Awake Spinal Fusion Is Associated with Reduced Length of Stay, Opioid Use, and Time to Ambulation Compared to General Anesthesia: A Matched Cohort Study

Current Status of Awake Spine Surgery: A Bibliometric Analysis

BACKGROUND

Spine surgery accounts for a large proportion of neurosurgical procedures, with approximately 313 million spine surgeries conducted annually worldwide. Considering delayed recovery and postoperative complications that are commonly reported, there has been a recent shift toward minimally invasive spine procedures conducted under local anesthesia. Despite proven success, there exists a limited body of literature on the use of awake surgery in spinal procedures.

METHODS

A bibliometric analysis was conducted to map the current landscape of work in this field. 190 articles were identified from the Web of Science (Clarivate, NY) database. A comprehensive bibliometric analysis was performed on a narrowed list of the most relevant articles using Bibliometrix, an R-based programming tool.

RESULTS

There has been a rise in academic papers published on the topic of awake spine surgery since 2016, with an increase in publication count by approximately 18% annually and each article cited approximately ten times on average to date. The year 2022 saw an uptick in publications, with 9 throughout the entire year. The most impactful article, with a total of 95 citations, was published by Sairyo et al.1 Thematic analysis revealed that the terms "lumbar spine" and "stenosis" are well-developed topics in the literature, whereas the topics of "complications," "fusion," and "cost-analysis" are less well-developed topics.

CONCLUSIONS

This study provides a comprehensive overview of the most-cited articles in the field of awake spine surgery. Specifically, it identifies areas that are well represented in the literature and those which are underrepresented and should be areas of continued future research.

Thoracic spinal anesthesia with intrathecal sedation for lower back surgery: a retrospective cohort study

Background

Spinal anesthesia (SA) is a good alternative to general anesthesia (GA) for spine surgery. Despite that, a few case series concern the use of thoracic spinal anesthesia for short-duration surgical interventions. In search of an alternative approach to GA and a better opioid-free modality, we aimed to investigate the safety, feasibility, and patient satisfaction of thoracic SA for spine surgery.

Materials and methods

We analyzed retrospectively a cohort of 24 patients operated on for a degenerative and osteoporotic pathology of the lower thoracic and lumbar spine. Data was collected from medical records, including clinical notes, operative and anesthesia records, and patient questionnaires.

Results

Twenty-one surgeries for herniated discs, two for degenerative spinal stenosis, and one for multi-level osteoporotic vertebral body fractures were performed under spinal anesthesia with intrathecal sedation. In all cases, we applied 0.5% isobaric bupivacaine and the following adjuvants: midazolam, clonidine or dexmedetomidine, and dexamethasone. We boosted the anesthesia with local ropivacaine due to inefficient sensory block in two patients. Nobody in the cohort received intravenous opioids, non-steroidal anti-inflammatory drugs, or additional sedation intraoperatively. Postoperative painkillers were upon the patient's request. No significant complications were detected.

Conclusion

Thoracic spinal anesthesia incorporating adjuvants such as midazolam, clonidine or dexmedetomidine, and dexamethasone demonstrates not only efficient conditions for spine surgery, a favorable safety profile, high patient satisfaction, and intrathecal sedation but also effective opioid-free pain management.

Airway Management for Emergency Spinal Epidural Hematoma Evacuation With Awake Spine Surgery: Case Report and Literature Review

BACKGROUND

Postoperative spinal epidural hematomas (pSEHs) are a rare complication of microdiscectomy surgery. The hematoma may be unnoticed intraoperatively, but timely treatment may prevent permanent neurologic impairment. Airway management in patients with a full stomach is generally performed with rapid sequence intubation and general anesthesia. Awake spine surgery without intravenous analgesia or sedation may be beneficial in patients with a full stomach who are at higher risk for pulmonary aspiration with general anesthesia due to a loss of non-per-oral (NPO) status. The authors propose that it can also be performed in cases of urgent/emergent postsurgical epidural hematoma evacuation.

METHODS

We present the airway management of a 41-year-old man who underwent a minimally invasive microdiscectomy with normal strength immediately after surgery but developed progressive weakness with right foot dorsiflexion, right extensor hallucis longus muscle weakness, and progressive right lower extremity ascending numbness over the course of the first 2 hours after surgery due to an epidural hematoma.

RESULTS

The patient underwent urgent awake epidural hematoma evacuation with a spinal anesthetic. Afterward, the patient recovered neurological function and was discharged the following morning.

CLINICAL RELEVANCE

pSEHs are a rare complication of microdiscectomy surgery. The purpose of this article is to describe the novel use of awake spine surgery in emergent epidural hematoma evacuation and demonstrate its feasibility.

CONCLUSIONS

In emergencies, when a patient is not NPO, awake spine surgery can safely be performed with no sedation, ensuring the patient can protect their airway and avoid the risk of aspiration.

LEVEL OF EVIDENCE: 3

Anaesthetic subspecialties and sustainable healthcare: a narrative review

The principles of environmentally sustainable healthcare as applied to anaesthesia and peri-operative care are well documented. Associated recommendations focus on generic principles that can be applied to all areas of practice. These include reducing the use of inhalational anaesthetic agents and carbon dioxide equivalent emissions of modern peri-operative care. However, four areas of practice have specific patient, surgical and anaesthetic factors that present barriers to the implementation of some of these principles, namely: neuroanaesthesia; obstetric; paediatric; and cardiac anaesthesia. This narrative review describes these factors and synthesises the available evidence to highlight areas of sustainable practice clinicians can address today, as well as posing several unanswered questions for the future. In neuroanaesthesia, improvements can be made by undertaking awake surgery, moving towards more reusables and embracing telemedicine in quaternary services. Obstetric anaesthesia continues to present questions regarding how services can move away from nitrous oxide use or limit its release to the environment. The focus for paediatric anaesthesia is addressing the barriers to total intravenous and regional anaesthesia. For cardiac anaesthesia, a significant emphasis is determining how to focus the substantial resources required on those who will benefit from cardiac interventions, rather than universal implementation. Whilst the landscape of evidence-based sustainable practice is evolving, there remains an urgent need for further original evidence in healthcare sustainability targeting these four clinical areas.