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

The Benefits of Awake Spinal Surgery on Minimizing Positioning-related Complications: A Narrative Review

STUDY DESIGN

Literature review and institutional analysis.

OBJECTIVE

This review examines the potential advantages of awake spinal surgery under neuroaxial anesthesia in minimizing positioning-related complications compared with traditional general anesthesia.

SUMMARY OF BACKGROUND DATA

Spinal surgeries performed in the prone position under general anesthesia are associated with perioperative complications, such as ocular injury and vision loss, nerve damage, and pressure ulcers.

MATERIALS AND METHODS

A comprehensive literature search was conducted for articles published from 1986 to 2023 focusing on awake spinal surgery and positioning-related complications. In addition, insights from the Mayo Clinic team were incorporated to assess the potential benefits of awake spine surgery.

RESULTS

The review identified several positioning-related complications associated with prone positioning during spine surgery, including perioperative visual loss, neuropathies, pressure ulcers, and intra-abdominal hypertension leading to systemic cardiovascular effects and potential organ dysfunction. Advances at the Mayo Clinic have enabled the use of awake spinal surgery under neuroaxial anesthesia for complex procedures such as robotic transforaminal lumbar interbody fusion. The use of awake lumbar spine surgery has demonstrated advantages, including reduced positioning-related complications, immediate patient feedback to avoid harmful maneuvers, shorter operating room times, and improved hemodynamic stability.

CONCLUSIONS

Awake lumbar spine surgery offers notable advantages in reducing positioning-related complications and presents a promising alternative to general anesthesia.

A protocol for lumbar spine surgery under spinal anesthesia in resource limited countries: illustrative case series

Introduction

Lumbar spine surgery can be performed under either general or spinal anesthesia. Numerous studies highlight the benefits of spinal anesthesia (SA), including cost-effectiveness, reduced anesthesia-related complications, and suitability for patients who do not favor general anesthesia (GA). Those informal case series emphasizes the advantages of SA and introduces a working protocol tailored for resource-limited countries (RLCs).

Presentation of case

Two patients, aged 35 and 58, underwent spinal surgery using SA combined with local infiltration for the skin and facet joints. We implemented a new protocol believed to be beneficial in RLCs. In both cases, intraoperative vital signs remained stable, and there was effective pain control postoperatively.

Clinical discussion

Spine surgery under SA has gained acceptance due to evidence indicating reduced perioperative risks and lower opioid consumption, alongside decreased healthcare costs. Although there are suggested protocols for SA in spine surgery, many are not applicable in RLCs. Our case series demonstrate similar advantages, suggesting that the protocol used in this study may be helpful. Despite its benefits, SA for spine surgery still faces resistance and has not been widely adopted in many neurosurgery centers.

Conclusion

The study aim to outline essential steps for initiating SA for spine surgery in RLCs. The guidelines utilized in this study have proven effective. SA can lead to reduced healthcare costs, lower opioid usage, and increased patient turnover. The two cases series demonstrate improved anesthesia outcomes. Future randomized clinical trials with sufficiently large sample sizes are necessary to establish high-quality evidence regarding the safety, efficacy, and cost-effectiveness of SA.

Spinal Anesthesia for Awake Spine Surgery: A Paradigm Shift for Enhanced Recovery after Surgery

Awake surgery has been applied for various surgical procedures with positive outcomes; however, in neurosurgery, the technique has traditionally been reserved for cranial surgery. Awake surgery for the spine (ASFS) is an alternative to general anesthesia (GA). As early studies report promising results, ASFS is progressively gaining more interest from spine surgeons. The history defining the range of adverse events facing patients undergoing GA has been well described. Adverse reactions resulting from GA can include postoperative nausea and vomiting, hemodynamic instability and cardiac complications, acute kidney injury or renal insufficiency, atelectasis, pulmonary emboli, postoperative cognitive dysfunction, or malignant hyperthermia and other direct drug reactions. For this reason, many high-risk populations who have typically been poor candidates under classifications for GA could benefit from the many advantages of ASFS. This narrative review will discuss the significant historical components related to ASFS, pertinent mechanisms of action, protocol overview, and the current trajectory of spine surgery with ASFS.

