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Awake spinal surgery: simplifying the learning curve with a patient selection algorithm

Vijay Letchuman, Nitin Agarwal, Valli P. Mummaneni, Michael Y. Wang, Saman Shabani, Arati Patel, Joshua Rivera, Alexander F. Haddad, Vivian Le, Joyce M. Chang, Dean Chou, Seema Gandhi, and Praveen V. Mummaneni

OBJECTIVE

There is a learning curve for surgeons performing “awake” spinal surgery. No comprehensive guidelines have been proposed for the selection of ideal candidates for awake spinal fusion or decompression. The authors sought to formulate an algorithm to aid in patient selection for surgeons who are in the startup phase of awake spinal surgery.

METHODS

The authors developed an algorithm for selecting patients appropriate for awake spinal fusion or decompression using spinal anesthesia supplemented with mild sedation and local analgesia. The anesthetic protocol that was used has previously been reported in the literature. This algorithm was formulated based on a multidisciplinary team meeting and used in the first 15 patients who underwent awake lumbar surgery at a single institution.

RESULTS

A total of 15 patients who underwent decompression or lumbar fusion using the awake protocol were reviewed. The mean patient age was 61 ± 12 years, with a median BMI of 25.3 (IQR 2.7) and a mean Charlson Comorbidity Index of 2.1 ± 1.7; 7 patients (47%) were female. Key patient inclusion criteria were no history of anxiety, 1 to 2 levels of lumbar pathology, moderate stenosis and/or grade I spondylolisthesis, and no prior lumbar surgery at the level where the needle is introduced for anesthesia. Key exclusion criteria included severe and critical central canal stenosis or patients who did not meet the inclusion criteria. Using the novel algorithm, 14 patients (93%) successfully underwent awake spinal surgery without conversion to general anesthesia. One patient (7%) was converted to general anesthesia due to insufficient analgesia from spinal anesthesia. Overall, 93% (n = 14) of the patients were assessed as American Society of Anesthesiologists class II, with 1 patient (7%) as class III. The mean operative time was 115 minutes (± 60 minutes) with a mean estimated blood loss of 46 ± 39 mL. The median hospital length of stay was 1.3 days (IQR 0.1 days). No patients developed postoperative complications and only 1 patient (7%) required reoperation. The mean Oswestry Disability Index score decreased following operative intervention by 5.1 ± 10.8.

CONCLUSIONS

The authors propose an easy-to-use patient selection algorithm with the aim of assisting surgeons with patient selection for awake spinal surgery while considering BMI, patient anxiety, levels of surgery, and the extent of stenosis. The algorithm is specifically intended to assist surgeons who are in the learning curve of their first awake spinal surgery cases.

In Neurosurgical Focus Volume 51 (2021): Issue 6 (Dec 2021): Anesthetic and Monitoring Techniques in Awake Spinal Surgery

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Editorial. The establishment of Neurosurgical Focus: personal reflections by the Editors-in-Chief

Martin H. Weiss and William T. Couldwell

In Neurosurgical Focus Volume 51 (2021): Issue 6 (Dec 2021): Anesthetic and Monitoring Techniques in Awake Spinal Surgery

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Introduction. Awake spinal surgery: where are we now and where are we going

Wilson Z. Ray, Asdrubal Falavigna, Praveen V. Mummaneni, and Robert C. Bucelli

In Neurosurgical Focus Volume 51 (2021): Issue 6 (Dec 2021): Anesthetic and Monitoring Techniques in Awake Spinal Surgery

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Single-level awake transforaminal lumbar interbody fusion: a Mayo Clinic institutional experience and national analysis

Kingsley Abode-Iyamah, Abdul Karim Ghaith, Archis R. Bhandarkar, Gaetano De Biase, Rami Rajjoub, Selby G. Chen, Alfredo Quiñones-Hinojosa, and Mohamad Bydon

OBJECTIVE

Awake transforaminal lumbar interbody fusion (TLIF) is a novel technique for performing spinal fusions in patients under conscious sedation. Whether awake TLIF can reduce operative times and decrease the hospital length of stay (LOS) remains to be shown. In this study, the authors sought to assess the differences in clinical outcomes between patients who underwent awake TLIF and those who underwent TLIF under general anesthesia by using institutional experience at the Mayo Clinic and the National Surgical Quality Improvement Program (NSQIP) database.

