to be further verified. Supine cardiopulmonary resuscitation is commonly used in posterior spinal surgery, retroperitoneal surgery, and so on, which can effectively improve the patient’s hypoxemia. Such surgeries require a high level of anesthetic management, and cardiopulmonary resuscitation is necessary if a patient in a prone position experiences cardiac arrest. In the process of cardiopulmonary resuscitation, supine cardiopulmonary resuscitation is often used, especially for some obese patients, if they are immediately changed to the supine position, it takes up more time, there may be wound infection, and there is a possibility of missing the optimal rescue and resuscitation time. Based on this, this paper reviews the use of prone-position cardiopulmonary resuscitation for spinal surgery in the prone position.

Small tidal volume hyperventilation relieves intraocular and intracranial pressure elevation in prone spinal surgery: a randomized controlled trial

To investigate the effects of different ventilation strategies on intraocular pressure (IOP) and intracranial pressure in patients undergoing spinal surgery in the prone position under general anesthesia. Seventy-two patients undergoing prone spinal surgery under general anesthesia between November, 2022 and June, 2023 were equally randomized into two groups to receive routine ventilation (with Vt of 8mL/kg, Fr of 12-15/min, and etCO2 maintained at 35-40 mmHg) or small tidal volume hyperventilation (Vt of 6 mL/kg, Fr of18-20/min, and etCO2 maintained at 30-35 mmHg) during the surgery. IOP of both eyes (measured with a handheld tonometer), optic nerve sheath diameter (ONSD; measured at 3 mm behind the eyeball with bedside real-time ultrasound), circulatory and respiratory parameters of the patients were recorded before anesthesia (T0), immediately after anesthesia induction (T1), immediately after prone positioning (T2), at 2 h during operation (T3), immediately after supine positioning after surgery (T4) and 30 min after the operation (T5). Compared with those at T1, IOP and ONSD in both groups increased significantly at T3 and T4(P < 0.05). IOP was significantly lower in hyperventilation group than in routine ventilation group at T3 and T4(P < 0.05), and ONSD was significantly lower in hyperventilation group at T4(P < 0.05). IOP was positively correlated with the length of operative time (r=0.779, P < 0.001) and inversely with intraoperative etCO2 at T3(r=-0.248, P < 0.001) and T4(r=-0.251, P < 0.001).ONSD was correlated only with operation time (r=0.561, P < 0.05) and not with IOP (r=0.178, P>0.05 at T3; r=0.165, P>0.05 at T4). Small tidal volume hyperventilation can relieve the increase of IOP and ONSD during prone spinal surgery under general anesthesia.

Perioperative Vision Loss Following Prone Spine Surgery: A Case-Control Study

PurposePerioperative vision loss (POVL) is a rare and devastating complication following prone spine surgery. Due to the rare nature of this complication, there is limited research available about patient and surgical risk factors that increase the risk of POVL. Study DesignThis study utilized a case-control secondary data analysis methodology that included 5 cases of POVL and 250 controls from the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) database who all underwent prone spine surgery between 2010-2020. MethodsEach POVL case was matched to 50 randomly selected controls (n = 250) based on type and year of surgery. Demographics and variables of interest were compared among the POVL cases, among POVL cases and the aggregate control group (n = 250), and POVL cases against their matched control group. Univariate and multivariate conditional logistic regression were then used to estimate the odds of developing POVL in relation to potential patient and surgical risk factors. FindingsWhen POVL cases were compared to the 250 control cases using univariate analysis, patients who developed POVL were more likely to have received a blood transfusion within 72 hours of surgery (p < 0.0001). and have longer operative times (OR =1.01, 95% CI [1.003, 1.017], p = 0.003). ConclusionsTwo surgical risk factors were determined to be statistically significant, including the need for perioperative blood transfusion and prolonged operative time. These findings support previous research on POVL which often identified blood loss and prolonged operative times as surgical risk factors. The narrow patient population used in this project may have limited the ability to perform a more robust study on POVL. Therefore, further research on POVL using the NSQIP database is strongly encouraged.

Increase in Intraoperative Intraocular Pressure in the Prone Position.

