Spinal versus general anesthesia for minimally invasive transforaminal lumbar interbody fusion: implications on operating room time, pain, and ambulation

Abstract

OBJECTIVE There has been increasing interest in the use of spinal anesthesia (SA) for spine surgery, especially within Enhanced Recovery After Surgery (ERAS) protocols. Despite the wide adoption of SA by the orthopedic practices, it has not gained wide acceptance in lumbar spine surgery. Studies investigating SA versus general anesthesia (GA) in lumbar laminectomy and discectomy have found that SA reduces perioperative costs and leads to a reduction in analgesic use, as well as to shorter anesthesia and surgery time. The aim of this retrospective, case-control study was to compare the perioperative outcomes of patients who underwent minimally invasive surgery (MIS)–transforaminal lumbar interbody fusion (TLIF) after administration of SA with those who underwent MIS-TLIF under GA. METHODS Overall, 40 consecutive patients who underwent MIS-TLIF by a single surgeon were analyzed; 20 patients received SA and 20 patients received GA. Procedure time, intraoperative adverse events, postoperative adverse events, postoperative length of stay, 3-hour postanesthesia care unit (PACU) numeric rating scale (NRS) pain score, opioid medication, and time to first ambulation were collected for each patient. RESULTS The two groups were homogeneous for clinical characteristics. A decrease in total operating room (OR) time was found for patients who underwent MIS-TLIF after administration of SA, with a mean OR time of 156.5 ± 18.9 minutes versus 213.6 ± 47.4 minutes for patients who underwent MIS-TLIF under GA (p < 0.0001), a reduction of 27%. A decrease in total procedure time was also observed for SA versus GA (122 ± 16.7 minutes vs 175.2 ± 10 minutes; p < 0.0001). No significant differences were found in intraoperative and postoperative adverse events. There was a difference in the mean maximum NRS pain score during the first 3 hours in the PACU as patients who received SA reported a lower pain score compared with those who received GA (4.8 ± 3.5 vs 7.3 ± 2.7; p = 0.018). No significant difference was observed in morphine equivalents received by the two groups. A difference was also observed in the mean overall NRS pain score, with 2.4 ± 2.1 for the SA group versus 4.9 ± 2.3 for the GA group (p = 0.001). Patients who received SA had a shorter time to first ambulation compared with those who received GA (385.8 ± 353.8 minutes vs 855.9 ± 337.4 minutes; p < 0.0001). CONCLUSIONS The results of this study have pointed to some important observations in this patient population. SA offers unique advantages in comparison with GA for performing MIS-TLIF, including reduced OR time and postoperative pain, and faster postoperative mobilization.

Bibliometric and Visualized Analyses of Research Studies on Different Analgesics in the Treatment of Orthopedic Postoperative Pain

“…The most cited article had 1013 citations and was published in 1997 by Collins et al [ 6 ], followed by Chung et al [ 7 ] with 271 citations in 1997 and Sinatra et al [ 8 ] with 252 citations in 2005. The first two published articles were by Laitinen and Nuutinen [ 9 ] and Baker [ 10 ] in February 1992, and the most recent articles were published in December 2021 by De Biase et al [ 11 ] and Rajput et al [ 12 ].…”

Spine surgery under neuraxial vs. general anesthesia: the current state of comparative outcomes research

“…These studies concluded significant benefits for length of stay and early recovery that were perhaps better explained by patient selection and expectation-setting than to effects of the anesthetic technique per se . More recently, awake spine surgery has expanded as a term in the surgical literature to refer to any patient undergoing spine surgery under regional anesthesia with or without regional analgesia, irrespective of level of sedation [8,13,14 ▪▪ ,18,19,22,23 ▪ ]. Indeed, the term is increasingly used interchangeably with neuraxial anesthesia, even in systematic reviews, which included RCTs comparing neuraxial anesthesia with sedation to general anesthesia and in population studies wherein details of sedation, if provided, are not captured [8,14 ▪▪ ].…”

Meta-Analysis of the Clinical Effect of MIS-TLF Surgery in the Treatment of Minimally Invasive Surgery of the Orthopaedic Spine

“…A posterior cervical discectomy was performed on 60 individuals, and an amniotomy or discectomy was performed on 18 patients (specific procedure per patient not reported). In RCTs, only 95 of 200+ MIS patients (42%) employed an anterior approach, compared to 190 of 200+ conventional open patients (88%) [ 3 , 4 ].…”

“…Both groups did not obtain fusion. Out of 500+ open patients, 500+ got discectomy, and 19 had percutaneous nucleosome, with the follow-up durations of 50–100 weeks (about 2 years) [ 4 – 6 ].…”