METHODS

Chart review was performed for a consecutive series of patients who underwent single-level minimally invasive surgery (MIS)–TLIF performed by a single surgeon (K.A.I.) at a single institution. Additionally, the NSQIP database was queried from 2016 to 2019 for patients who underwent awake TLIF as well as propensity score–matched patients who underwent TLIF under general anesthesia.

RESULTS

A total of 20 patients at Mayo Clinic underwent awake single-level MIS-TLIF. The mean operative time was 122 ± 16.68 minutes, and the mean estimated blood loss was 39 ± 30.24 ml. No intraoperative complications were reported. A total of 96 patients who underwent TLIF (24 awake and 72 under general anesthesia) were analyzed from the NSQIP database. The mean LOS was less in the awake cohort (1.4 ± 1.381 days) than the general anesthesia cohort (3 ± 2.274 days) (p = 0.002).

CONCLUSIONS

Evidence from the authors’ institutional experience and national analysis has demonstrated that awake MIS-TLIF is efficient and can reduce hospital LOS.

In Neurosurgical Focus Volume 51 (2021): Issue 6 (Dec 2021): Anesthetic and Monitoring Techniques in Awake Spinal Surgery

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

Roberto J. Perez-Roman, Vaidya Govindarajan, Jean-Paul Bryant, and Michael Y. Wang

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.

In Neurosurgical Focus Volume 51 (2021): Issue 6 (Dec 2021): Anesthetic and Monitoring Techniques in Awake Spinal Surgery

Free access

Spinal versus general anesthesia for minimally invasive transforaminal lumbar interbody fusion: implications on operating room time, pain, and ambulation

Gaetano De Biase, Shaun E. Gruenbaum, James L. West, Selby Chen, Elird Bojaxhi, James Kryzanski, Alfredo Quiñones-Hinojosa, and Kingsley Abode-Iyamah

OBJECTIVE

There has been increasing interest in the use of spinal anesthesia (SA) for spine surgery, especially within Enhanced Recovery After Surgery (ERAS) protocols. Despite the wide adoption of SA by the orthopedic practices, it has not gained wide acceptance in lumbar spine surgery. Studies investigating SA versus general anesthesia (GA) in lumbar laminectomy and discectomy have found that SA reduces perioperative costs and leads to a reduction in analgesic use, as well as to shorter anesthesia and surgery time. The aim of this retrospective, case-control study was to compare the perioperative outcomes of patients who underwent minimally invasive surgery (MIS)–transforaminal lumbar interbody fusion (TLIF) after administration of SA with those who underwent MIS-TLIF under GA.

METHODS

Overall, 40 consecutive patients who underwent MIS-TLIF by a single surgeon were analyzed; 20 patients received SA and 20 patients received GA. Procedure time, intraoperative adverse events, postoperative adverse events, postoperative length of stay, 3-hour postanesthesia care unit (PACU) numeric rating scale (NRS) pain score, opioid medication, and time to first ambulation were collected for each patient.

RESULTS

The two groups were homogeneous for clinical characteristics. A decrease in total operating room (OR) time was found for patients who underwent MIS-TLIF after administration of SA, with a mean OR time of 156.5 ± 18.9 minutes versus 213.6 ± 47.4 minutes for patients who underwent MIS-TLIF under GA (p < 0.0001), a reduction of 27%. A decrease in total procedure time was also observed for SA versus GA (122 ± 16.7 minutes vs 175.2 ± 10 minutes; p < 0.0001). No significant differences were found in intraoperative and postoperative adverse events. There was a difference in the mean maximum NRS pain score during the first 3 hours in the PACU as patients who received SA reported a lower pain score compared with those who received GA (4.8 ± 3.5 vs 7.3 ± 2.7; p = 0.018). No significant difference was observed in morphine equivalents received by the two groups. A difference was also observed in the mean overall NRS pain score, with 2.4 ± 2.1 for the SA group versus 4.9 ± 2.3 for the GA group (p = 0.001). Patients who received SA had a shorter time to first ambulation compared with those who received GA (385.8 ± 353.8 minutes vs 855.9 ± 337.4 minutes; p < 0.0001).

CONCLUSIONS

The results of this study have pointed to some important observations in this patient population. SA offers unique advantages in comparison with GA for performing MIS-TLIF, including reduced OR time and postoperative pain, and faster postoperative mobilization.