This study aimed to measure the intraocular pressure (IOP) of patients undergoing open surgery in the supine position (control group) and spine surgery in the prone position (spine group) to clarify IOP range and change by posture, determine the risk factors for increased IOP in the prone position, and reduce visual complications after surgery in the prone position. A prospective cohort study was conducted in healthy adults (34-83 years of age) with an American Society of Anesthesiologists classification I/II. The spine group was examined for IOP, anterior chamber angle (ACA), and fundus findings the day prior to surgery. On the day of surgery, IOP measurements were taken at fixed time points: immediately after intubation; at 0.5, 1, and 2 h after intubation; at suture closure; and at the end of surgery in the control group. In the spine group, they were taken immediately after intubation; at 0.5, 1, and 2 h after prone position; at suture closure; and immediately and 5 min after returning to the supine position. The risk factors for increased IOP in the prone position were examined. The control group showed no significant changes in IOP within the normal range (<20 mmHg) during surgery. In the spine group, IOP was higher at each time point than immediately after intubation. IOP increased sharply above the normal range within 1 h after changing from the supine to the prone position and continued to gradually increase until suture closure. IOP decreased 5 min after the patient returned to the supine position. ACA, body mass index, blood loss, time in the prone position, and operative time were not risk factors for increased IOP in the prone position. Patients were constantly exposed to above-normal IOP during prone spinal surgery. However, neither group reported visual impairment. No risk factors were identified for increased IOP in the prone position.

An Innovative Prone-Position Head Support for Spine Surgery: An Alternative Aimed at Mitigating Risks while Maintaining Good Exposure and Facilitating Effective Anesthesiological Interventions - A Technical Note

This article aims to describe the development of a head support for prone spinal surgery, which allows the patient's head to be positioned in neutral alignment with the body and enables monitoring of the position of the eyes, mouth, nose, and orotracheal tube, thus avoiding damage due to poor positioning during surgery. A literature review was conducted focusing on complications resulting from head positioning in different supports to develop an option that would reduce the risks of injury. It was developed a support that protects the patient's head and allows easy visualization of the face during surgery, with sufficient space for the anesthesia team to manage the orotracheal tube if necessary. Since its creation, no serious complications have been observed in the use of this support.

The effect of restrictive vs. liberal fluid protocols on ocular parameters in patients undergoing prone spine surgery: a randomized controlled trial

BackgroundElevated intraocular pressure (IOP) and optic nerve edema occurring during prone surgeries may cause ocular and optic nerve ischaemia injury. We hypothesized that a liberal fluid protocol might further increase IOP and optic nerve sheath diameter (ONSD) than a restrictive fluid protocol for patients in the prone position.MethodsA single-centre, prospective and randomized trial was conducted. Patients were randomly allocated into 2 groups: the liberal fluid infusion group, in which repeated bolus doses of Ringer’s lactate solution were given to maintain pulse pressure variation (PPV) within 6~9%, and the restrictive fluid infusion group, where PPV was maintained within 13–16%. IOP and ONSD were measured in both eyes at 10min after the anaesthesia induction in the supine position, 10min after the prone position placement, and 1h and 2h since the prone position was placed, at the conclusion of surgery, and returned to the supine position.ResultsA total of 97 patients were recruited and completed the study. IOP increased significantly from 12±3mmHg in the supine position to 31±5 mmHg (p<0.001) at the end of surgery in the liberal fluid infusion group and from 12±2 to 28±4 mmHg (p<0.001) in the restrictive fluid infusion group. There was a statistically significant difference in the change of IOP over time between the two groups (p=0.019). ONSD increased significantly from 5.3±0.3mm in the supine position to 5.5±0.3mm (p<0.001) at the end of surgery in both groups (both p<0.001). There was no statistically significant difference in the change of ONSD over time between the two groups (p>0.05).ConclusionsCompared to the restrictive fluid protocol, the liberal fluid protocol increased IOP but not ONSD in patients undergoing prone spine surgery.Trial registrationThe study was registered in ClinicalTrials.gov (https://clinicaltrials.gov) prior to patient enrollment, ID: NCT03890510, on March 26, 2019. The principal investigator was Xiao-Yu Yang.

Rib fixation for flail chest physiology and the facilitation of safe prone spinal surgery: illustrative case.

Spine fractures are frequently associated with additional injuries in the trauma setting, with chest wall trauma being particularly common. Limited literature exists on the management of flail chest physiology with concurrent unstable spinal injury. The authors present a case in which flail chest physiology precluded safe prone surgery and after rib fixation the patient tolerated spinal fixation without further issue. Flail chest physiology can cause cardiovascular decompensation in the prone position. Stabilization of the chest wall addresses this instability allowing for safe prone spinal surgery. Chest wall fixation should be considered in select cases of flail chest physiology prior to stabilization of the spinal column in the prone position. Further research is necessary to identify patients that are at highest risk to not tolerate prone surgery.

