Abstract

Background:Lumbar spine surgery for discectomy or laminectomy is mostly performed under general anesthesia (GA). Here, we explored whether, in a series of 84 patients, better peri-operative outcomes and lower complication rates could be achieved for those undergoing diskectomy/laminectomy under spinal anesthesia (SA) versus GA.

Methods:From 2022 to 2023, 84 patients were randomly assigned to undergo lumbar discectomy/laminectomy for stenosis under SA: 42 patients versus GAGA: 42 patients. For these two populations, we analyzed and compared multiple variables, including duration of anesthesia, estimated blood loss (EBL), and outcomes (i.e., including pre/post-operative Visual Analogue Scale, Oswestry disability index, and short-form 36 questionnaires).

Results:Major advantages of SA versus GA included a reduced mean EBL, shorter mean operative time, reduced mean hospital length of stay, and fewer post-operative side effects. Notably, baseline heart rate or mean arterial blood pressure showed no significant differences between SA and GA groups.

Conclusion:Based on this small preliminary sample of patients undergoing lumbar disc/stenosis surgery, it appeared that SA reduced the mean EBL, offered shorter mean operative times, mean hospital lengths of stay, and fewer post-operative side effects versus GA.

Keywords: Awake surgery, Complications, Lumbar discectomy, Operative time, Spinal anesthesia

INTRODUCTION

Multiple studies have previously compared the risks versus benefits of performing lumbar diskectomy/stenosis surgery under spinal anesthesia (SA) versus general anesthesia (GA) [ Table 1 ].[ 2 , 6 , 7 , 9 ] Here, in a prospective randomized sample of 42 patients undergoing lumbar diskectomy/laminectomy for stenosis under SA versus 42 performed under GA, we asked which anesthetic regimen would reduce mean estimated blood loss (EBL), shorten mean operative times, decreases hospital lengths of stay, and result in fewer post-operative side effects.

Table 1:

Summary table for references.

MATERIALS AND METHODS

Prospectively, 84 patients undergoing discectomy/laminectomy for stenosis were randomly assigned to SA: 42 patients versus GA: 42 patients groups during 2022–2023. We utilized multiple inclusion and exclusion criteria [ Table 2 and Figure 1 ]. Surgeons were aware of the type of anesthesia, but the surgeon evaluating the data 3 months later was blinded to the study design.

Table 2:

Inclusion and exclusion criteria.

Figure 1:

Flowchart of enrollment, randomization, and follow-up of patients.

Anesthetic techniques

Pre-operative pre-medication included midazolam 0.02 mg/kg IV, and the following vital signs were monitored: Heart rate, mean arterial blood pressure, and oxygen saturation (SpO₂). Patients underwent different permutations/combinations of lumbar diskectomy/laminectomy for stenosis [ Table 3 and Figures 2 - 7 ].

Table 3:

Procedure vs. anesthesia.

Figure 2:

During initiation of spinal anesthesia after insertion of the spinal needle.

Figure 3:

The OR setting during performing microscopic discectomy under spinal anesthesia. OR: Operating Room.

Figure 4:

The skin incision after microscopic discectomy.

Figure 5:

After insertion of the tubular dilator system in a case of endoscopic discectomy.

Figure 6:

The OR setting during performing endoscopic discectomy under spinal anesthesia.

Figure 7:

Surgical incision after performing endoscopic discectomy.

Clinical data

Eighty-four patients enrolled in the study had an average of 42.3 years of age: 47 were males and 37 were females [ Table 4 ]. Notably, multiple clinical and outcome data were analyzed (i.e., most importantly, the mean EBL, mean operative times, mean hospital lengths of stay, and incidence of post-operative side effects) for patients managed with SA versus GA. At 3 and 6 months postoperatively, outcomes were evaluated utilizing the (Visual Analog Scale [VAS] score/Oswestry Disability Index [ODI] questionnaire/short form-36 [SF-36] questionnaire (i.e., the latter two using the Arabic Version)). Notably, all patients had 3-month postoperative magnetic resonance imaging.

Table 4:

Patient Characteristics, diagnosis, and levels.

Statistical analysis

Statistical analyses utilized the Statistical Package for the Social Sciences (SPSS) version 25.0 (SPSS. Chicago, the USA), the Kolmogorov–Smirnov test (i.e., to determine variable distribution), the independent sample t-test, and the Chi-square test. Heterogeneous variables were analyzed using non-parametric statistical methods (i.e., using the Mann–Whitney U-test).