In Neurosurgical Focus Volume 51 (2021): Issue 6 (Dec 2021): Anesthetic and Monitoring Techniques in Awake Spinal Surgery

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Spine surgery under awake spinal anesthesia: an Egyptian experience during the COVID-19 pandemic

Mohamed Fawzy M. Khattab, David A. W. Sykes, Muhammad M. Abd-El-Barr, Romaric Waguia, Amr Montaser, Sherief El Ghamry, and Youssry Elhawary

OBJECTIVE

Despite tremendous advancements in biomedical science and surgical technique, spine surgeries are still associated with considerable rates of morbidity and mortality, particularly in the elderly. Multiple novel techniques have been employed in recent years to adequately treat spinal diseases while mitigating the perioperative morbidity associated with traditional spinal surgery. Some of these techniques include minimally invasive methods and novel anesthetic and analgesic methods. In recent years, awake spine surgery with spinal anesthesia has gained attention as an alternative to general anesthesia (GA). In this study, the authors retrospectively reviewed a single-institution Egyptian experience with awake spine surgery using spinal anesthesia during the COVID-19 pandemic.

METHODS

Overall, 149 patients who were admitted to As-Salam International Hospital in Cairo for lumbar and lower thoracic spine surgeries, between 2019 and 2020, were retrospectively reviewed. Patient demographics and comorbidities were collected and analyzed. Visual analog scale (VAS) and Oswestry Disability Index (ODI) scores were assessed at different time intervals including preoperatively, immediately after surgery, and 1 year postoperatively. Patient satisfaction was queried through a questionnaire assessing patient preference for traditional anesthesia or spinal anesthesia.

RESULTS

Of the 149 patients who successfully received spine surgery with spinal anesthesia, there were 49 males and 100 females. The cohort age ranged from 22 to 85 years with a mean of 47.5 years. The operative time ranged from 45 to 300 minutes with a mean estimated blood loss (EBL) of 385 ± 156 mL. No major cardiopulmonary or intraoperative complications occurred, and patients were able to eat immediately after surgery. Patients were able to ambulate without an assistive device 6 to 8 hours after surgery. Decompression and fusion patients were discharged on postoperative days 2 and 3, respectively. VAS and ODI scores demonstrated excellent pain relief, which was maintained at the 1-year postoperative follow-up. No 30- or 90-day readmissions were recorded. Of 149 patients, 124 were satisfied with spinal anesthesia and would recommend spinal anesthesia to other patients. The remaining patients were not satisfied with spinal anesthesia but reported being pleased with their postoperative clinical and functional outcomes. One patient was converted to GA due to the duration of the procedure.

CONCLUSIONS

Patients who received spinal anesthesia for awake spine surgery experienced short stays in the hospital, no readmissions, patient satisfaction, and well-controlled pain. The results of this study have validated the growing body of literature that demonstrates that awake spine surgery with spinal anesthesia is safe and associated with superior outcomes compared with traditional GA. Additionally, the ability to address chronic debilitating conditions, such as spinal conditions, with minimal use of valuable resources, such as ventilators, proved useful during the COVID-19 pandemic and could be a model should other stressors on healthcare systems arise, especially in developing areas of the world.

In Neurosurgical Focus Volume 51 (2021): Issue 6 (Dec 2021): Anesthetic and Monitoring Techniques in Awake Spinal Surgery

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Surgical decompression via the unilateral intervertebral foraminal approach with local anesthesia for treating elderly patients with lumbar central canal stenosis

Weibo Pan and Boqing Ruan

OBJECTIVE

Surgical decompression via a posterior interlaminar approach is widely used for treating lumbar central canal stenosis (LCCS). However, this surgical approach poses a challenge for elderly patients with comorbidities. Thus, the authors tried a new surgical decompression via the unilateral intervertebral foraminal approach with local anesthesia to treat such patients. The aim of this study was to evaluate the safety and effectiveness of surgical decompression via the unilateral intervertebral foraminal approach with local anesthesia for patients with LCCS.

METHODS

Patients with LCCS who underwent surgical decompression, performed by a single surgeon, between January 2016 and March 2019 were retrospectively analyzed. All patients received decompression via the unilateral intervertebral foraminal approach with local anesthesia. Visual analog scale (VAS) scores, Oswestry Disability Index (ODI) scores, modified Macnab criteria, walking distance, and Schizas classification were used as outcome predictors. Additionally, a decompression evaluation method was designed for use after spinal endoscopic surgery.