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.

New Frontiers in Wide-Awake Surgery

LEARNING OBJECTIVES

After studying this article, the participant should be able to: 1. Explain the most important benefits of wide-awake surgery to patients. 2. Tumesce large parts of the body with minimal pain local anesthesia injection technique to eliminate the need for sedation for many operations. 3. Apply tourniquet-free surgery to upper and lower limb operations to avoid the sedation required to tolerate tourniquet pain. 4. Move many procedures out of the main operating room to minor procedure rooms with no increase in infection rates to decrease unnecessary cost and solid waste in surgery.

SUMMARY

Three disruptive innovations are changing the landscape of surgery: (1) minimally painful injection of large-volume, low-concentration tumescent local anesthesia eliminates the need for sedation for many procedures over the entire body; (2) epinephrine vasoconstriction in tumescent local anesthesia is a good alternative to the tourniquet and proximal nerve blocks in extremity surgery (sedation for tourniquet pain is no longer required for many procedures); and (3) evidence-based sterility and the elimination of sedation enable many larger procedures to move out of the main operating room into minor procedure rooms with no increase in infection rates. This continuing medical education article explores some of the new frontiers in which these changes affect surgery all over the body.

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.

Spinal anesthesia in elective lumbar spinal surgery

Spinal anesthesia (SA) is gaining recognition as a safe and efficacious regional alternative to general anesthesia for elective lumbar surgery. However, unfamiliarity with management issues related to its use has limited the adoption of awake spine surgery, despite its benefits. Few centers in the United States routinely offer SA for elective lumbar surgery, and a comprehensive workflow to standardize SA for lumbar surgery is lacking. In this article, we examine recent literature on the use of SA in lumbar surgery, review the experience of our institution with SA in lumbar surgery, and provide a cohesive outline to streamline the implementation of SA from the perspective of the anesthesiologist. We review the critical features of SA in contemporary lumbar surgery, including selection of patients, methods of SA, intraoperative sedation, and management of several important technical considerations. We aimed to flatten the learning curve to improve the availability and accessibility of the technique for eligible patients.

Efficacy of the erector spinae plane block with sedation for unilateral biportal endoscopic spine surgery and comparison with other anesthetic methods

BACKGROUND

Erector spinae plane block (ESPB) is a new regional anesthesia. Unilateral biportal endoscopic (UBE) spine surgery, a minimal invasive technique, has been performed under not only general anesthesia (GA) but regional anesthesia including spinal anesthesia (SA). The aims of this study were to evaluate the efficacy of ESPB with sedation for UBE lumbar decompression and compare it with GA and SA.

METHOD

A retrospective age matched case-control study design was performed. Three groups (20 patients in each group) of patients who underwent UBE lumbar decompressions under each anesthetic method (GA, SA, or ESPB) were formed. The total anesthesia time excluding operation time, postoperative analgesia effects, hospital days, and complications related to anesthetic methods were evaluated.

RESULTS

In the ESPB group, all the operations were performed without change of anesthetic methods and without anesthetic complications. But there were no anesthetic effects in the epidural space, which resulted in additional intravenous fentanyl usage. The mean of time from initiation of anesthesia to completion of surgical preparation was 23.3 ± 4.7 min in the ESPB group, which was shorter than 32.3 ± 10.8 min in the GA (p value = 0.001) or 33.3 ± 6.7 min in the SA group (p < 0.001). The proportion of patients requiring first rescue analgesia within 30 min was 30% in the ESPB group, which was lower than 85% in the GA (p < 0.001), but no significant different with 10% in the SA (p = 0.11). The mean of total hospital days in the ESPB was 3.0 ± 0.8, shorter than 3.7 ± 1.8 in the GA (p = 0.02) or 3.8 ± 1.1 in the SA group (p = 0.01). There was no case of postoperative nausea and vomiting in the ESBB even without prophylactic antiemesis.

CONCLUSION

ESPB with sedation is a viable anesthetic option for UBE lumbar decompression.