RESULTS

Multiple demographic characteristics were similar for both groups [ Tables 4 and 5 ]. Both groups also showed statistically significant clinical improvement after surgery [ Table 6 ]. Further, there were no significant differences in pre-operative, 3 months, and 6-month post-operative VAS scores, ODI, and SF-36 between the SA versus GA group patients (i.e., except at 3-month post-operative VAS scores were lower in the SA versus GA group) [ Table 7 ].

Table 5:

HR and MABP vs. anesthesia.

Table 6:

Pre-operative versus post-operative VAS and ODI.

Table 7:

Pre-operative versus post-operative VAS and ODI in the SA group versus GA group.

Benefits of SA versus GA

Multiple other variables showed significant improvement/benefits for utilizing SA versus GA for performing lumbar diskectomy/laminectomy for stenosis, including better immediate post-operative peripheral SpO₂, reduced mean EBL, shorter surgical duration, less time in the post-anesthesia care unit, reduced post-operative pain, reduced post-operative analgesia, less post-operative nausea/vomiting, and urinary retention, shorter lengths of stay, and overall costs [ Tables 8 - 10 ]

Table 8:

Blood loss, anesthetic time, procedure time, and PACU time.

Table 9:

Post-operative analgesia vs. anesthesia.

Table 10:

Nause, vomiting, and urine retention vs. anesthesia type.

Comparable incidence of adverse events utilizing SA versus GA for diskectomy/laminectomy

Patients from both the SA and GA groups sustained comparable and relatively minimal post-operative adverse events. Four patients sustained intraoperative traumatic durotomies: 2 patients in the SA group (4.76 %) and 2 in the GA group (4.76 %). There were also 2 cases of post-operative discitis, one from each of the SA and the GA groups; both responded to conservative intravenous antibiotic therapy. An additional GA patient had a recurrent disc herniation that occurred 1 week postoperatively, requiring operative revision.

DISCUSSION

In our series, as seen in other studies, there was no statistically significant difference in outcomes for the 42 patients undergoing diskectomy/laminectomy utilizing SA versus the 42 having GA; patients in both of our groups showed statistically significant and comparable clinical postoperative improvement based on post-operative VAS, ODI, and SF-36 scores at 3 months or 6 months postoperatively.[ 3 ]

Our incidence of post-operative adverse events for both groups, including dural tears, infection, and recurrent disc herniations, was also similar to Baenziger et al.,[ 3 ] McLain et al.,[ 8 ] Hebl et al.,[ 5 ] and Dripps and Vandam[ 4 ] studies.

Like our findings, Jellish et al.[ 6 ] and McLain et al.[ 8 ] reported that SA was associated with less post-operative pain, less post-operative analgesic requirements, and less nausea/vomiting versus GA.

Although we documented a statistically significant reduction in intraoperative blood loss for the SA versus GA groups, other studies showed more variable results.[ 6 , 9 ]

Despite our documenting a reduced time for SA versus GA, other studies came to different conclusions (i.e., McLain et al.,[ 8 ] Attari et al.,[ 2 ] and Sadrolsadat et al.[ 9 ])

Our patients having SA (2.33 days) exhibited faster recoveries and earlier discharges from the hospital versus GA (3.07 days), findings similar to those in McLain et al.[ 8 ] series.

Our data and findings from other studies showed nearly equal perioperative adverse events occurring in each group.[ 4 , 9 ]

We, like others, have noted that SA was associated with lower overall costs versus GA for patients undergoing lumbar diskectomy/laminectomy.[ 1 ]

CONCLUSION

SA for patients undergoing lumbar diskectomy/laminectomy reduced the mean EBL and offered shorter mean operative times and mean hospital lengths of stay, along with fewer post-operative adverse events versus GA.

Ethical approval

The research/study was approved by the Institutional Review Board at Cairo University Hospitals, number MD - 114– 2022, dated May 22, 2022.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

Use of artificial intelligence (AI)-assisted technology for manuscript preparation

The authors confirm that there was no use of artificial intelligence (AI)-assisted technology for assisting in the writing or editing of the manuscript and no images were manipulated using AI.

Disclaimer

The views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of the Journal or its management. The information contained in this article should not be considered to be medical advice; patients should consult their own physicians for advice as to their specific medical needs.

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