RESULTS

Overall, 23 patients with a mean age of 69 years were included in this study, with a mean follow-up of 28 months. Low-back and leg pain were significantly improved after decompression surgery. Postoperative ODI scores and walking distances were statistically significantly better than before surgery. Postoperatively, the Schizas classification for all patients was improved by at least 1 grade compared with the preoperative grade. No complications occurred during the follow-up period. According to the novel decompression evaluation method, all patients had at least achieved decompression in part 123+B.

CONCLUSIONS

Surgical decompression via the unilateral intervertebral foraminal approach with local anesthesia showed promising outcomes in the treatment of elderly patients with LCCS. Additionally, a proposed postoperative decompression evaluation method can help guide surgical decompression.

In Neurosurgical Focus Volume 51 (2021): Issue 6 (Dec 2021): Anesthetic and Monitoring Techniques in Awake Spinal Surgery

Open access

Eight cases of sudden-onset dropped head syndrome: patient series

Kenji Endo, Yasunobu Sawaji, Takato Aihara, Hidekazu Suzuki, Kazuma Murata, Yuji Matsuoka, Hirosuke Nishimura, Taichiro Takamatsu, Takamitsu Konishi, and Kengo Yamamoto

BACKGROUND

As the proportion of elderly people continues to increase, the number of patients with dropped head syndrome (DHS) also grows. However, the relationship between onset and clinical course of DHS has hardly been studied, particularly, that of sudden-onset DHS has not been reported and remains unclear.

OBSERVATIONS

Sudden-onset DHS was defined as presenting with chin on chest deformity within 3 days from the time of awareness of cervical weakness. Sixty-six patients with DHS visited our facility. Among them, 8 of the total cases (12.1%) had experienced sudden onset DHS (6 females and 2 males; average age: 71.9 ± 10.9 years). Six of 8 cases showed recovery by conservative treatment, whose first interventions were from 0.1 to 12 months, but 3 experienced recurrence. Diffuse spinal kyphotic-type DHS was seen in 2 cases, and both had recurring horizontal gaze disturbance after initial recovery. Two unimproved cases underwent surgery of combined anterior and posterior cervical fixation, and their first interventions were at 5 and 24 months. After surgery, cervical sagittal alignment was improved, and they could walk maintaining horizontal gaze.

LESSONS

Sudden-onset DHS can be expected to have a better outcome, but recurrence is possible in global imbalanced-type DHS.

In Journal of Neurosurgery: Case Lessons Volume 2 (2021): Issue 22 (Nov 2021)

Open access

Predicting clinical outcomes using morphometric changes in adults with complex Chiari malformation undergoing occipitocervical fusion with or without ventral decompression: patient series

John K. Chae, Neelan J. Marianayagam, Ibrahim Hussain, Amanda Cruz, Ali A. Baaj, Roger Härtl, and Jeffrey P. Greenfield

BACKGROUND

The authors assessed the connection between clinical outcomes and morphometrics in patients with complex Chiari malformation (CM) who have undergone posterior fossa decompression (PFD) and subsequent occipitocervical fusion (OCF) with or without ventral decompression (VD).

OBSERVATIONS

The authors retrospectively reviewed 33 patients with CM aged over 21 years who underwent PFD and OCF with or without endoscopic endonasal odontoidectomy at the authors’ institution (21 OCF only and 12 OCF + VD). Clivoaxial angle (CXA), pB-C2 (perpendicular line to the line between the basion and C2), atlantodental interval (ADI), basion-dens interval (BDI), basion-axial interval (BAI), and C1 canal diameter were measured on preoperative and approximately 3-month postoperative computed tomography or magnetic resonance imaging scans. Common symptoms included headache, paresthesia, and bulbar symptoms. Clinical improvement after surgery was observed in 78.8% of patients. CXA, ADI, and BDI all significantly increased after surgery, whereas pB-C2 and BAI significantly decreased. OCF + VD had a significantly more acute CXA and longer pB-C2 preoperatively than OCF only. Patients who clinically improved postoperatively showed the same significant morphometric changes, but those who did not improve showed no significant morphometric changes.

LESSONS

Patients showing improvement had greater corrections in skull base morphometrics than those who did not. Although there are various mutually nonexclusive reasons why certain patients do not improve after surgery, smaller degrees of morphometric correction could play a role.

In Journal of Neurosurgery: Case Lessons Volume 2 (2021): Issue 22 (Nov 2021)