AWAKE SPINAL SURGERY
Awake Spinal Surgery simply refers to a form of surgery involving the spine or its contents, in which the patient remains conscious throughout the course of this procedure. Surgeons usually perform awake surgery in multiple subspecialties nowadays, but originally, surgeons limited awake surgery in the field of neurosurgery to craniotomies. Over the past 20 years, spinal surgeons have pushed for certain methods that only require local anesthesia as it may reduce the financial weight on the patient, reduce length of hospital stay, aid faster recovery rate, and reduce the risk of complications. These regional anesthesia surgeries refer to lumbar spinal surgeries such as lumbar laminectomies and discectomies. Also, multiple surgical subspecialties perform awake surgery. These includes; obstetrics, neurosurgery, cardiothoracic surgery, and orthopedics. In 2016, a study done by Wang and Grossman explained an endoscopic approach for one of the first minimally invasive TLIF that made use of local anesthetics. Since then, various research has described other adaptations to that technique, as well as other forms of awake spinal surgery.
Common Applications of Awake Spinal Surgery
Laminectomy/Discectomy
Spinal anesthesia for lumbar surgery increases in popularity by the day, as specialists can perform it with a myriad of techniques and medication, and this often produces better outcomes as regards to the patient than general anesthesia. Early reports of the use of spinal anesthesia for lumbar laminectomy and/or discectomy have proved promising. Awake spinal surgery allows for less postoperative nausea, lower occurrence of spinal headache and urine retention in comparison to general anesthesia. A similar study supported these findings, as well as taking note that the average perioperative blood pressures and heart rates turned out lower with local anesthesia. Overall, local anesthesia presents a better option for healthy patients undergoing lumbar decompression procedures or for patients at risk for developing complications from general anesthesia.
Lumbar fusion
Neurosurgeons have more recently performed lumbar fusion surgery without the use of general anesthesia in order to improve patient results and speed up recovery rate. The current procedure used in awake lumbar fusion presents more advantages due to the reduced risk associated with the use and side effects of general anesthesia. It also provides direct feedback to the surgeon in traversing neural structures. Conclusions regarding the success rate of awake lumbar fusion have proved difficult to draw due to a patient selection that may have already favorable positive results. Criteria for patients selected for this study included low anesthesia risk, easy accessibility to family care post operation, along with certain cardiac and BMI restrictions.
Advantages and Limitations
Awake spinal surgery provides the patient with a wide range of health benefits. Avoidance of general anesthesia along with its associated potential risks and negative outcomes presents as the most significant advantage for patients.
Patient reviews and observations have associated general anesthesia with side effects such as bleeding complications, postoperative hallucination and extended exacerbation in elderly patients and patients with multiple comorbidities. With awake spinal surgery as an alternative, it significantly reduces the side effects and provides the most favorable recovery route for elderly or seriously ill patients.
Elimination of general anesthesia in awake spinal surgery also decreases postoperative length of stay (LOS), which leads to increased patient satisfaction, reduce occurrence of surgical site infection (SSI), and decrease financial burden on the patient.
Neurosurgeons also gain massively from the use of awake methods for spinal procedures. With patients remaining conscious, patients provide real-time feedback of any discomfort, tension or nervous complications due to operating in close proximity to nervous structures. Also, neurosurgeons administer conservative intraoperative therapy techniques, such as music therapy, to help decrease postoperative anxiety and pain in patients. In addition, the previously mentioned reduced LOS and decreased risk of SSI brings down rate of reoperation and improves overall patient satisfaction.
Although awake spinal surgery presents many benefits, one must also consider its limitations/disadvantages. In comparison to general anesthesia, local anesthesia has a shortened duration of action, thereby reducing the operating time for the surgeon.
Awake spinal surgery also predisposes the patient to increased risk of symptomatic CSF leak on administration and introduces chances of infectious and operative complications.
Not all types of spinal procedures can use awake spinal surgery, and the use depends on the specific case and the patient’s medical condition. Awake spinal surgery finds common use in procedures where the patient’s feedback bring value for the surgical team or when general anesthesia presents higher risks due to the patient’s health status.
The decision to employ awake spinal surgery involves consulting the patient, and the anesthesiologist, taking into account the patient’s medical history, surgical requirements, and preferences. The surgical team ensures the patient’s comfort and safety throughout the procedure, making awake spinal surgery a viable option for selected spinal surgeries.
Conclusion
Awake spinal surgery presents a new method that makes use of regional anesthesia and minimally invasive techniques. This reduces the requirement for general anesthesia. As regards to its limitations, future studies should centre on expanding available evidence supporting this method and defining its long term efficacy.
References
- Ames WA, Songhurst L, Gullan RW. Local anesthesia for laminectomy surgery. Br J Neurosurg.
- Brown MJ. Anesthesia for Elective Spine Surgery in Adults. 2018.