Prone spine surgery in a morbidly obese patient: Anesthesia challenges and management

India is seeing a rapid epidemiological transition from underweight to overweight, with an overall prevalence of obesity reported to be 40.3%. Anesthesiology concerns in an obese patient are well known. We elaborate on the anesthesia management in a 68-year-old male patient with a body mass index of 66.3 kg/m2 who underwent spine surgery in prone position. Challenges faced ranged from the size of the table to the difficult airway, difficulty in positioning, maintenance of airway and ventilation, maintaining a free abdomen, and anesthesia management with meticulous use of anesthetic drugs for an uneventful recovery.

Upper Extremity Monoplegia following Prone Surrender Position for Spinal Surgery.

Background Secondary peripheral nerve injuries remain a significant perioperative problem due to patient positioning and contribute to reduced patient quality of life and exacerbated professional liability. Comorbidities and concomitant lesions can further elicit these injuries in patients undergoing spinal surgeries. Case Presentation We report a case of a 70-year-old male polytrauma patient presenting with a left first-rib fracture and an adjacent hematoma around the brachial plexus without preoperative deficits. Subsequent to a lumbar spinal fusion in the prone position, he developed a postoperative left upper extremity monoplegia. The postoperative magnetic resonance imaging revealed an enhanced asymmetric signal in the trunks and cords of the left brachial plexus. He progressively improved with rehabilitation, a year after the initial presentation, with a residual wrist drop. Conclusions Pan brachial plexus monoplegia, following spine surgery, is rare and under-reported pathology. To minimize the occurrence of this rare morbidity, appropriate considerations in preoperative evaluation and counseling, patient positioning, intraoperative anesthetic, and electrophysiological monitoring should be performed. We emphasize an unreported risk factor in polytrauma patients, predisposing this rare injury that is associated with prone spinal surgery positioning, SEPs being an extremely sensitive test intraoperatively and highlight the importance of counseling patients and families to the possibility of this rare occurrence.

Facial Pressure Ulcers: Unsightly Complication of Prone Positioning.

The image depicts a 67-yr-old man who had significant periorbital skin injury after 5 h of prone spine surgery using a foam headrest with standard taping of eyes. The patient underwent facial laser skin resurfacing 2 months before the event.Facial pressure ulcers are a serious complication that may lead to pain, additional treatment, longer hospital stays, disfigurement or scarring, increased medical cost, and subsequent lawsuits.1 Facial pressure ulcer has an incidence of 27% in prone spine surgery lasting more than 3 h and occurs most commonly over the bony prominence of the chin, maxilla, and forehead.1 Skin damage is due to prolonged and excessive pressure and/or shear that blocks capillary blood flow.2 Risk factors include operation duration, hyperthermia, hypotension, aggressive fluid replacement, and cervical hyperextension or hyperflexion.1,2Patients with recent facial laser skin resurfacing are at greater risk of perioperative facial pressure ulcers due to increased skin fragility.3 Laser skin resurfacing uses thermal damage of epidermis and parts of dermis to stimulate repair for ultimate facial rejuvenation.3 Complete recovery could take up to 1 yr, particularly in older patients.3 Perioperative considerations should include adequate healing of resurfaced skin, consultation with dermatologist, and communication about increased risk of skin injury.3Preventive measures for facial pressure ulcers during prone position surgery include assessment of skin risk area, application of moisturizer barrier cream, using pressure redistribution support surfaces or positioning devices to offload pressure points (silicone-foam dressings, face-contoured prone device, Mayfield clamp, or Gardner–Wells tongs with traction), and minimizing risk factors.1,2The authors declare no competing interests.

