Awake spine surgery: An eye-opening movement

Abstract

Background: Awake surgery is performed in multiple surgical specialties, but historically, awake surgery in the field of neurosurgery was limited to craniotomies. Over the past two decades, spinal surgeons have pushed for techniques that only require regional anesthesia as they may provide reduced financial burdens on patients, faster recovery times, and better outcomes. The list of awake spine surgeries that have been found in the literature include: laminectomies/discectomies, anterior cervical discectomy and fusions (ACDFs), lumbar fusions, and dorsal column (DC) stimulator placement. Methods: An extensive review of the published literature was conducted through PubMed database with articles containing the search term “awake spine surgery.” No date restrictions were used. Results: The search yielded 293 related articles. Cross-checking of articles was conducted to exclude of duplicate articles. The articles were screened for their full text and English language availability. We finalized those articles pertaining to the topic. Findings have shown that lumbar laminectomies performed with local anesthesia have shown shorter operating time, less postoperative nausea, lower incidence of urinary retention and spinal headache, and shorter hospital stays when compared to those performed under general anesthesia. Lumbar fusions with local anesthesia showed similar outcomes as patients reported better postoperative function and fewer side effects of general anesthesia. DC stimulator placement performed with local anesthesia is advantageous as it allows real time patient feedback for surgeons as they directly test affected nerves. However, spontaneous movement during the placement of DC stimulators is associated with higher failure rates when compared to general anesthesia (29.7% vs. 14.9%). Studies have shown that the use of local anesthesia during ACDFs has no significant differences when compared to general anesthesia, and patient’s report better tolerated pain with general anesthesia. Conclusion: The use of awake spine surgery is beneficial for those who cannot undergo general anesthesia. However, it is limited to patients who can tolerate prone positioning with no central airway (i.e., normal BMI with a healthy airway), have no pre-existing mental health conditions (e.g., anxiety), and require a minimally invasive procedure with a short operating time. Future studies should focus on long-term efficacies of these procedures that provide further insight on the indications and limitations of awake spine surgery.

How to start an awake spine program: Protocol and illustrative cases

“…The use of spinal anesthesia expands the patient population eligible for spinal surgery; however, it is still limited by the same contraindications of any surgical procedure ( Fiani et al, 2021 , Meng et al, 2017 ). The main exclusions to spinal anesthesia are patient refusal, coagulopathy or anticoagulation that would preclude safe neuraxial procedures ( Horlocker et al, 2010 ), infection near the surgical site, or cardiovascular contraindications (ie patients who cannot withstand spinal anesthesia-induced reductions in systemic vascular resistance and cardiac preload).…”

“…There is an increasing appreciation of the side effects of general anesthesia such as opioid use and cardiopulmonary complications ( Fiani et al, 2021 , Meng et al, 2017 ). These complications of anesthesia have been reported to be worse in elderly patients ( Fiani et al, 2021 , Meng et al, 2017 ). With the awake alternative, these side effects are significantly reduced, making elderly patients’ prime candidates for awake spine surgery ( Fiani et al, 2021 ).…”

“…ASPS has been used for a wide variety of spinal procedures and commonly performed awake spinal surgeries include, but are not limited to laminectomy, discectomy, anterior cervical discectomy and fusion, lumbar fusion, and dorsal column stimulator placement ( Fiani et al, 2021 ).…”

“…This is associated with an increase in prevalence of degenerative spinal disorders, leading to an increase for surgical treatment of these conditions ( O’Lynnger et al, 2015 ). Despite increasing evidence recommending avoidance of general anesthesia in older patients ( Berthoud and Reilly, 1992 , Xie et al, 2018 , Patel et al, 2015 , Fiani et al, 2021 ; Meng et al, 2017 ), surgical management using traditional general anesthesia remains the standard of care for several surgeons.…”

A one-step foraminoplasty via a large trephine in percutaneous endoscopic transforaminal discectomy for the treatment of lumbar disc herniation

“…Meanwhile, it shows little impact on the spine stability and exhibits advantages including less trauma, improved surgical outcomes, and fast recovery [ 7 ]. PELD can be completed under local anesthesia, providing surgical opportunities for patients who cannot tolerate the risk of general anesthesia [ 8 , 9 ]. The classic techniques of PELD include Yeung endoscopy spine system (YESS) and transforaminal endoscopic spine system (TESSYS) techniques [ 10 ].…”