Spinal anesthesia in awake surgical procedures of the lumbar spine: a systematic review and meta-analysis of 3709 patients

Abstract

OBJECTIVE Awake surgery has previously been found to improve patient outcomes postoperatively in a variety of procedures. Recently, multiple groups have investigated the utility of this modality for use in spine surgery. However, few current meta-analyses exist comparing patient outcomes in awake spinal anesthesia with those in general anesthesia. Therefore, the authors sought to present an updated systematic review and meta-analysis investigating the utility of spinal anesthesia relative to general anesthesia in lumbar procedures. METHODS Following a comprehensive literature search of the PubMed and Cochrane databases, 14 clinical studies were included in our final qualitative and quantitative analyses. Of these studies, 5 investigated spinal anesthesia in lumbar discectomy, 4 discussed lumbar laminectomy, and 2 examined interbody fusion procedures. One study investigated combined lumbar decompression and fusion or decompression alone. Two studies investigated patients who underwent discectomy and laminectomy, and 1 study investigated a series of patients who underwent transforaminal lumbar interbody fusion, posterolateral fusion, or decompression. Odds ratios, mean differences (MDs), and 95% confidence intervals were calculated where appropriate. RESULTS A meta-analysis of the total anesthesia time showed that time was significantly less in patients who received spinal anesthesia for both lumbar discectomies (MD −26.53, 95% CI −38.16 to −14.89; p = 0.00001) and lumbar laminectomies (MD −11.21, 95% CI −19.66 to −2.75; p = 0.009). Additionally, the operative time was significantly shorter in patients who underwent spinal anesthesia (MD −14.94, 95% CI −20.43 to −9.45; p < 0.00001). Similarly, when analyzing overall postoperative complication rates, patients who received spinal anesthesia were significantly less likely to experience postoperative complications (OR 0.29, 95% CI 0.16–0.53; p < 0.0001). Furthermore, patients who received spinal anesthesia had significantly lower postoperative pain scores (MD −2.80, 95% CI −4.55 to −1.06; p = 0.002). An identical trend was seen when patients were stratified by lumbar procedures. Patients who received spinal anesthesia were significantly less likely to require postoperative analgesia (OR 0.06, 95% CI 0.02–0.25; p < 0.0001) and had a significantly shorter hospital length of stay (MD −0.16, 95% CI −0.29 to −0.03; p = 0.02) and intraoperative blood loss (MD −52.36, 95% CI −81.55 to −23.17; p = 0.0004). Finally, the analysis showed that spinal anesthesia cost significantly less than general anesthesia (MD −226.14, 95% CI −324.73 to −127.55; p < 0.00001). CONCLUSIONS This review has demonstrated the varying benefits of spinal anesthesia in awake spine surgery relative to general anesthesia in patients who underwent various lumbar procedures. The analysis has shown that spinal anesthesia may offer some benefits when compared with general anesthesia, including reduction in the duration of anesthesia, operative time, total cost, and postoperative complications. Large prospective trials will elucidate the true role of this modality in spine surgery.

Degenerative Lumbar Spine Surgeries Under Regional Anesthesia in a Developing Country: An Initial Case Series

“…Perez-Roman et al conducted a meta-analysis of 3709 patients undergoing SA for lumbar discectomies and laminectomies. Also, they concluded that patients who underwent SA had decreased total anesthesia time, operative time, and post-operative complications [ 12 ]. Meng et al replicated these findings [ 13 ].…”

Spinal Versus General Anesthesia for Spine Surgery During the COVID-19 Pandemic: A Case Series

“…It is demonstrated that SA has some advantages over GA: Less post-operative nausea and vomiting, less cardiopulmonary concerns, less post-operative narcotics for pain relief, less hospitalization time and cost, reduced possibility of cardiac attacks, less venous and arterial thrombosis, fewer complications related to the prone position such as compressive sore, and less cognitive dysfunction. Moreover, during the COVID-19 pandemic, SA has more advantages, including less concern about disease transmission during intubation and extubation, decreased likelihood of ventilator and other instrument contamination, and decreased risk of COVID-19-related pulmonary complications (1,3,4,7).…”

“…Some studies evaluated the effectiveness of spinal anesthesia as an excellent alternative to GA for spine surgery. Spinal anesthe-sia (SA) has some advantages over GA: Decreased blood loss, decreased post-operative pain score, less post-operative hospitalization, less need for blood transfusion, reduction of anesthesia and operation time, reduction of postoperative hypoxic episodes, less possibility of brachial plexus injury and pressure ulcer, and less likelihood of post-operative complications (2)(3)(4).…”

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

“…There have been a few studies trying to compare the results of GA vs SA in spine surgery; most have been meta-analyses ( Perez et al, 2021 ). It will be important to have more robust studies such as matched cohort studies or randomized control studies.…”