Implications of anesthetic approach, spinal versus general, for the treatment of spinal disc herniation

Presented at the 2018 AANS/CNS Joint Section on Disorders of the Spine and Peripheral Nerves

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Healthcare costs continue to escalate. Approaches to care that have comparable outcomes and complications are increasingly assessed for quality improvement and, when possible, cost containment. Efforts to identify components of care to reduce length of stay (LOS) have been ongoing. Spinal anesthesia (SA), for select lumbar spine procedures, has garnered interest as an alternative to general anesthesia (GA) that might reduce cost and in-hospital LOS and accelerate recovery. While clinical outcomes with SA or GA have been studied extensively, few authors have looked at the cost-analysis in relation to clinical outcomes. The authors’ objectives were to compare the clinical perioperative outcomes of patients who received SA and GA, as well as the direct costs associated with each modality of care, and to determine which, in a retrospective analysis, can serve as a dominant procedural approach.


The authors retrospectively analyzed a homogeneous surgical population of 550 patients who underwent hemilaminotomy for disc herniation and who received either SA (n = 91) or GA (n = 459). All clinical and billing data were obtained via each patient’s chart and the hospital’s billing database, respectively. Additionally, the authors prospectively assessed patient-reported outcome measures for a subgroup of consecutively treated patients (n = 75) and compared quality-adjusted life year (QALY) gains between the two cohorts. Furthermore, the authors performed a propensity score–matching analysis to compare the two cohorts (n = 180).


Direct hospital costs for patients receiving SA were 40% higher, in the hundreds of dollars, than for patients who received GA (p < 0.0001). Furthermore, there was a significant difference with regard to LOS (p < 0.0001), where patients receiving SA had a considerably longer hospital LOS (27.6% increase in hours). Patients undergoing SA had more comorbidities (p = 0.0053), specifically diabetes and hypertension. However, metrics of complications, including readmission (p = 0.3038) and emergency department (ED) visits at 30 days (p = 1.0), were no different. Furthermore, in a small pilot group, QALY gains were statistically no different (n = 75, p = 0.6708). Propensity score–matching analysis demonstrated similar results as the univariate analysis: there was no difference between the cohorts regarding 30-day readmission (p = 1.0000); ED within 30 days could not be analyzed as there were no patients in the SA group; and total direct costs and LOS were significantly different between the two cohorts (p < 0.0001 and p = 0.0126, respectively).


Both SA and GA exhibit the qualities of a good anesthetic, and the utilization of these modalities for lumbar spine surgery is safe and effective. However, this work suggests that SA is associated with increased LOS and higher direct costs, although these differences may not be clinically or fiscally meaningful.

ABBREVIATIONS ED = emergency department; GA = general anesthesia; LOS = length of stay; OR = operating room; SA = spinal anesthesia.

Article Information

Correspondence Neil R. Malhotra: University of Pennsylvania, Philadelphia, PA.

INCLUDE WHEN CITING Published online November 2, 2018; DOI: 10.3171/2018.7.SPINE18460.

Disclosures Dr. Welch reports owning stock in Transcendental Spine.

© AANS, except where prohibited by US copyright law.




Agarwal PPierce JWelch WC: Cost analysis of spinal versus general anesthesia for lumbar diskectomy and laminectomy spine surgery. World Neurosurg 89:2662712016


Attari MAMirhosseini SAHonarmand ASafavi MR: Spinal anesthesia versus general anesthesia for elective lumbar spine surgery: a randomized clinical trial. J Res Med Sci 16:5245292011


Chen HTTsai CHChao SCKao THChen YJHsu HC: Endoscopic discectomy of L5-S1 disc herniation via an interlaminar approach: prospective controlled study under local and general anesthesia. Surg Neurol Int 2:932011


De Rojas JOSyre PWelch WC: Regional anesthesia versus general anesthesia for surgery on the lumbar spine: a review of the modern literature. Clin Neurol Neurosurg 119:39432014


Demirel CBKalayci MOzkocak IAltunkaya HOzer YAcikgoz B: A prospective randomized study comparing perioperative outcome variables after epidural or general anesthesia for lumbar disc surgery. J Neurosurg Anesthesiol 15:1851922003


Jellish WSThalji ZStevenson KShea J: A prospective randomized study comparing short- and intermediate-term perioperative outcome variables after spinal or general anesthesia for lumbar disk and laminectomy surgery. Anesth Analg 83:5595641996


Kahveci KDoger COrnek DGokcinar DAydemir SOzay R: Perioperative outcome and cost-effectiveness of spinal versus general anesthesia for lumbar spine surgery. Neurol Neurochir Pol 48:1671732014


McLain RFBell GRKalfas ITetzlaff JEYoon HJ: Complications associated with lumbar laminectomy: a comparison of spinal versus general anesthesia. Spine (Phila Pa 1976) 29:254225472004


Mok JMMartinez MSmith HESciubba DMPassias PGSchoenfeld A: Impact of a bundled payment system on resource utilization during spine surgery. Int J Spine Surg 10:192016


Puffer RCPlanchard RMallory GWClarke MJ: Patient-specific factors affecting hospital costs in lumbar spine surgery. J Neurosurg Spine 24:162016


Rossi VJAhn JBohl DDTabaraee ESingh K: Economic factors in the future delivery of spinal healthcare. World J Orthop 6:4094122015


Rung GWWilliams DGelb DEGrubb M: Isobaric spinal anesthesia for lumbar disk surgery. Anesth Analg 84:116511661997


Sadrolsadat SHMahdavi ARMoharari RSKhajavi MRKhashayar PNajafi A: A prospective randomized trial comparing the technique of spinal and general anesthesia for lumbar disk surgery: a study of 100 cases. Surg Neurol 71:60652009


Tetzlaff JEDilger JAKodsy Mal-Bataineh JYoon HJBell GR: Spinal anesthesia for elective lumbar spine surgery. J Clin Anesth 10:6666691998


Walcott BPKhanna AYanamadala VCoumans JVPeterfreund RA: Cost analysis of spinal and general anesthesia for the surgical treatment of lumbar spondylosis. J Clin Neurosci 22:5395432015




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