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. 2025 Jun 1;28(6):855-861.
doi: 10.1227/ons.0000000000001380. Epub 2024 Sep 27.

Spinal Anesthesia for Multilevel Awake Minimally Invasive Transforaminal Lumbar Interbody Fusion: Single-Center Experience

Juan P Navarro-Garcia de Llano  1 , Macarena Fuentes-Fernandez Cueto  1 , Andrew P Roberts  1 , Jesus E Sanchez-Garavito  1 , Siddharth Shah  2 , Gaetano De Biase  1 , Harshvandan Iyer  1 , Ogechuku Ariwodo  1 , Loizos Michaelides  1 , Jennifer S Patterson  3 , Kate E White  3 , Elird Bojaxhi  3 , Rodrigo Navarro-Ramirez  1 , Ian A Buchanan  1 , Alfredo Quinones-Hinojosa  1 , Kingsley O Abode-Iyamah  1
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Spinal Anesthesia for Multilevel Awake Minimally Invasive Transforaminal Lumbar Interbody Fusion: Single-Center Experience

Juan P Navarro-Garcia de Llano et al. Oper Neurosurg. .

Abstract

Background and objectives: Awake minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) generates minimal surrounding tissue damage and has been shown to be a safe, time-effective, and cost-reductive technique in single-level procedures. The purpose of this study was to advocate for the utilization of multilevel MIS-TLIF even in challenging cases as it has demonstrated positive outcomes.

Methods: Chart review was conducted for consecutive patients undergoing awake multilevel MIS-TLIF from 2020 to 2023. Various demographic, preoperative, and postoperative variables were collected and descriptively analyzed.

Results: Sixteen patients underwent multilevel awake MIS-TLIF at our institution during the specified period. Among them, 87.5% underwent a two-level procedure and 12.5% a three-level procedure. The median age ± IQR was 69.5 ± 11 years, with a slight male predominance (56.25%). Common comorbidities included hypertension (56.25%), obesity (37.5%), sleep apnea (25%), and type 2 diabetes (18.75%). The American Society of Anesthesiologists risk was 2 in 43.75% of patients and 3 in 56.25%. All patients presented pain, and 12.5% showed motor deficit. Intraoperative data showed a median of 196 minutes in the operating room where 156 ± 27.75 minutes corresponded to actual procedure time. The median estimated blood loss was 50 ± 70 cc. In the immediate postoperative period, 1 patient had nausea and emesis, and 1 reported fatigue. The median pain score during this period was 4.6 ± 2.03. Pain control medications were required for various patients, with methocarbamol (50%), hydromorphone (37.5%), and oxycodone (25%) being the most commonly prescribed in the postanesthesia care unit. No patient had new neurological deficits after the surgical intervention. The median length of stay was 2 days ±1.25. All patients were discharged with no complications.

Conclusion: Multilevel awake MIS-TLIF emerges as a safe and effective technique for complex cases, enhancing patient quality of life with minimal blood loss and postoperative pain.

Keywords: Awake TLIF; Awake fusion; Awake lumbar fusion; Length of stay; Minimally invasive transforaminal lumbar interbody fusion.

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