118. Reduction of facial pressure injuries after prone positioning in spine surgery: a multidisciplinary approach

<h3>BACKGROUND CONTEXT</h3> Spine surgery requiring prone positioning subjects the skin to friction, shear, moisture, and pressure. These factors increase the risk of facial pressure injuries. Prone positioning for thoracolumbar spine surgery allows the surgeon access to the dorsal spine and is the most common positioning method. Facial pressure injury must be carefully considered during prone positioning with pressure sore rates reported between 5%-66%. These injuries may result in longer hospital stays, patient morbidity and increased health care costs. Literature addressing facial pressure injury prevention strategies during prone spinal surgery is limited. <h3>PURPOSE</h3> The purpose of this study was to assess the efficacy of a multidisciplinary-derived pressure ulcer prevention bundle intended to prevent facial pressure injuries during prone spinal surgery. <h3>STUDY DESIGN/SETTING</h3> Review of pre- and postintervention consecutive cases. <h3>PATIENT SAMPLE</h3> Patients undergoing prone spinal surgery between November 2018 and August 2020. <h3>OUTCOME MEASURES</h3> Total case volume, pre- and postintervention monthly case volumes, total and monthly facial pressure ulcer rates. <h3>Methods</h3> A multidisciplinary group at a quaternary academic medical center developed a plan to address facial pressure injuries. The group reviewed institutional baseline facial pressure injury data and a literature review was conducted for previously studied prevention techniques. A pressure injury prevention bundle was developed including the following elements: (1) prophylactic placement of silicone foam dressings on the chin and forehead, (2) use of a contoured foam head positioner, and (3) application of a skin barrier wipe prior to securing the endotracheal tube with tape. A preoperative baseline skin assessment was performed. Postoperative pressure injury staging was assessed on our inpatient unit postoperatively. Monthly ulcer rates were calculated by dividing the number of pressure injuries by the monthly case volume. Differences in monthly ulcer rates were evaluated between intervention groups. A cross-tabulation of intervention group versus presence/absence of an ulcer was performed and an odds ratio of ulcer occurrence was calculated. <h3>Results</h3> Intervention compliance was greater than 90% within 1 week of bundle implementation. There were 22 total months of data reviewed with 2,331 total prone spinal procedures. Mean cases per month for the entire period was 106.0±23 (range 20-127). There were no significant differences in mean cases per month between intervention groups (P>0.05). There were 17 total facial ulcers encountered across all 2,331 cases (0.73%). There were 15/992 (1.50%) total ulcers in the preintervention group and only 2/1339 (0.15%) ulcers in the postintervention group. Monthly ulcer rates were calculated and displayed a non-normal distribution. The median monthly ulcer rate was significantly lower in the postintervention vs the preintervention group (0.000% vs 0.820%, P=0.021). Cross-tabulation of the intervention group vs presence/absence of an ulcer revealed a 10.1x higher odds of sustaining an ulcer in the preintervention group (odds ratio 10.1; 95% confidence interval 2.3-44.2). <h3>Conclusions</h3> Utilizing a standardized pressure injury prevention bundle during prone spinal surgery reduces the occurrence of facial pressure injuries. <h3>FDA DEVICE/DRUG STATUS</h3> This abstract does not discuss or include any applicable devices or drugs.

Risk Factors for Facial Pressure Ulcers in Patients Who Underwent Prolonged Prone Orthopedic Spine Surgery.

This study evaluated incidence and risk factors associated with the development of facial pressure ulcers (FPU) in patients who underwent spine surgery in prone position. A total of 300 cases were studied. The incidence of FPU after prone spine surgery using head padded device >3 hours was 27.3%. Hypotension, higher temperature, prolonged operation time, and much crystalloid therapy were the independent risk factors.

The Potential Role of Lung-Protective Ventilation in Preventing Postoperative Delirium in Elderly Patients Undergoing Prone Spinal Surgery: A Preliminary Study.

BackgroundPostoperative delirium (POD) is a frequent complication in elderly patients, usually occurring within a few days after surgery. This study investigated the effect of lung-protective ventilation (LPV) on POD in elderly patients undergoing spinal surgery and the mechanism by which LPV suppresses POD.Material/MethodsSeventy-one patients aged ≥65 years were randomized to receive LPV or conventional mechanical ventilation (MV), consisting of intermittent positive pressure ventilation following induction of anesthesia. The tidal volume in patients who received MV was 8 ml/kg predicted body weight (PBW), and the ventilation frequency was 12 times/min. The tidal volume in patients who received LPV was 6 ml/kg PBW, the positive end-expiratory pressure was 5 cmH2O, and the ventilation frequency was 15 times/min, with a lung recruitment maneuver performed every 30 min. Blood samples were collected immediately before anesthesia induction (T0), 10 min (T1) and 60 min (T2) after turning over, immediately after the operation (T3), and 15 min after extubation (T4) for blood gas analysis. Simultaneous cerebral oxygen saturation (rSO2) and cerebral desaturation were recorded. Preoperative and postoperative serum concentrations of interleukin (IL)-6, IL-10 and glial fibrillary acidic protein (GFAP) were measured by ELISA. POD was assessed by nursing delirium screening score.ResultsCompared with the MV group, pH was lower and PaCO2 higher in the LPV group at T2. In addition PaO2, SaO2, and PaO2/FiO2 were higher at T1, and T4, and rSO2 was higher at T3, and T4 in the LPV than in the MV group (P<0.05 each). Postoperative serum GFAP and IL-6 were lower and IL-10 higher in the LPV group. The incidences of cerebral desaturation and POD were significantly lower in the LPV group (P<0.05).ConclusionsLPV may reduce POD in elderly patients undergoing spinal surgery by inhibiting inflammation and improving cerebral oxygen metabolism.

