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

Abstract

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.

Keywords: awake spine surgery; awake surgery; enhanced recovery after surgery (ERAS); minimally invasive surgery; spine surgery.

Figure 1

Methods of achieving sensory blockade in awake spine surgery. (A) Local anesthesia is delivered to the erector spinae plane to achieve temporary sensory blockade. (B) Epidural anesthesia is administered continuously into the epidural space via a catheter throughout the operation. (C) Intrathecal administration is administered as a single shot to the intrathecal space and provides the highest quality of sensory blockade for the most significant duration.