Awake Spine Surgery

Introduction

• Awake spine surgery under spinal anesthesia has emerged as an effective alternative to GA for selected patients. Meta-analyses show that spinal anesthesia can reduce operative time, perioperative complications, opioid use, and length of stay compared with GA.^1,2
• National registry data also indicate growing adoption of awake spine surgery techniques across US centers.³
• Although not suited for complex deformity or multilevel spine procedures, this approach offers a streamlined, patient-centered option for certain lumbar spine interventions.

Patient Selection

• Published studies highlight the importance of identifying patients who can tolerate being awake or lightly sedated while in the prone position for the duration of the procedure.^4,5

Indications^4-6

• Single-level or two-level lumbar stenosis, disc herniation, or grade I spondylolisthesis.
• Procedures such as microdiscectomy, laminectomy, minimally invasive transforaminal lumbar interbody fusion (TLIF), or short-segment fusion.
• Anticipated surgical duration should not exceed the duration of a typical spinal anesthetic block
• American Society of Anesthesiologists (ASA) physical status I–III patients with stable cardiopulmonary status and anatomy favorable for prone positioning.
• Psychological suitability: Patients must be comfortable with being awake, able to understand instructions, and willing to report discomfort.

Contraindications^4,5

• Severe or nearly obliterated lumbar canal stenosis that may limit safe or effective spread of intrathecal anesthetic.
• Prior extensive lumbar surgery at the intended puncture site.
• Significant anxiety disorders, claustrophobia, cognitive impairment, or language barriers.
• Standard contraindications to spinal anesthesia (e.g., coagulopathy, anticoagulation, infection at the insertion site).

Preoperative Preparation

• Success relies on counseling and setting realistic expectations, which improves cooperation and anxiety.
• Coordination among the surgical, anesthesia and nursing teams helps streamline positioning, sedation plans, and postoperative mobilization.
• Enhanced recovery pathways complement the awake technique through multimodal analgesia and early ambulation.^5,6

Anesthetic Management

Monitoring

Standard ASA monitors including

• 5-lead EKG
• Pulse oximetry
• Noninvasive blood pressure
• End-tidal CO2 → particularly important for early detection of airway compromise.

Neuraxial Anesthesia Techniques

Neuraxial anesthesia is the primary anesthetic for awake spine surgery.

• Spinal anesthesia produces a predictable block in both density and duration. An alternative option is epidural anesthesia, but this may not provide a sufficiently dense block and is typically not favored.6 Depending on spinal deformity or prior surgeries, neuraxial anesthesia may be technically challenging or impossible to complete even for experienced teams.
• In the absence of robust scientific data, technical aspects and drug selection are primarily based on institutional or provider experience, resulting in considerable variability.
  • Approach: Midline or paramedian technique (e.g., when scoliotic deformity is present), at or one level above the operative site to ensure sufficient proximal spread.
  • Local anesthetic choice: Our preference is the use of isobaric 0.5% bupivacaine, or 1.5% mepivacaine, without adjuvants, with a goal to provide a sensory block to roughly T4–T8. 9-15 mg of bupivacaine typically lasts approximately 120-150 minutes, while 45-60 mg of mepivacaine may have a shorter duration and is suitable only for predictably short cases.
  • Intrathecal adjuncts: Fentanyl, clonidine, or dexmedetomidine are options to enhance analgesia and minimize sedative requirements.

Regional Anesthesia

• An erector spinae plane (ESP) block can provide additional myofascial and dorsal rami analgesia. Although no studies address the role of ESP block specifically in awake spine surgery, the benefit in lumbar spine surgery is well characterized, and include:⁷
  • Lower incisional pain, systemic opioids, smoother intraoperative conditions and earlier recovery
  • Easy to perform using ultrasound guidance during pre-, intra-, or postoperative phases, depending on preferred workflow6 (Figure 1).

Sedation Strategies

• Sedation goals include:
  • Maintaining responsiveness to verbal stimuli.
  • Avoiding airway obstruction is crucial in the prone position.
  • Combining systemic multimodal analgesia with local wound infiltration as needed.
• Dexmedetomidine is a popular choice in this setting because it maintains oriented responsiveness and causes minimal respiratory depression.^4-6

Hemodynamic and Respiratory Considerations

• Compared with GA, spinal anesthesia often provides stable or even improved hemodynamic profiles. Hypotension from sympathetic blockade can occur but is typically manageable with fluids or vasopressors.
• Lower intraabdominal pressure from self-positioning may help reduce epidural venous congestion and bleeding
• Because airway instrumentation is avoided and systemic anesthetic exposure is lower, respiratory complications are less frequent.^1-3,6 However, preparedness for emergency airway management in the prone position remains a crucial safety consideration.

Other Intraoperative Considerations

Conversion to GA^1,2,4-6

Conversion to GA remains uncommon, typically ranging from 3–7%, with multiple potential factors contributing (Figure 2).

• Most conversions occur due to discomfort or anxiety rather than technical failure or sedation-related complications.
• Contingency plans and protocols should be in place for conversion to GA, including rapidly repositioning the patient in the event of an airway emergency. Regular simulation drills involving all members of multidisciplinary teams who participate in awake spine surgeries help maintain clinical skills and team dynamics in such an event.

Procedural Limitations

• Surgeon’s experience, procedural speed, and comfort level.
• Patient movement is more likely to occur; this can be mitigated by effective positioning and communication.^4,5

Postoperative Recovery and Outcomes Compared with GA

Operative Time and Length of Stay

• Multiple meta-analyses that have included over 10,000 patients confirm that spinal anesthesia is consistently associated with shorter operative times (approx. 19 minutes) and anesthesia times, and reduced length of stay (approx. 0.4 days) compared with GA.^1,2

Complication Rates and Postoperative Symptoms

• Regional anesthesia is associated with lower overall complication rates and markedly reduced rates of PONV and urinary retention.
• Patients can position themselves, which helps alleviate pressure points and can alert the team to any concerning symptoms. This feedback can help prevent rare but serious issues like postoperative vision loss or peripheral neuropathies.⁸
• Decreased opioid use further contributes to the improved postoperative symptom profile. Randomized, prospective studies confirm improved early pain control and patient satisfaction with regional techniques.^2,10

Functional Recovery and Ambulation

• Patients undergoing minimally invasive TLIF or short-segment fusion under spinal anesthesia often ambulate earlier and experience smoother and shorter recoveries.^9,11

Adoption Trends and Health-System Considerations

• National data demonstrate increasing use of awake spine surgery and corresponding reductions in readmissions and complication rates among patients treated without GA.
• Yet overall adoption remains modest, which reflects concerns about workflow disruption, training gaps, and patient comfort.³

Advantages and Disadvantages