Vasopressor Infusion During Prone Spine Surgery and Acute Renal Injury: A Retrospective Cohort Analysis.

Hypotension is associated with acute kidney injury, but vasopressors used to treat hypotension may also compromise renal function. We therefore tested the hypothesis that vasopressor infusion during complex spine surgery is not associated with impaired renal function. In this retrospective cohort analysis, we considered adults who had complex spine surgery between January 2005 and September 2014 at the Cleveland Clinic Main Campus. Our primary outcome was postoperative estimated glomerular filtration rate. Secondarily, we evaluated renal function using Acute Kidney Injury Network criteria. We obtained data for 1814 surgeries, including 689 patients (38%) who were given intraoperative vasopressors infusion for ≥30 minutes and 1125 patients (62%) who were not. Five hundred forty patients with and 540 patients without vasopressor infusions were well matched across 32 potential confounding variables. In matched patients, vasopressor infusions lasted an average of 173 ± 100 minutes (SD) and were given a median dose (1st quintile, 3rd quintile) of 3.4-mg (1.5, 6.7 mg) phenylephrine equivalents. Mean arterial pressure and the amounts of hypotension were similar in each matched group. The postoperative difference in mean estimated glomerular filtration rate in patients with and without vasopressor infusions was only 0.8 mL/min/1.73 m (95% CI, -0.6 to 2.2 mL/min/1.73 m) (P = .28). Intraoperative vasopressor infusion was also not associated with increased odds of augmented acute kidney injury stage. Clinicians should not avoid typical perioperative doses of vasopressors for fear of promoting kidney injury. Tolerating hypotension to avoid vasopressor use would probably be a poor strategy.

Postoperative Pressure Injury in Patients Undergoing Prone Spinal Surgery

Postoperative Pressure Injury in Patients Undergoing Prone Spinal Surgery

Assessment of Volume Status During Prone Spine Surgery via a Novel Point-of-care Ultrasound Technique.

BackgroundOperations performed with the patient in the prone position can pose a significant challenge to the anesthesiologist. Hypotension is a commonly encountered complication. Intravascular volume depletion and decreased cardiac output secondary to decreased preload are thought to be the most likely cause of hypotension in the prone position. Measurement of inferior vena cava (IVC) diameter via point-of-care ultrasound examination (POC_US) has been used to provide an estimate of intravascular volume status. However, this measurement is most often obtained with the patient in the supine position.Materials and methodsIn this study, we describe a technique for evaluating IVC diameter via POC_US in the prone position. Right lateral long axis imaging of the IVC was used to assess the intravascular volume status of 10 patients undergoing lumbar spine surgery in the prone position. In addition, we used a non-invasive measure of cardiac output to correlate changes in IVC width with changes in cardiac output.ResultsImages of the IVC in the prone position were obtainable in all 10 patients. IVC diameter increased in six out of 10 patients on going from supine to prone position. The increase in IVC diameter corresponded to an increase in cardiac output, measured noninvasively in five out of the six patients.ConclusionsOur findings indicate that POC_US examination of the IVC is possible in the prone position. Further study of a larger patient population could demonstrate the utility of this technique in assessing intravascular volume status in patients undergoing surgery in the prone position.

The Effect of High vs. Low Fluid Volume on Ocular Parameters in Prone Spine Surgery

The Effect of High vs. Low Fluid Volume on Ocular Parameters in Prone Spine Surgery

Unilateral visual loss after spine surgery: Lesson to be learnt from unexpected devastating complication

Abstract Visual loss following spinal surgery is a potentially devastating and rare complication. Spinal surgery is the leading cause of POVL. Although the etiology of POVL is not clearly understood, multiple risk factors have been proposed. The horseshoe is no longer an appropriate device for prone spinal surgery and its use should not be supported. Awareness, evaluation and timely management of this rare devastating complication is crucial. It is advisable to inform high-risk patients that there is a small, unpredictable risk of perioperative visual loss. We discuss a case of 32 year old lady; who had experienced unexpected visual loss after elective spine surgery.